Seeing a tiger when it’s just a cat

One of the few good things the late Balaji Sadasivan implemented when Minister of State for Health, was universal ante-natal screening for HIV, allowing for early intervention. From four cases of mother-to-child transmission in 2004, it was brought down to zero in 2008 and 2009. However, two more cases popped up in 2010.

It is truly tragic for anyone to be born with an infection as serious as HIV.

One of the films at the 24th Singapore International Film Festival touches on this. Living with the Tiger (Thursday, 22 Sept 2011, 9:30 pm, Lido cinema) follows two children at Baan Gerda, a small community in Thailand that cares for about 80 children affected by HIV.

Director Mike Thomas says of his involvement in making this film:

. . .  came about through an opportunistic visit to Baan Gerda, the orphanage featured in the film. I hadn’t planned on getting involved and I don’t have a background in HIV or filmmaking. I was very moved by the plight of the kids and angered that they could be abandoned by society. I first offered to help design a website and do some fundraising, and then about a year later I started filming.

It would stretch over three years. He first filmed Bruce Gaston as the latter started teaching music to the children of Baan Gerda in early 2007, but soon the idea of getting the children to perform an opera took shape. Children from other schools and organisations were invited to participate, demonstrating not only their abilities but their integration with non-infected children.

The feature-length story is principally told through the eyes of two of the children over that period, Oy, aged 13, and Bla, 16, both of whom had leading roles in the opera. Both too had been abandoned by their families.

After his parents died from Aids, Oy lived with his uncle and aunt for about 4 or 5 years. When he began to develop a skin rash the local school refused to teach him. The villagers stopped going to the family shop, fearful that they would catch the disease. Unable to care for him and ostracised by the community, the uncle and aunt sent Oy away to a hospice to die.

Bla too lost both his parents at an early age; after which the extended family rejected him. He has memories of his parents, but also of the stigma he faced after their deaths. In the film, he describes the loneliness he felt and the realisation that his uncle didn’t want him around.

However, in the course of the film, Oy and Bla each had an opportunity to be reunited with their extended families, making journeys back to their hometowns. But would they really be accepted?

So, while the film explores how music can benefit people’s lives, it is even more about issues which are important to everyone: identity, family and belonging. Along the way, it highlights the problems that HIV sufferers around the world have to deal with, and how society continues to shun those who are infected due to a lack of understanding.

Thomas (right) says of his personal journey, stumbling into filmmaking:

Sometimes you embark on a project without really knowing what is involved.

The experience of making the film and spending so much time with the children has had a big impact on myself and the other members of the team. It’s hard to imagine a worse scenario than being born with a life-threatening disease, losing both of your parents and then being rejected by society. Their spirit and zest for life is a lesson to all of us. They deserve a better future from a society that doesn’t judge them.

* * * * *

I began by saying that Balaji did something right. But in virtually all other ways, Singapore’s efforts have been uncoordinated and largely ineffective. The number of new cases has risen every year, except for a slight dip 2010 over 2009. Many countries, less developed and with fewer resources (e.g. Cambodia, Thailand and Uganda), have managed to reverse trends dramatically, but we have not.

Our overarching strategy is hard to discern. You may think that the Ministry of Health is concerned about reducing the incidence of HIV, but what they actually do (plus the lack of results) does not convince you that that is the aim, their policies being so misdirected. Inescapably, one wonders if there is another underlying agenda. For sure, the people in charge will protest that reducing HIV is indeed their aim, but then it is also possible that they may earnestly believe so and be completely unaware of their own subconscious motivations.

It’s like this: As far as I can see, the main thrusts have been to exhort people, preacher-style, to abstain from sex, and for those in at-risk populations, to get tested.

And that’s about as far as policy programs go.

What if people do not abstain? What if people do not get tested? What about addressing the reasons why people don’t want to get tested? What if people get tested and find out that they are HIV-positive?

You may find it hard to believe, but for all practical purposes, we don’t have meaningful policies to address these questions. There is no Plan B. It’s as if the entire ministry has this huge mental block that stops them from thinking beyond “abstain” and “get tested”. Naturally, we wonder, why this mental block? If one is really interested in combatting HIV, one would pursue these issues and design effective responses. That we do not suggests, as I said above, some other agenda at work.

For example: What if people do not abstain? The solution should be obvious: Promote condom use. Yet, this is a no-no. The government refuses to promote condom use. The police has been known to actively interfere if private citizens do so on their own initiative. The Pope will be pleased.

What if people get tested and find out that they are HIV-positive? The solution should be affordable treatment. Yet, the government refuses to do anything meaningful in this regard. Singapore continues to refuse to subsidise HIV medication. All they have done is to open an access route to grants from Medifund, but there are so many conditions (one of which is that the patient’s extended family must all be penniless) and the grants are limited in duration, that this “help” is much less than it appears.

