Fridae Statement in Response to Dr Balaji Sadasivan’s Speech on HIV
Fridae.com,
November 13, 2004
http://fridae.com/newsfeatures/article.php?articleid=1345&viewarticle=1
By Dr Stuart Koe
Fridae responds to the Singapore Health Minister’s
speech on article that advocated a “promiscuous and reckless lifestyle,”
AfA’s role in AIDS education, and gay men and HIV in Singapore. In a speech
by Dr Balaji Sadasivan, Senior Minister of State for Health on 10 November
2004 titled “The AIDS Epidemic in Singapore” (Transcript: http://app.sprinter.gov.sg/data/pr/2004111090.htm
[reproduced at the bottom of
his article. -Bob]), it was highlighted that there is an emerging epidemic
amongst MSMs (men who have sex with men) in Singapore.
Fridae’s has strong working relationships with the
region’s AIDS NGOs, including Action for AIDS, Malaysian AIDS Council, and
the Hong Kong AIDS Concern. Safe sex ads like the one above are also hosted
free of charge on the site. Dr Balaji’s concern over the sharp increase of
HIV infection amongst MSM is ironic. Even though MSMs have always represented
a high-risk group, Singapore’s public health service has systematically
ignored and left MSMs out of all their public health messages. Focusing
instead on abstinence and monogamy, the Ministry has rarely advocated the use
of condoms, and never once addressed MSMs directly since its first education
program against HIV/AIDS in 1985.
It should thus come as no surprise that this marginalised
demographic now finds itself at increased risk for HIV as a result of this
gross negligence. That it has taken 20 years for MSMs to finally gain the
attention of our public health service is a clear indication of the
institutionalised homophobia that MSMs face.
Dr Balaji singled out Action for AIDS, an NGO dedicated
to fighting AIDS, for criticism, citing that it was “not doing enough.” In
fact, it is probably a direct result of AfA’s unceasing efforts that MSM
transmission rates have been kept relatively low for the last 20 years. Yet,
an AfA operated booth at the Nation party in August this year was asked to
shut down by the local police jurisdiction who thought that giving out safer
sex brochures and condoms was promoting gay sex. In another incident earlier
this year, AfA was also stopped from circulating its new range of safer sex
postcards by the Advertising Standards Authority of Singapore which objected
to any reference to oral and anal sex on the grounds that such acts were
illegal.
Therein lies the conundrum: Since gay sex is illegal, how
then, can any agency or organisation in Singapore promote safe sex amongst
MSMs without being complicit in abetting illegal activity? Do these structural
mechanisms restrict our Ministry of Health and organisations such as AfA from
fulfilling their public health obligations? How is the MSM community expected
to mobilise itself to combat AIDS in the face of such blatant discrimination?
In his speech, Dr Balaji made reference to a website,
Fridae.com, where he came across an article that he felt was advocating a
“promiscuous and reckless lifestyle.” As CEO of Fridae, I would urge for
this article to be considered in a larger context.
Fridae.com is the region’s largest gay and lesbian web
portal. As a trusted information source to a quarter million readers every
month, we recognise the important role we play in the fight against AIDS.
Fridae’s articles are a mix of serious, fact-based features and news, as
well as light hearted, lifestyle entertainment pieces, not unlike what may be
found in numerous mainstream publications. It is easy to distinguish between
the two. We strongly believe that acknowledging a healthy sexual lifestyle is
important in getting our readers to relate to our public health messages,
which in turn has the highest chance of success in encouraging safe sex
behaviours. It is clear that continuing a simplistic message of abstinence or
faithfulness to one’s spouse (which has no relevance to many in the MSM
community) has extremely limited efficacy.
Fridae’s commitment to AIDS work began with the
company’s inception in 2001, with strong working relationships with the
region’s AIDS NGOs, including Action for AIDS, Malaysian AIDS Council, and
the Hong Kong AIDS Concern. Not only have we been active in fundraising and
implementing AIDS prevention strategies, we have also taken the initiative to
mass produce and distribute at close to cost, our own “Combat AIDS”
condoms. We make sure that safe sex messages are prominent in all our
communications with our members, and are instrumental in research that helps
us understand our local epidemiology. This is only one of many instances where
private monies are being used to fund what ought to be a public health
initiative. Yet, we believe that the grassroots has to mobilise and take
action even if public policy lags behind.
