INFECTIOUS DISEASES (AMENDMENT NO. 2) BILL

[Mr Speaker in the Chair]

Debate resumed.

Mr Tan Soo Khoon (East Coast): Mr Speaker, Sir, in the space of slightly over a month, the Infectious Diseases Act is being amended twice. This reflects how swift the spread of SARS has been that makes it necessary for us to make further provisions in the Act.

When we amended the Act on 21st March, there were then 37 cases of SARS and no death as yet. As of yesterday, we had 192 cases, including 17 who have since died plus two other deaths which have yet to be confirmed as SARS cases. And now, about 2,500 people are under Home Quarantine Orders.

Today, the House is being asked to amend the Act again, this time notably to increase the penalties for those who break their Home Quarantine Orders. Sir, these are steps that I fully support. That there are those who have broken their HQOs so blatantly and thereby putting others at risk or being affected with SARS have aroused the anger of many Singaporeans. In my opinion, there are no two ways to deal with those who flout their HQOs. If someone puts the rest of society at risk and in danger, then we have to ensure that the full force of the law comes down hard. We are now at war with the deadly disease and this calls for strict and draconian measures, I may say. And for some, it must mean a loss of freedom as they submit to the well-being of the country ahead of their own personal needs.

Sir, the two cases highlighted by the Prime Minister in his open letter - one of the family of eight who went wandering away from the doctor's clinic while waiting for an ambulance to take them to Tan Tock Seng Hospital and the other of a sick man from the Pasir Panjang Wholesale Centre who went doctor- and sinseh-hopping before landing up in TTSH - reflect the dilemma we are all in.

Sir, in the case of the family of eight, they were asked to wait outside the doctor's clinic and, as we understand from subsequent reports, they had just gone through the funeral service of a member of their family who died the previous day and, in all probability, they were tired, they were hungry and they went round looking for food. And I believe that if the ambulance had come a bit earlier, they would probably not have gone away from where they were waiting. As we were told a call for the ambulance was made at 10.30 am, but the ambulance only arrived at 12.30 pm, and this begs the question of why it took so long for the ambulance to turn up.

Sir, we know that they have acted irresponsibly. But, on the other hand, there are also people like those who continue to be in denial mode or who fear stigmatisation by the rest of the society - the fear of being quarantined because they fear the loss of income and jobs. There are those who, for reasons best known to themselves, simply do not want to admit that they are sick. And, as has been said yesterday, there are people who think that going to Tan Tock Seng Hospital in the event that they have SARS means stigmatisation by their friends and, worse still, they will die there. We therefore need to emphasise the positive side of the fight against SARS, as was done yesterday in the House, when DPM said that TTSH is in fact a very safe place and offers the best chance of survival in case you get hit by SARS.

Sir, I recall that, in the 1950s, when tuberculosis was prevalent in Singapore, TTSH was the hospital of treatment for those suffering from TB. In those days, many of the older generation feared going to hospitals. Going to TTSH was, in fact, facing a death sentence. But, over time, many also came to realise that TTSH offered them the best hope of recovery from tuberculosis. I hope that those who are hit by SARS will also understand this. Yes, if you are in Tan Tock Seng Hospital, you can recover, you can be saved.

What about stigmatisation? Here, I would like to urge the authorities and the media to stop labelling certain categories of SARS patients as "super infectors" or "super spreaders". I think these terms have negative connotations. In fact, I was upset to read an article in the Straits Times of 11th April which traced the steps of how SARS came to Singapore. What upset me most was a chart that illustrated how it all started, with the headline in very bold print that read: "Chain effect: How one person infected more than 120 people", and right at the top of the chart, under the label "Super spreader No. 1" was the name of the woman who, through no fault of hers, was our first SARS victim. Her only fault was that she happened to be on holiday, like what many of us do, and she just happened to be in the wrong place at the wrong time.

Sir, I sympathise with this person who has already suffered the loss of her family members and her pastor. But I would like to urge the media to stop bandying her name around because it does nothing to help her and neither does it help us in our efforts to overcome the concerns of those who fear stigmatisation.

Sir, fighting SARS involves everyone of us. We all need to ensure responsibility, not for ourselves, but also for our family members, for our colleagues and for our fellow citizens. Much has been said in the past few days about what we must do to protect ourselves. One day, not too far in the future, carrying a thermometer would be as common place as carrying a pen in our pocket. There are many little but significant things we can do to safeguard our personal hygiene. Perhaps, it is even time for the Government to consider reviving the old Keep Singapore Clean and Anti-Littering Campaigns because these campaigns, in their own ways, are efforts that contribute to a healthier environment for Singapore.

Sir, these amendments therefore in a way reflect the strong stand we are taking in the fight against SARS. The World Health Organisation has stated that what we are doing are, in fact, above their guidelines.

Sir, we are doing the right thing and we need to show to the world that, in fact, Singapore is a safe place, after all.

Sir, I support the amendments.

Mr Steve Chia Kiah Hong (Non-Constituency Member): Mr Speaker, Sir, first, we would like to take this opportunity to join the many Singaporeans out there to show support, appreciation and to commend our conscientious doctors, nurses and related healthcare staff assigned to the frontline duty of combating the SARS virus. Without their dedicated sense of duty and responsibility, our society and economy would have been even more severely crippled. For their contributions, we look forward to their being individually commended at the National Day Awards Ceremony.

Second, we want to thank and appreciate the more than 90% of Singaporeans who have been willing and responsible in abiding by the quarantine orders fully. Without their full cooperation, the war against the SARS virus would have failed miserably.

Third, we recognise the Government's announcement yesterday of a Home Quarantine Allowance scheme of up to $70 per order per day, and an ex-gratia payment for businesses that are ordered to be quarantined. While this is not the full compensation for some, it is better than nothing, and I think most people under quarantine will appreciate this small gesture. I can only hope that specific individuals with a higher economic burden can apply, on a case-by-case basis, for a higher ex-gratia allowance, if they have suffered a greater loss as a result of the Home Quarantine Orders.

Fourth, we are happy to note the open and transparent actions taken by the Ministry of Health in this crisis. By going public and making all information available to the people, it helps to build trust and confidence between our national institutions and the people. As an Opposition politician, I am pleased to provide moral and emotional support to the Ministry of Health in its tough struggle to combat this virus. In this respect, I have strongly refuted calls from some irate members of the public asking for the resignation of the Minister for Health for failing to contain the virus at its first onset. They are being unreasonable.

On the Bill under discussion, Sir, we support the amendments to the Infectious Diseases Act. We recognise that there will be a small element of defiant people out there who will not abide by any orders, and that some of these unfortunately quarantined individuals may cause the whole containment exercise to fail, if they happen to be infected and not obeying Home Quarantine Orders.

We cannot allow the efforts of the 90-plus percent of law-abiding quarantined citizens to go to waste by having a handful of people disobeying the Home Quarantine Orders and, potentially, endangering the health and livelihood of others.

Thus, we would like to endorse the Government's move to introduce harsher measures for quarantine violators. If fines and electronic tagging do not work for some of these irate violators, I would even suggest that the Government publicise their names and let the public ostracise them. This will definitely work, because the general public is very concerned about being infected and impacted, and will put great social pressure on the violators to observe the Home Quarantine Orders.

Our only concern is that Government officials are not too trigger-happy and start fining and shaming everyone, without at least giving a warning or an opportunity for the violators to explain their actions. There could be some genuine and acceptable reasons that we may not know of, and we must ensure that the harsh punishment is meted out only to the unrepentant recalcitrant.

Sir, some people may argue that electronically tagging someone for quarantine violations may seem a very drastic measure and an infringement of civil liberties. But I do not think so. Most people will see that anything which can be done should be done to restrict the spread of the SARS virus, even if there is some human right price to pay.

Before concluding, Sir, I have some questions for the Minister for Health to respond to.

One, why was it that when surgeon Alex Chao was cremated within 24 hours for suspected SARS, those who had treated him while he was in hospital and those who were at his cremation service were not issued with any quarantine orders? Is the Ministry of Health 100% sure that they are not probable cases, and would it not have been better off for them to be served with HQOs to play it safe?

Two, if family members can be infected without showing symptoms before any suspect patient dies, is it not better to play it safe by issuing Home Quarantine Orders to the family members, instead of allowing them to mix around with friends and others, causing undue anxiety and fear later, if the patient is subsequently found to be a genuine SARS case?

Three, if the incubation period is from 3-10 days, would a first quarantined suspect - who may have a longer incubation period and who later turns out to be an atypical SARS case where there is no high fever and living with a non-quarantined family member with a shorter incubation period of, say, three days - not cause the spread of the disease unknowingly, if the latter is not quarantined at all? Is it not better to play safe to quarantine all family members living together, if one is quarantined at all?

Do we know the disease well enough to take such unnecessary risk by exempting one over the other? I hope the Ministry of Health can be a bit more kiasu in issuing Home Quarantine Orders. If unsure or uncertain, issue the Home Quarantine Orders first, and then confirm later. In this way, we will have a better chance of closing all escape routes totally.

Finally, if the outbreak should become too serious and not contained, then we need to seriously consider Dr Tan's recommendation and what I put forward yesterday to the Minister for Health, ie, to set up intermediate and separate fever testing centres, away from TTSH. This will cost additional resources, but it will help to prevent further unknowing spread through GPs and polyclinics, which may not be equipped to treat or identify SARS effectively. It will also encourage more of those who are fearful of going to TTSH to come forward for fever testing. The needed resources can be activated from the SAF Field Hospital set-up which, I believe, is well-trained and prepared for this supporting task.

To conclude, and to provide some cheer, I would like to quote a correspondent from the BBC programme that was aired yesterday morning where he said:

"Singapore's containment measures have been very effective. There are fewer than 200 cases in Singapore so far. People are worried about the virus, but they are not so worried about it at the moment that they cannot go about their daily lives. So, for the most part, they do seem to be working quite well."

Kudos to the Health Team at work. Now is the time to be more kiasu, and we will win the battle.

Mr Speaker, Sir, I support the Amendment Bill.

Mr Speaker: I now call upon Dr Vivian Balakrishnan to address the House via video.

The Minister of State for National Development (Dr Vivian Balakrishnan): Mr Speaker, Sir, the SARS virus has struck down more than its fair share of healthcare professionals. This is because it is most contagious in hospitals and, if you have unprotected exposure, it strikes otherwise fit young professionals in their prime of life. All of us practising medicine today have not faced such a situation before, and I can honestly tell you that the practice of medicine will be changed forever.

I have spent the past one week in the Singapore General Hospital, and I can tell you that there is real fear in the corridors. This fear does not just affect the healthcare professionals themselves, but extends also to their families. And a few have made the ultimate sacrifice. They have died alone, without touching their relatives, and with indecently hurried small funerals.

Yet, we must ask ourselves: why do healthcare professionals put themselves in harm's way? I can tell you it has nothing to do with money, nothing to do with National Day Awards. Healthcare professionals face these risks because of a higher calling, a deep instinctive sense of duty to care for their patients and for their fellow human beings. This sense of duty is so strong that I have had great difficulty forcing the doctors and nurses to stand down, in order to rest or to recharge themselves during this crisis.

Our healthcare professionals do not deny their fears. But neither do they panic. They take the necessary precautions in order to minimise the risk and quietly get on with their duties.

Mr Speaker, Sir, I think the example of healthcare professionals has some lessons for ordinary Singaporeans. Many of them have asked me, "Is it safe? Is it safe to do this or do that, or to go to this place or that place?" They asked me, "The Government says 'life must go on'. What do you mean by that?" People want a "Yes" or a "No" answer. Unfortunately, life is not so simple. I wish to make two points to answer these questions.

First, that it is impossible to totally eliminate the risks, but there is a lot that we can do to reduce the risks by taking sensible precautions.

Second, it is not just a matter of personal risk. But our health has an impact on others around us. Consequently, we have an obligation to our families, neighbours and the community. And social norms must change.

Let me deal with the first point. We cannot eliminate all risks totally. Any activity in life carries some risk. But it is possible to minimise that risk and get on with that activity. All of us need to review our personal thresholds for risk, and get on with doing what we need to be done. In the case of the healthcare professionals, we accept a higher risk, because that is our calling. For everyone else, we must carry on with our daily activities of life.

Yet, we must have sensible precautions in place. The Ministry of Health has published a whole long list, and I do not want to belabour the point. But there is no point looking for absolute protection. It does not exist. But we can protect ourselves to a large extent by practising good personal hygiene, diet, exercise, self-monitoring of temperature, and the like.