Perhaps Dr Balaji’s speech signals a newfound
willingness for the MOH to address and engage the MSM community. There needs
to be greater communication between the public sector with the grassroots to
understand the nature of the epidemic in Singapore, and formulate strategies
that take into account the unique needs of the MSM community. If the MOH is
serious about avoiding a public health crisis, as it should be, then it ought
to engage the community directly, not through a proxy such as the CDC, which
has more of a clinical, rather than preventive role. Fridae is prepared to
make available the significant resources at our disposal to the Ministry to
promote its public health messages, and hope that the government sees this as
a valuable and important opportunity for outreach to this high risk, yet
difficult to reach community.
We have to continue to develop targeted, effective,
sustained prevention efforts that build community capacity to deliver ongoing,
lifelong prevention programming for those at risk and those already infected.
The only way to start this process is to first put aside our prejudices, and
strive towards an open and honest dialog between all the stakeholders. For
these public health efforts to be effective in the MSM community, the
authorities have to first agree to work WITH the MSM community. The
consequences of not doing so will be a continued disconnect between the two
parties, and a potentially dire impact on the rates of HIV transmission in
Singapore.
Speech By Dr Balaji Sadasivan,Senior Minister Of State
For Information, Communications And The Arts And Health, At The 6th Ttsh
Oration At The Tan Tock Seng Hospital Doctors’ Night 2004, 10 November 2004,
7.00 Pm At Raffles Town Club, Dunearn Ballroom
I am honored to be here to address you. Tan Tock Seng
Hospital is probably Singapore’s most famous and most respected hospital in
the world. This is an achievement that you have earned for yourselves. All
eyes were on you during SARS. You proved to the world that SARS could be
managed in a hospital without spread to Health Care Workers. And in the
process Tan Tock Seng Hospital became the standard against which other
hospitals in Singapore and around the world compared themselves with. You have
much to be proud of and I am proud to be here. Some of you know that I spent
many years learning, training and working in Tan Tock Seng Hospital. I left a
bit of my heart in the hospital and I carry a bit of TTSH in my heart; And so
although I had no direct part in your achievements, nevertheless, I share your
pride in what you did last year.
2 Tan Tock Seng Hospital did not always have this pride
in itself. When the hospital was being rebuilt, there was talk about changing
the name of the hospital to a more English sounding name. I for one did not
like that idea. Tan Tock Seng, our benefactor, to me represents the best of
our Singapore heritage. Tan Tock Seng was a Singapore success story. Coming to
Singapore to sell fresh produce and chickens to ships in the newly established
British trading post, he was Singapore’s first rags to riches story. A story
of the rewards of hard work and enterprise – a story still relevant today.
3 In the 19th century, the rich were taken care of at
their homes by physicians. The poor and discarded, yes, there were discarded
people. Sailors who fell ill were discarded at the port and left to fend for
themselves. The poor and discarded sick had no where to go. Tan Tock Seng in a
philanthropic act paid for a building to house and care for these persons.
This is probably Singapore’s first major act of philanthropy – a gesture
still relevant today. Today, Singapore has become rich and prosperous but
there are still a few who have difficulty keeping up. We as a society must
have the same generosity as Tan Tock Seng to help the poor and ensure that no
one is left behind as Singapore moves forward.
4 Tan Tock Seng built the hospital for people of all
races. This gesture resonates with our pledge to be one united people
regardless of race, language or religion. At a time when slavery was the norm
in a large part of America, and Englishmen made a name for themselves as slave
traders and drug peddlers, Tan Tock Seng had a humanistic vision far ahead of
his time.
5 Medical people are sometimes myopic and do not see the
greatness in achievements that are non-medical. Hence, the suggestion to
change the name of the hospital. But now, the name Tan Tock Seng will forever
be associated with medical excellence when last year, you showed that you are
equal or better than the best in the world. But last year is history and you
have new challenges to meet. But if the only way to judge the future is by
looking at the past, I am confident you will measure up to the new challenges.
6 I am here to tell you what you already know and have
heard, but sometimes it has to be said again and again. Rene Laennec, the
Regius Professor of Medicine in France during the Napoleonic era said “do
not fear to repeat what has already been said. Men need the truth dinned into
their ears many times and from all sides. The first rumor makes them prick up
their ears, the second registers and the third enters.” And so I have
decided to repeat a message that you have heard before:
7 We are facing an alarming AIDS epidemic in Singapore.
This should not surprise us since much of the world faces the same crisis. In
2003, an estimated 4.8 million people became newly infected with HIV. This is
more than in any one year before. Today some 38 million people are living with
HIV which killed 2.9 million in 2003. Over 20 million have died since the
first case of AIDS was identified in 1981, which is less than 25 years ago.
The epidemic remains extremely dynamic. We are a global city and Singaporeans
travel around the world. When global efforts to control AIDS have failed
dismally, we should not be surprised that we now face the same problem that
the world has been grappling with. In Asia, the HIV infection remains largely
concentrated in MSM, and sex workers and their clients. This is the case in
Singapore too.
8 For those hearing the term MSM for the first time, let
me explain what it means. It does not mean Minister’s Staff Meeting although
that is also called MSM. MSM is now the politically correct term in AIDS
circles to mean gays or homosexuals. It stands for Men having Sex with Men.
Even the UN Secretary General, Mr. Kofi Anan uses this term. Personally, I
find the term a bit graphic and prefer gay which at least has a happy
connotation associated with it.
9 Most Singaporeans often read about AIDS in other
countries. They may come across reports that in Sub-Saharan counties like
Swaziland and Botswana, more than one-third of pregnant women delivering are
HIV positive, or that there are about 5 million HIV cases in India, or that
there will be 10 million infected cases in China by 2010. The Aids problem in
Singapore is not as dramatic as these reports but nevertheless just as
dangerous because it has quietly crept into our society over the last two
decades without much fanfare.
10 Most doctors are only peripherally involved in the
management of AIDS and follow its development as spectators. I remember that
as a young Medical Officer at Tan Tock Seng Hospital in 1981, I first read
about the new disease that was affecting young healthy homosexuals in
California. The following year, the term “AIDS” was coined. In 1985, just
before I left for the United States, the first case was reported in Singapore.
The rate of new cases diagnosed that year was 0.8 new cases per million
population. When I returned in 1990, there were about 17 cases reported that
year, giving a rate of 6 new cases per million population. Doctors were afraid
of treating AIDS patients. I remember a young gay singer with AIDS who had a
brain lesion which did not respond to treatment. He was referred for a brain
Biopsy. We could not do the operation at Tan Tock Seng Hospital and so we did
the case at CDC. I believe it was the first neurosurgery case done at CDC. I
remember another AIDS patient, who developed paraplegia. Investigations were
normal and we could not explain his paralysis. When he died, we got a consent
to do a limited autopsy to discover the cause of his paralysis. However, the
pathologists were reluctant to do the autopsy. After speaking to the late Prof
Chao Tzee Cheng and getting his permission, I did the autopsy at CDC. The
spinal cord showed inflammation from vacuolating myelitis. I think it was the
first AIDS autopsy at CDC.
11 I left Tan Tock Seng Hospital at the end of 1993. The
number of new cases that year was 64 giving a rate of 22 new cases per million
population. When I returned to public service as Minister of State in the
Ministry of Health in 2001, the number of new cases that year was 237 giving a
rate of 71 new cases per million population. This year CDC expects the number
of new cases to exceed 300 which will give a rate of about 100 new cases per
million population. The number of new cases diagnosed appears to double every
3 to 4 years. At this rate of increase, we can expect more than a thousand new
cases to be diagnosed in the year 2010. What is more, this is only the tip of
the iceberg. According to WHO, there are about four thousand people in
Singapore with HIV. We have only diagnosed less than half of them. If we do
not act, by 2010, we may have more than 15,000 HIV persons in Singapore. Then,
sometime in the next decade, Tan Tock Seng may very well become the AIDS
hospital. There is a difference between AIDS and SARS. SARS hit you without
warning. With AIDS, you can foresee the crisis. CDC is part of TTSH. If all of
you put your minds together, you can come up with the solutions needed to stop
this epidemic, in the same way that you conquered and stopped the spread of
SARS.
12 We are fortunate that at the present time, the
explosion in HIV infection is occurring in two distinct groups of men. HIV has
not entered the mainstream population in a big way. The two groups are MSM
i.e. the gays, and heterosexual men having casual sex in other countries.
13 Of the two, the gays are the bigger concern. CDC
briefed me on the AIDS situation in Singapore. CDC believes that there is a
real explosion of the disease among gays. CDC doctors told me that the gays
are themselves concerned by the increase in AIDS among gays. Last year, there
were 54 gays who were diagnoses with AIDS. By October, this year, 77 cases
have been diagnosed. There has been a high incidence of sero-conversion among
gays diagnosed this year. This indicates that the infections are recent. This
recent explosion of cases is due to the promiscuous and unsafe lifestyle
advocated and practiced by some gays. Men who have sex with men are at
extremely high risk because of the variety of their sexual practices, the
large number of sexual partners with whom they engage with in these sexual
practices, and the high percentage of homosexual men who are already HIV-
positive.