On the second point, it is not just a matter of personal risk. SARS underlines the fact that we are all interdependent on each other. Your health affects me, and my health affects my family. Even if I am willing to take the risk, my family and my friends may not. I have to think of others, and practise social responsibility in a very real sense and protect others where possible. If I am ill, I have no right to infect others.

If I have to be here, then I must be honest and transparent about it. I must tell those around me of the added risk that I pose to them. They must have the chance to decide whether they still wish to be with me, or they may decide, as this Parliament has, that it is better for me to be in this room, speaking to you via a video link.

Our social norms must change. Perhaps, shaking hands may not be as common. We will have to review and achieve the right balance between privacy and collective security.

I hope Singaporeans will look beyond the fines and the penalties that are spelt out in this amendment to the Infectious Diseases Act. If you actually stop to think about it, this amendment places more, not less, responsibility on Singaporeans. There is only so much that the Government knows, or that the Government can do. But there is a lot more that Singaporeans have got to learn to do for themselves.

I want to look beyond this crisis. What would we have at the end of this crisis? I think we will have a better society. Singapore will have a society in which we have learnt that taking risks is a part of daily life. But we would also have learnt that it is silly to take unnecessary risks. We would have learnt that we are responsible for each other's survival, and that we will live or die together. We would have developed a collective instinct, and we would have learnt that, yes, the Government can do a lot, but there is much, much more that we must do for ourselves.

Ironically, the SARS virus would have re-made Singapore. Just like a patient who recovers has gained immunity and strength, I believe a post-SARS Singapore will be stronger, more cohesive and better able to face whatever comes our way.

This is a chance for the new generation to pass our own test of survival, and we will be the better for it.

Mr Speaker, I support this Bill. 4.15 pm

Dr Warren Lee (Sembawang): Sir, I speak in support of the amendments, not only because its legislation is of public health importance, but because I believe it is an important step in the fight for public and international confidence in Singapore's future and economic recovery.

I know many fellow Singaporeans would have lost out on business deals because they are afraid to travel to SARS-affected countries, not just because of the risks to themselves but because of the risks that they may pose by bringing the infection back. I and my colleagues have skipped medical conferences and speaking engagements for the same reason. If we do not tackle SARS and restore confidence in Singapore as a safe destination, not only will our tourism industry, but all of Singapore will face a bleak future.

On the other hand, measures, such as a very simple temperature taking campaign, prescribe tangible, transparent, measurable and logical actions, would all help rebuild confidence and, in fact, position Singapore favourably as a safer destination in an increasingly dangerous world.

The problem of SARS merely presages a brave new world where we can expect, from time to time, new diseases to appear. Some may be epidemics of well-known diseases brought to Singapore by the forces of globalisation; others may be caused by mutations of known pathogens; still others, completely new agents like SARS, and perhaps even biological agents conceived originally as weapons of terror or mass destruction. In such cases, conventional medical methods to treat and contain the disease may fail, as the appropriate cure will not yet have been found. If such new diseases are highly infectious, one patient appearing in our midst may kill many people.

Indeed, history tells us of several instances of this. The Black Death of Europe, caused by Bubonic Plague has been immortalised by the nursery rhyme, "Ring a ring a rosy, a pocket full of posies, a tissue, a ah-choo, a tissue, all fall down." The advent of measles and other viral diseases among North American natives after the arrival of European settlers actually killed off many of them. The 1918 influenza pandemic also killed millions around the world. SARS, therefore, may be a new disease, but does not represent a new situation in the world. We all can learn from the lessons of history in dealing with this.

The first lesson is whether or not we are able to save the individual patient. We must at least prevent the disease from affecting the entire nation.

Contact tracing, quarantining and isolation of index cases and at-risk persons can only succeed if all were to cooperate. Firm measures then need to be instituted to ensure compliance, and the loss of some personal freedom would be a small price to pay for the survival of the nation. We would not need this legislation if everyone were to cooperate. Sadly, however, I and my medical and nursing colleagues will tell you that this is often not at all the case. Doctors are at the mercy of patients who may not always tell the truth.

The provisions of this Bill will help doctors perform their duties more effectively simply because they are more likely to be told the truth by their patients. Some patients lie to the staff at triage points. Others try to sneak extra visitors past the hospital staff or argue with the staff. I have had patients telling triage staff that their kids are well and then admitted to me that actually their child has been coughing for days. Others can be downright anti-social. One doctor close to me told me of a patient from Guangdong who deliberately coughed into her face and the receptionist's face when asked whether he had come from a SARS-affected place. This piece of legislation would help add the weight of the law to societal disapproval of this type of obnoxious behaviour.

In normal circumstances, what a patient tells his or her doctor is confidential. However, the Bill would compel a doctor to release information about the patient's contacts, travel and illnesses to the competent authorities when the need arises, such as during this present SARS crisis. As a doctor, I see that the principle of confidentiality of information given to the doctor will, in these circumstances, need to be subject to the greater good of the majority.

Some may also hold the view that post-mortems are against their religious beliefs. However, it may be crucial to know, through a post-mortem examination, whether the deceased has shown signs that a certain disease has affected the internal organs in a specific way not seen in other conditions. This information may be crucial in a disease such as SARS, where a reliable single test has yet to be developed, as it would then decide whether or not a large group of the living is or is not at risk, and whether this group needs treatment or quarantine.

Even the process of grieving will have to be changed, as the authorities will be empowered to withhold permission for wakes for the deceased. However, we need to remind ourselves of the reasons why this is so. The body of the deceased and the personal effects may still be infectious. Persons close to the deceased may unwittingly be harbouring the disease in its early stages. While this may not be applicable to SARS, there may be diseases where even well-looking people could be transmitting the disease. The law must therefore make the necessary provisions for this.

I would urge though, that when an individual has to be jailed because he or she is in breach of the provisions of this Bill, he or she should still have to continue to have access to appropriate medical attention, and that the other inmates of the facility or prison be protected from the hazards of this disease.

I would also urge that when the law is implemented on the ground, medical practitioners can be given practical assistance to help refer uncooperative members of the public to the proper authorities for appropriate actions. It is unlikely that medical workers would knowingly contravene the provisions of this amendment Bill. It would be helpful if the law were to assist them in this regard. As a doctor in a restructured hospital, I know my colleagues and I face the daily stress of SARS. Our patient load is down but the stress load is much higher.

This Bill will help us to breathe a little easier. On behalf of my other healthcare workers, I would like to thank Members of this House and members of the public for their many expressions of support. These gestures are much appreciated.

On that note, Sir, I support the proposed legislation.

Mr Speaker: I now call upon Dr Ng Eng Hen to address the House via video.

The Minister of State for Education and Manpower (Dr Ng Eng Hen): Mr Speaker and Members of Central Command Singapore, this is the SARS combat unit reporting. It is the 43th day of battle since the SARS enemy entered our territory. I have been embedded in the flanking private hospital division this past week. They have seen some skirmishes but they have managed to beat back the enemy. The private hospital division remains intact.

Sir, this enemy is not to be underestimated. We should fear and respect it. The SARS enemy uses a cunning strategy. It attaches bombs onto our people. These bombs are invisible. We do not have any test to detect these bombs. They cause a fever which triggers explosions that send even more bombs that attach themselves to people around them and infect them. This sequence is repeated. Sir, the enemy uses our own people to multiply itself.

So, to prevent further spread, we have had to restrict movement and change social customs. We tell people where to go when they are sick and we do not even allow visitors to visit them when they are in hospital. We quarantine people in their homes, close schools, close businesses. We even deny some a proper funeral. We do not like doing these things but we do them to protect Singaporeans and protect our livelihoods. It is a difficult time for all of us.

We have not seen such an enemy since the 1950s when we closed schools because of the polio epidemic. This national crisis is unprecedented. Our people have become fearful. Some fear everything. They fear other people, taxis, buses, vegetables, banks, hawker centres, shopping malls. This fear paralyses all of us and is even a greater threat than the SARS bombs.

But, Sir, I have some good news. The Group commander, Lim Hng Kiang, has not been `shocked and awed'. Instead, he and his generals have launched a counter-offensive swiftly and decisively. His battalions - Alexandra Hospital, Changi General Hospital, SGH, NUH, KKH, Tan Tock Seng Hospital - have been magnificent. They have managed to isolate and contain 84% of the enemy into our hospitals and 12% into houses. Only 4% escaped their ring-fencing. Other foreign armies have noticed our efforts. One of them gave us the ultimate compliment. He said, "If Singapore cannot contain this enemy, no one else can."

Once isolated, these bombs on our people have to be disarmed and disposed. The Tan Tock Seng Hospital battalion is our main bomb disposal unit. They have specially trained personnel to disarm bombs. They wear protective gear when they do this, otherwise they themselves risk getting wounded or killed. The Tan Tock Seng Hospital battalion has done well and, for the last four weeks, no explosions have occurred and no one has been infected by SARS bombs in Tan Tock Seng Hospital. It is not humanly possible for them to keep this perfect record. And indeed, one of their troops, a doctor, may have been infected last week. But after these minor breakthroughs, they are on renewed alert and have tightened their protection. They have been able to save 92% of our Singaporeans who have been infected.

But, Sir, as I have said, the enemy is cunning. SARS can disguise its bombs and many have triggered these bombs while handling it unknowingly and unprotected. The other battalions at SGH, KKH, NUH, Changi General Hospital were affected this way. Half of those wounded have been these healthcare workers. Some have died. But we are getting more careful and have learnt from our mistakes. They are fighting to eliminate pockets of resistance and we can be proud of them.

Sir, you asked how it is that Tan Tock Seng Hospital has managed not to have any explosions. To find out, I went to see their bomb disposal unit. I stepped into their ICU last Sunday. This is the place where bombs are likely to go off, if handled wrongly. Why did I go? Well, Sub-Commander Khaw and I needed to see how they do it so that we could assure other troops that it could be done. And their officer, Lim Suet Wun, told us it is safe. He and his other officers walk around Tan Tock Seng Hospital routinely every day.

Do not worry, Sir, I did not touch or trigger any bombs, but we wore protective gear anyway. The staff at the Tan Tock Seng Hospital are expert and professional. They do their work with a measured calm and routine. My heart swelled with pride when I saw how they worked. They are confident with their own protection and go home to their families after work for comfort and support. Some civilians though are less understanding. Initially, they shunned these Tan Tock Seng Hospital workers and some chased them out of their homes. But recently, they have given their full support to our healthcare worker (HCW) troops. The nation is rallying, Sir.

Sir, you asked if our troops in the hospital understand the importance of their mission. Without a doubt. They know the consequences of failure. They are aware that this is a defining moment for the medical community. If they allow the SARS enemy into the community, more bombs will go off and lives will be lost and our livelihoods will suffer. Hotels and restaurants will remain empty. Taxis will wait for hours for passengers. Markets, schools and public areas will be deserted. Tourists will not come back. Other nations will shun Singaporeans. The nation depends on them. They know this well.

Sir, you asked about morale. It is steady. But something has happened that will sabotage the efforts and destroy the morale and we will lose this war. Singaporeans who know they have bombs on them are not going to the right bomb disposal unit. Worse still, they do not warn the doctors that they have bombs on them. Singaporeans lie or withhold information of contact or travel to SARS-affected regions. They go to Guangdong and do not tell the doctors. They have contacts with family and friends with suspected SARS and this information is not told. So our troops did not isolate these people and touch them unprotected. In some cases, the bombs went off and the doctors and those around them were wounded and infected. Some with bombs are frightened and stayed at home, until they are very sick. Even then they refused to go to Tan Tock Seng Hospital and instead go to other Accident & Emergency Units. They collapsed but healthcare workers do not know that they have SARS bombs on them. Many procedures are performed on them by our unprotected troops and more bombs go off. Still others, with exploding bombs, are told to stay put, but they walked right into public and crowded places.

Sir, our healthcare workers are pleading to Singaporeans. They say: we are willing to risk our lives to disarm you, but please give us a chance to protect ourselves and others around you. Let us know that you have been in contact with SARS patients or have travelled to affected places. If you have SARS bomb, go to the Tan Tock Seng Hospital to be disarmed. The SARS combat units are prepared to fight the enemy but, Singaporeans, please do not shoot and kill your own troops.