14 Recently “Her World” had a feature story with a
title that went “I slept with a hundred men and one of them could be your
husband.” It was a story of a gay who had sex with a hundred men, some of
whom were married men. I asked doctors who are involved in contact tracing if
this type of reckless promiscuous behavior occurs and they said “Yes”.
This means our AIDS prevention message is not getting through to the gay
population.
15 Action for Aids is a Non Governmental Organization or
NGO that does AIDS prevention education in Singapore. CDC has left much of the
gay community education effort to this NGO. I went into their web site to see
how educational it was. In Capital letters, there was the statement “NOT
EVERYONE WHO HAS SEX CONTACT WITH AN INFECTED PERSON WILL GET INFECTED.” The
statement is true but the statement misleads and promotes the spread of the
infection by giving assurance when alarm would be more appropriate. The proper
statement should be “YOU HAVE A HIGH CHANCE OF GETTING AIDS IF YOU HAVE
UNPROTECTED SEX WITH AN INFECTED PERSON”. Without clear messaging, we may
actually make things worse by promoting unsafe sex.
16 I next went into www.fridae.com. It was started by a
Singaporean and there was some hype about this site in the media. I was
shocked by what I read. A “sexpert” called Alvin Tan, I presume
“sexpert” means a sex expert, was advocating a promiscuous and reckless
lifestyle. In an interview with the Far Eastern Economic Review, the CEO of
the web-site said “Change at the grass roots is outpacing change at the
policy level. But things are moving in the right direction.” However from a
public health perspective, the lifestyle advocated in the website which is a
life-style of reckless regard to sexual health and safety is dangerous. Those
who follow such a lifestyle will run the risk of getting AIDS. There were also
many advertisements for saunas. Why so many saunas? We are not Russians or
Finns.
17 Randy Shilts, a gay journalist wrote a book called
“And the band played on”. He eventually died of AIDS. As a journalist, he
covered San Francisco during the early days of AIDS and he describes the
events in San Francisco in his book. San Francisco had many bath-houses where
rampant reckless sexual activity occurred despite the danger of AIDS. This was
one reason why so many in San Francisco died of AIDS. He was attacked by many
in the gay community in the US for his honest and accurate description of the
promiscuous behavior of some gays which was a contributing factor to the AIDS
epidemic in the US. In response to the AIDS epidemic, the San Francisco Health
Department eventually banned bathhouses in the city, a health measure that
helped stem the epidemic in San Francisco. CDC must ensure that saunas in
Singapore do not become San Francisco style bath-houses.
18 Recently, Taipei police raided an all male party and
tested 27 people arrested at the party. Fifteen or 55% of them tested
positive. We do not know how high the incidence of HIV is in our gay
population. If we do not have champions to spread the anti-AIDS message among
the gay, a high percentage of them will get infected and many will eventually
die. Action for Aids needs to review its messaging so that it is simple, it is
effective and it promotes safety. CDC should look for more community partners
in its fight against AIDS.
The second group who are HIV positive are males who have
casual sex outside Singapore. Fortunately, 70% do not have a Singaporean
spouse. Many are poorly educated. Spreading the prevention message to them is
difficult. Perhaps a different approach will be needed. If CDC can screen high
risk Singaporeans at our borders when they return, we may be able to protect
Singapore women from catching AIDS from these men.
19 When I visited CDC, I wanted to give them a
hypothetical case to ponder on. You may have read about the German who knew he
had HIV but nevertheless went to Thailand and infected hundreds of women. He
refused to give consent to the Thais to test him. The Thais deported him. We
do not know who this German is. I wanted to ask CDC, what they would do if
this German came to Singapore.
Before I gave them the question, they gave me a
hypothetical case which they wanted me to ponder over. I want to share this
hypothetical case with you, so that you may all sleep over the problem too. A
30 year old Singapore man develops HIV. He decides to go to another country
and gets himself a bride who he brings back to Singapore and marries. He does
not tell her he has HIV. She now becomes positive. What should we do?
20 The fight against AIDS is not going to be easy. Many
will oppose public health measures like contact tracing and compulsory testing
arguing that the right of the individual over-rides the safety of society. In
the end, we must convince these people that public health measures protect
everyone and it is better to have living people complaining about their rights
than dead people buried with their last rights. Everyone has a role to play in
this battle. As healthcare workers, you can mobilize the public and public
opinion in support of CDC and the measures it may recommend in this fight.
Then we will make progress. Progress in this battle will be the sum of small
victories won by each of you.
Thank you.
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