Sir, our healthcare workers are willing to lay down their lives to protect and heal Singaporeans. Some, like Dr Ong and Dr Chao, have died. I knew Dr Chao who was a few years younger than I was. He has often been described as the son of the late-famous Professor Chao. He himself was a likeable and very talented character. He had his MBBS in 1989 and FRCS four years later. I remember my recollections of him. I had taken a holiday in Sydney with my family and there he was with his father, as usual, looking for good food. Both of them were burly characters. They have what the French called joie de vivre - joy of living. When I entered political office, I thought of Alex as a suitable candidate perhaps to introduce to the party. He could sing very well, was entertaining, extremely likeable, talented and bright. But in 1999 he was doing his vascular fellowship in Sydney. We will never know whether Alex could have contributed more to society. He sacrificed his life to protect our nation, caring for SARS patients.

Sir, we should not let the sacrifices be in vain. Singaporeans must be truthful and responsible. We can overcome this enemy. Even if Singaporeans choose to lie, our healthcare workers would still pledge to protect you. This is their sacred duty and they will do it even if it costs them their lives.

Sir, you asked what the next battle plan is. We must continue to isolate and contain these SARS bombs in hospitals. Then the rest of Singapore can go on living and working. They need to do this to get more resources to help our troops fight this enemy. It is a costly fight but we cannot afford to lose. We stand and fight united. This Bill will help our fight. I support it.

Assoc. Prof. Low Seow Chay (Chua Chu Kang): (In Mandarin): Mr Speaker, Sir, at the moment, SARS is seriously threatening us. Due to the fear and reaction to this threat, our economy and even our social lives are affected. In order that life could go back to normal, we must control the spread of SARS.

Theoretically, if every Singaporean assumes his own responsibility, for example, everyone who has been to a SARS-affected area or in contact with suspected SARS patients should isolate himself, and everyone who shows symptoms of SARS infection should go to the hospital for examination and treatment, then we will be able to contain the spread of SARS. But, in reality, the matter is not that simple. We have a pastor who visited his church member to pray for her but ended up getting infected himself and succumbed to the disease. We have also an affected person who simply refused to accept the fact that he had been affected with SARS, and went doctor-hopping, thereby causing the entire neighbourhood to be shut down, and a lot of people inconvenienced. We have also the founder of an education centre, presumably one who is well-educated, who recently returned from Guangzhou, a declared SARS-affected area (he had fever in Guangzhou) but refused to be examined and even escaped from the hospital where he was isolated for observation. If we have in our midst more of such ignorant and irresponsible persons, then our efforts to contain SARS would be made much more difficult.

Apart from mobilising all our people to be on the alert and to expose the irresponsible ones in the community, we should also have good legislation to severely punish and physically force those who choose not to comply with the isolation orders. The introduction of this Amendment Bill is most timely, and I support it. However, I would like to make a few observations.

First, how do we deal with any person who may have been infected with SARS, refused to go and see a doctor, but preferred to stay at home by taking some Chinese medicine and herbs, and hoping that he will be cured? In the process, his family members, and even his neighbours, would get into trouble. The proposed amendment to section 4(10) of the principal Act seeks to require any medical practitioner to obtain from his patient, who is suspected to be a case or carrier or contact, such information relating to his contact with any infected persons, and to transmit such information to the relevant authority. But how extensive is the coverage of the term "medical practitioner"? As we know, there are people who prefer to seek alternative treatment for their illness. Some go to Chinese physicians, while others may go to acupuncturists, and even foot reflexologists instead of western doctors for treatment. If we talk about healthcare providers, then I think we should also include all these people - the Chinese physicians, acupuncturists and foot reflexologists. In this way, the coverage is more comprehensive. The identity of any suspected case will be picked up and sent to Tan Tock Seng Hospital much earlier.

The proposed new section 14 of the Bill deals with the funerals of the deceased SARS patients. We read about this person who died on 14th April, and it was not ascertained whether or not she died of SARS. There was a wake for three nights and, as a result, many friends and relatives of the family are now worried that they may have been infected. So this was something that should have been contained. Yet, it was only on 24th April, some 10 days after her death, that she was confirmed to have died of SARS. Can the Minister please enlighten us how such an event could be prevented from occurring again under the amended law?

There is also this new section 17(5) of the Bill which says that any person who, without reasonable excuse, contravenes an order under subsection (3) shall be guilty of an offence. I think this is misleading. It would appear that anyone who violates the order could get away with it so long as he can come out with a reasonable excuse. This will surely lead to some unnecessary trouble. In my opinion, the phrase "without reasonable excuse" should be deleted.

Bearing in mind that the first three index cases actually caught the virus when they were on a shopping holiday in Hong Kong, we should require anyone who has gone overseas on official duty or otherwise to conscientiously check his temperature for at least three days upon his return to Singapore to see whether or not he has been infected. If he has visited a SARS-affected area or country, then he would need to impose self-quarantine for 10 days. Nowadays, many organisations are making arrangements to this effect. Some Government departments and statutory boards are sectionalising their offices so that, if anyone is infected, only the section in which he works will be quarantined.

I think in Singapore we should send a very clear and precise signal to our people. If you go to a SARS-affected country or area, then you have this responsibility to impose self-isolation for 10 days. If this had been done earlier, the three primary index cases would not have infected so many people and the consequential effects on our economy and social lives would have been minimised.

I think the Ministry of Health should make it very clear to all the people that if anyone is to visit a foreign country, he would have to check his temperature at least twice a day for three days upon his return to Singapore. If he has been to any of the SARS-affected areas, then he will have to impose self-isolation for 10 days, upon his return to Singapore. I think this will be very effective in preventing this disease from being brought into Singapore.

I support the Bill.

Mr Ahmad Khalis Bin Abdul Ghani (Hong Kah): Mr Speaker, Sir, I speak in support of the Bill whose main thrust is to strengthen enforcement measures to curb the spread of infectious diseases such as SARS. Current enforcement provisions need to be enhanced so that the spread of diseases such as SARS can be contained more effectively. I also appreciate the compelling reasons why the Government sought to have this Bill passed urgently. These points had been raised by speakers before me. Sir, while I agree with the general intent of the Bill, I wish to raise a certain concern. It relates in particular to clause 5 of the Bill as regards the proposed section 14. This point was touched by Dr Warren Lee and Assoc. Prof. Low before me. Section 14(1) as proposed, provides, amongst others, that the Director be empowered to prohibit the wake of a person who was a case or contact of SARS.

Sir, funeral rites and wakes are serious events. They are important to the majority of, if not all, Singaporeans. They are of great religious and personal significance. The need for this particular amendment must be explained properly. The people have to be made to understand why it may be necessary for the Director to make such prohibition orders in certain circumstances, and what these circumstances are must also be explained clearly. Otherwise, this clause may appear to be an affront to religious beliefs or social norms dearly held by many Singaporeans. Without adequate explanation, a prohibition order under this proposed section is likely to stigmatise the SARS victim and his family. This only adds to the stress and trauma suffered by family members of the deceased victim, in addition to their bereavement. The possibility of a prohibition order may even act as a disincentive for a SARS case, carrier or contact, or his family members from owning up and being examined for SARS as they fear being deprived of proper funeral rites in the event of death.

In addition, Sir, such an order would cause consternation to religious groups who may feel that their religious beliefs are not sufficiently respected by the State. In the premises, there is merit to make provisions to ensure that the Director does two things prior to issuing the prohibition order. Firstly, the Director should consult the relevant religious authority for views and advice. Secondly, the Director should also counsel the immediate family members of the deceased.

I believe, Sir, that the measures proposed would go in some way to make the otherwise harsh but necessary measures more humane, more acceptable, and thus more readily supported.

Ms Irene Ng Phek Hoong (Tampines): Mr Speaker, Sir, the measures proposed in the Bill are harsh but necessary.

I commend the Health Ministry for all its good work in trying to contain the spread of SARS, and plugging all the holes so that we can be kept safe from SARS.

Sir, we need to go all out to break the chain of infection in Singapore. What one individual does, if he is exposed to SARS, or what he does not do, can affect the entire nation. We cannot risk the spread of SARS into the wider community, especially given the fact that Singapore is such a small and compact place.

It is a good sign that Singaporeans are flowing back into the streets, going out to restaurants and cinemas. I took my parents to watch a movie last weekend. We went to the Cineplex in town and found that the 7.30 pm and 9.30 pm shows were almost sold out by 7.00 pm. None of the people thronging the Cineplex or the shopping complex was wearing a mask. This is all a sign of confidence that we are on top of the situation. We must build on this confidence. But people will only feel safe going out and carrying on with their lives if they are sure that those who are sick, those who might have SARS, are at home and not going out. If they believe that it is easy for those who are on Home Quarantine Orders to break it and roam about, then their level of confidence will be shaken. We cannot allow that to happen. We cannot allow fear to rule our lives.

That said, it is important that we do not treat those on HQOs like criminals. They did not ask to be exposed to the SARS virus, and it is a frightening time for them. Their fear is real, as they have been exposed to SARS suspects. They deserve our understanding and compassion. Although regular checks are made on them, they must be treated humanely. The Health Ministry should explain to them very clearly the reasons for the HQO and why it is necessary that they obey it and stay at home. Many of those served with HQOs so far are the older people and the lower-educated. They may need more help to understand the need for the HQO. They should not be made to feel like criminals - until they break the HQO.

Can I ask the Minister what is being done to make sure that those on HQOs have easy access to food and other daily necessities that they need to purchase? We also need to address the fears of their neighbours. Some residents know that their neighbours are on HQOs and they do not know how to react to it. Often, they react to it with fear. I know of some residents who have moved away to stay with their relatives in other parts of the island just to escape living in the same block of those who have been served with HQOs. Can I ask the Minister what is being done to allay the concerns and fears of residents who are living next to those served with HQOs?

Sir, we must also stop the rumours flying about on the spread of SARS. Almost daily, there are SMS-es and e-mails spreading rumours of SARS infecting a certain department store, a certain school, a certain supermarket or, a certain person. Such rumours fan the fears of people and they complicate our efforts to get people to live their lives as normally as possible. People hearing the rumours can over-react and they avoid the places.

Unlike some other countries, Singapore's Government has been very open and transparent with the new cases and the spread of the infection. This should minimise rumours. The public should also be able to verify rumours by calling up the SARS hotline. But, Sir, those who persist in spreading rumours about SARS should be dealt with firmly by the law. They should be treated like those who are guilty of bomb hoaxes. Both spread fear by scaring the public with false alarms. The maximum fine for transmitting a hoax message in Singapore is seven years in jail and a $50,000 fine. We should send a strong message to all those who spread rumours on SARS, just as we send a strong message to those who break the HQOs: Stop it, or you will be dealt with by the law.

Finally, I believe that our battle against SARS can be turned into a positive thing. Let me explain.

First, we already see heroes emerging among us. Other than the healthcare workers at the frontline of the battle, we have also seen community leaders and volunteers working so hard at helping us to build confidence on the ground. Their work is often unnoticed, unglamorous but very important. If I may give an example of the Chairman of my constituency's Hawkers and Merchants Association, Mr Soh Peck Kiat.

His father had just died from a heart attack, and Mr Soh had not slept for the last few nights because of the funeral wake. In fact, I just went to his father's wake on Monday night, and I saw him looking very tired. His eyes were all red. And I told him, "Please don't worry about our grassroots work. Let us handle this SARS outbreak - we will take care of the need to spread the message to the residents ourselves." So I appointed somebody else to take over.

But Mr Soh shares our concern about containing SARS and insisted, even though he is in deep mourning, even though he has hardly slept, on coming down at 6.00 in the morning to help us take the temperatures of the hawkers and to spread the message to the people who are patronising the market and the hawkers of the need to contain SARS. I could see his unwavering commitment to safeguarding the well-being of our residents.

Sir, we would not have been able to build the confidence on the ground so effectively without the selfless and untiring work of such grassroots volunteers.

At this point, I would also like to salute the members of the Ministerial Combat Unit, whom we have heard from, who have worked so hard to contain SARS from spreading within the hospitals. I think they have done a good job, and we wish them well. Their work is also not without risk. Sir, we need the help of every citizen to combat SARS. It is not only the job of the Government.

There is another positive aspect to the SARS outbreak, and it is this. The threat of terrorism has not vanished. One reason why bombs have not gone off in Singapore is because we have made ourselves a very hard target. So they had gone off and bombed Bali instead. But we have been quite worried about biological weapons falling into the hands of terrorists. Indeed, this is one reason why we supported the war against Iraq. I think, after terrorists see how Singapore has reacted so swiftly to counter SARS and in such a united manner, they will think twice about using biological weapons to attack Singapore. It is just not worth their while.

We have shown the world that, together, we can overcome any crisis that comes our way. Even if a lunatic decides to use biological weapons in Singapore, Singaporeans are well prepared for it, thanks to their experience with SARS. We have put in place a series of measures and a whole slew of laws to deal with it. We are psychologically prepared to deal with any outbreak.

This Bill is one step towards making sure that we are prepared for any eventualities. Hence, I give my full support to it.

Dr Jennifer Lee (Nominated Member): Sir, SARS has been with us for some six weeks since mid-March. I do not think that we would claim to know all that there is about the virus - far from it. But we have been learning painfully but quickly, and the enemy is now no longer so unknown to us. We have the experience of TTSH which has been leading the vanguard of our troops in this battle. We know what we need to do to beat the bug.

I am not surprised that our healthcare workers have responded without hesitation to the situation, their own fears notwithstanding. All our days and all our hours are now focused on SARS-related needs and issues. Not just our frontline healthcare workers, but our staff who are usually in the backroom have been mobilised and trained to help with screening and triaging and contact tracing, and all of them have responded to take on these new and additional duties.

The first challenge was coming to a realisation of this new enemy in our midst. Next, coming to an understanding of what it takes to deal with it. For a while, we hesitated, still trying to balance tough measures and restrictions with concerns about convenience and compassion for our patients and their visiting families. I think we are well past this now, recognising what is necessary for the greater good.

Now that we have put a high level of precautions and protective measures in place in our hospitals, we must work hard and relentlessly on getting out of old habits and old practices and being constantly on high alert, constantly remembering all the small but important things that we should do and must do and cannot do as we look after our patients, never letting our guard drop. This is very hard to do, but we must try our best.

We will beat this bug. But the path ahead will be uneven and we will not get to our destination overnight. In our hospitals in the coming weeks, we will have good days free of news of new infection, and bad days when the frailty of human nature results in a breach in our precautions and consequent minor setbacks. So long as these are minor and isolated setbacks, we will still be in reasonable shape. Our biggest challenge now is not the immediate mobilisation to the highest level of alert. It will be the ability to sustain these efforts beyond the immediate into the mid-term, beyond next week into next month.

This is what is constantly on my mind these days, even as I am nagging, hassling and encouraging my people, as we are ramping up our measures how to sustain this extraordinary effort for the longer term. To help ease the burden on our hospitals and healthcare workers and to simplify our tasks, we need the public's support and cooperation to accept these inconveniences and restrictions.

I am confident that we will beat this bug. But to do so, we need to work together with the understanding and cooperation of the public and, where necessary, with the backing of the force of the law. The proposed amendments to the Infectious Diseases Act will give Government the muscle and the tools to do this.

Sir, I support the Bill.

Mr Low Thia Khiang (Hougang): Mr Speaker, Sir, the Government has rightly placed the highest priority in containing the spread of SARS. It would have been preferred if there was no need to resort to punishment and social responsibility was enough. But it is disturbing that some have chosen to breach the quarantine orders. Those who may be tempted to breach such orders must be deterred from doing so before the problem balloons out of control.

I am of the view that quick and effective measures are indeed appropriate under such a crisis situation. Singapore is already suffering painful consequences from SARS, not just in terms of healthcare challenges but also economically. This is a time where every Singaporean should rally behind the Government in its effort to fight SARS.

I support the Bill and urge the Government to spare no effort in ensuring that Singaporeans are protected until a vaccine is found.

Mr Lim Hng Kiang: Mr Speaker, Sir, first, I would like to thank all Members for their very strong support of the amendments in the Bill. I think, in the same spirit shown by Mr Low Thia Khiang, I would also be short in my response.

I just want to make a few key points and summarise what many Members have said.

First of all, I think we all agree that tough measures are necessary. Without these tough measures, we cannot win this war. Second, we must all be united. This is not a fight by the healthcare workers alone. This is not a fight by the Government alone. This is a fight by all Singaporeans. Third, if we want Singaporeans to join us in this fight, we must educate them. We must tell them the facts and they must be convinced that this is their fight. Otherwise, they will not join us in the trenches. So public education is very important and we will take in all the suggestions that Members have made and we will improve our public education. Fourth, we must be mentally prepared for the long haul. As Dr Jennifer Lee says, there will be ups and downs, there will be small victories, there will be some setbacks, but we must prepare ourselves. This is going to be for the long haul. We must look for sustainable strategies and we must look for sustainable efforts. At the end, we will overcome. Because we all know that too much is at stake and we must all unite to make sure we overcome this crisis.

These, I think, are the key points made by most Members. I would not go into the detailed responses to all the various issues raised. I will get my staff to send the responses to Members individually. I think that is more efficient. But I just want to cover a few areas which are of public concern. First, the Quarantine Orders. I have explained yesterday the need for the Home Quarantine Orders and why it is so important, our strategy to isolate people who have contact with suspect SARS, or probable SARS cases, keep them in their home and then isolate them so as to prevent the spread.

I think it is worth reiterating that the people who are placed on Home Quarantine Orders are generally well. They are not yet sick. They are not yet infectious. We must educate them and we must keep in constant touch so that the moment they are infectious, the moment they are unwell, we will pull them out to Tan Tock Seng Hospital to be screened, to be kept under observation and to be isolated. That is a sensible balance, instead of quarantining everybody, because sometimes we all want to be extra kiasu. But we must also be careful that if we become too kiasu, the whole society will be paralysed. So we need to strike a balance.

Sir, there were some suggestions about a quarantine island. That is not necessary because these are not people with leprosy that you need to put them in a quarantine island. They are not sick. They are well. And if they work with us, there is no reason why they cannot stay in their home. They will not infect their family members if they follow the precautions that we tell them - they keep in constant communication with us and they come forward to Tan Tock Seng for screening, observation and treatment, if they indeed come down with SARS.

The second area which I want to address is the suggestion of a fever station or fever centre, put forward by Dr Tan Cheng Bock and Mr Steve Chia. I have responded that this is a suggestion worth considering. But I must say that it cannot be something that is run by our polyclinics or hospitals. Because, quite realistically, our polyclinics today only provide 20% of the market share for primary care and we have only 12 to

15 MOs in each polyclinic and they look after chronic care as well as acute care. If we run such a fever centre, then I would need to call upon the private sector GPs to volunteer and to come forward and serve, because the private sector caters for 80% of the market share and having fever and acute care is very much the daily kind of cases which they see. But the Government will work with them and provide the facilities, space and support. But for the doctors and nurses, we would like to see how we can work with the private sector so that they can come forward and serve.

The other area which I thought is worth my while to go through in some detail is the provision that we are putting in for post-mortem, for extra precautions in the disposal of the deceased and in the prohibition of the wake. This is a dilemma facing the medical professionals and the Ministry. We have cases where a person does not go through the whole progression of the disease. If a person comes to us and starts off with being suspected of SARS, the chest X-ray shows, and he becomes a probable SARS case, he goes to ICU and if he dies, then it is a clear-cut case that this is a SARS case. Then all the measures would be taken. But, unfortunately, at this stage when we do not have a diagnostic method that can give us quick and reliable results, we have quite a number of cases that fall in the grey area. People who come to us very, very sick with no contact history, or little contact history, the doctors have to make a judgement whether in fact this is a SARS case or not.

Just to illustrate the example of the lady who died in one of the cases in the Pasir Panjang Wholesale Centre. The lady from the family of eight is the grandmother. She fell ill, she remained at home and she died at home. The family had a wake. Then the family went to see the GP on Saturday and the funeral service was on Sunday. During the period when she died and the period by which we can confirm that, through our diagnostic method, she was tested positive through the PCR test, and that took us six or seven days. What do we do during these six or seven days? This is why we need this amendment in the Bill to cater for such situations. In that case, we had no reason to believe that she was a suspect SARS case because the cluster of the Pasir Panjang Wholesale Centre cases only appeared on Saturday. By which time, the family had already had the wake and the funeral service was on the next day.

So with this amendment to the Act, if we are faced with such cases, or if we think that there is a high suspicion that the death could be due to SARS, then of course we can get the family to cooperate with us, with the backing of the law, to treat it like a SARS case, in which case the body would be double bagged and put in a casket, sealed with silicone and cremated immediately within 24 hours. And that is safe for the family and safe for the community.

Some Members asked why so many bags and you cannot see the face. We understand the stress to the family. But this is something that we hope everybody will bear with us. In such a situation, the risk is not just to the people handling the body and the immediate family, the risk is also to the visitors who come to the wake. Because the visitors who come to the wake did not know that the family could be infected and they are putting themselves at risk. If the family does not inform them, people who come to the wake out of goodwill and friendship could inadvertently be infected. So I think Singaporeans need to work out a new social norm or social behaviour. That is the reason why I met with a group of religious leaders to find ways in which we can still respect the dead and the wishes of the family, but still find a sensible way to organise the wake. One suggestion offered by a religious group was that the family can have a small funeral service limited to just the family members, and all friends and well wishers can then attend a memorial service later on. This particular religious group has suggested 21 (3x7) days later, which is way beyond the incubation period and therefore it would be clear whether or not the family is infected.

I thought that is a sensible way to reorganise, or readjust, our lives knowing that SARS is with us. On this issue of disposal of the body and prohibition of wake, I would like to assure Members that we will take in all the comments and we will handle this very sensitively. But, at the back of our mind, public health is paramount and we will always err on the conservative side. But in doing so, we will make sure that we are sensitive to the needs of the family and their religious beliefs.

Sir, these are the key points I would like to emphasise. I am sorry I cannot go through all the details. We will deal with Members' suggestions individually.

Dr Lily Neo: Could I seek clarification on the statement made by Dr Balaji earlier on public hospital doctors who have recovered from SARS taking throat swabs for patients suffering from SARS? May I ask the Minister whether we may have the same disease pattern, as reported in Hong Kong, that they had been resistant cases to previous treatment in Hong Kong suggesting maybe a new mutated virus? Do we have the same problem in Singapore and should we be cautious, rather than presuming that all our recovered healthcare workers are now immune with antibodies to the same virus? Before we go to the Third Reading, could the Minister just clarify on section 21A(1) and (2) on the word "contact" and the other one on "having the care"?

Mr Lim Hng Kiang: I am sure Dr Balaji did not intend to give the wrong impression. When these recovered doctors go back to serve and work, they will be fully protected. If they do procedures, they will be hooded and they will have all the protection. But I think they volunteer for this job because, theoretically, they should have higher immunity than somebody who has not. So it is a recognition of their sense of service that between two doctors, the one who has recovered probably or theoretically should have higher immunity than somebody who has not gone through the disease. All said and done, they would be fully protected and they would do it with due care.

As to whether we are seeing a mutated form, there are still a lot of e-mails running around among all the various laboratories and various centres. I do not think the issue has been settled. The coronavirus is known to have this habit of mutating. But, at the same time, many laboratories find that the samples which they have been using are fairly stable. If indeed we have a virus that mutates so rapidly, then that would be a setback to us. Because your diagnostic test methods would also have to change in keeping with the mutation. So far, the laboratories around the world are working on these samples. I think our main task now is to get the reliability of these samples and get a high turnaround rate first. This issue of mutation has not been proven one way or the other. So we have to keep an open mind.

On the definition of the two points, we have to make an assessment. A "contact" means somebody that has close enough contact that can cause the infection to take place. So in the Pasir Panjang Wholesale Centre's case, our contact tracing teams could not make an assessment. And that is the reason we were forced to close the whole centre down. But if Singaporeans and companies can work out a system in which contacts or interactions are recorded or limited, then whenever we encounter a case, we do not have to shut the whole company or system down. We will just look for the group that has close contact with the affected people.

The other definition is about the person "having the care". According to AG's Chambers, what they meant is any person who is responsible for the care of others, and this largely refers to parents and guardians. It will not refer to other caregivers, doctors or other categories.

Dr Lily Neo: Could I have the Minister's clarification again that Tan Tock Seng Hospital's medical staff are not meant to be the contact of the disease under section 21A(1), because it says anybody that has "contact of a disease". This is because, if we follow it closely, then Tan Tock Seng Hospital staff are in the definition. Could I have a clarification?

Mr Lim Hng Kiang: The Member is right. It is not intended to cover the Tan Tock Seng Hospital staff or any other hospital staff.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. - [Mr Lim Hng Kiang].

Bill considered in Committee; reported without amendment; read a Third time and passed.