Lately, a Facebook posting by Workers’ Party member of parliament Yaw Shin Leong made the rounds. He pointed out something he recently learned:

. . . a delegate from Nepal during the conference quipped that ‘For a HIV+ patient, Singapore is one of the worst countries to live in’. Shawn explained that, the reason behind the observation is because, once diagnosed with HIV in Singapore, there would be lots of emotional & financial fear and unknowns for both the patients and society at large.

[snip]

Shawn noted that the hefty price tag of patented HIV drugs and the relative limitations of using [Central Provident Fund] monies to purchase HIV drugs (usage of CPF monies for the purchase of generic drugs are not permissible). As such patients’ options will be severely limited.

He shared that if cheaper and generic HIV drugs are made available, it will certainly encourage individuals with HIV to seek earlier access to medication/ treatment (early usage). Shawn shared that according to studies this will lower the transmission of ‘viral-load’.

The last sentence doesn’t read right, with the terms a bit mixed up. Effective treatment indeed reduces the viral load in the bloodstream of an HIV-positive person to such an extent that even with sex, the transmissibility is much reduced. So not only is the HIV-positive person no threat to others in everyday situations — which he is even without effective treatment — even as a sex partner, the likelihood of transmission is much reduced, with effective treatment.

What this means is that effective treatment does not only benefit him as a patient, it benefits the entire society because transmission of the virus is interrupted. Spread is curtailed. It thus makes sense, from a public health point of view, to subsidise HIV medication. As Yaw said:

This is because suspected HIV individuals, who know about the affordability of the medications are not likely to delay the seeking of screening, treatment and medication. Hence knowing that one is infected, and on HIV medication early on, will likely and indirectly reduce the unknown transmission of the HIV virus.

And yet, the government refuses to subsidise.

See it from the person’s perspective: Getting tested and finding out that one is HIV-positive is thus the gateway to financial ruin. On top of that, there is social stigma. Here again, the government has done nothing to educate the population that there should be no discrimination against HIV-positive persons; that they are not a threat to the community.

So, is it any wonder, if testing is the shortcut to financial and social death, people would not want to test? Won’t the average person try to put off facing that Hobson’s Choice as long as possible? Exhorting people to get tested is meaningless without addressing questions of cost and discrimination.

It’s as if our government and, to be frank, many Singaporeans, insist on seeing a tiger, working ourselves up to be fearful, justifying all sorts of panicky responses, when in front of us, is a cat. The situation is manageable, yet by terrorising ourselves, making the wrong responses, we create a bigger problem.

Go watch the film. See, reflected in the mirror of Thai communities, the same unfounded fear and prejudice that is so pervasive in Singapore. But see too, through these HIV-positive children, a zest for life and a deep desire to belong and be loved.

25 Responses to “Seeing a tiger when it’s just a cat”


  1. 1 Chow 15 September 2011 at 19:19

    I have heard that many go overseas (to Thailand for example) to seek testing and treatment. This was, and probably still is, because at one point we did not have anonymous testing, rapid-test kits and also because they were only available at the CDC. I think many still probably hop over to Thailand to buy generic anti-HIV drugs because they are cheaper. At any rate I sometimes can’t help but wonder that it’s a mixture of conservatism, the need to always report black entries in the ledger, and the strong urge to sweep things under the carpet to maintain the myth that Singapore is LaLaland.

  2. 2 Anonymous 15 September 2011 at 22:36

    Promoting safe sex is illegal in Singapore – that is pretty stupid.

  3. 3 Rabbit 15 September 2011 at 23:31

    @Chow

    There are clinics in Singapore that conduct anonymous HIV screening and I think AFA is one of them. Unfortunately, Singapore Govt will not even try to prolong or protect its own people life if they are found to be infected with HIV virus.

    Ironically, if one day our data showed a reduced in HIV infection in our population, we need to thank anonymous testing center and our neighbouring countries for doing a good job in saving Singaporeans with cheap generic anti_HIV drugs. These group of people and their family owe their life to the foreign government who gave us hope to live. At this point, I am not proud to say our government did nothing to save and prevent more life losses in this respect. Bluntly put, we live in a hopeless country with no cure – literally speaking.

    • 4 Chow 17 September 2011 at 20:17

      Yes, but I think that it was only of late that clinics could offer anonymous testing. Prior to that I think one had no option but to take a regular blood test or else to go to CDC? I might be mistaken about the anonymous testing at the CDC but I’m pretty sure that it was only of late that certain clinics could offer anonymous testing. But at any rate my point was that it drives it underground. I have no good explanation why they are slow in getting HIV drugs on the subsidized list. I can only imagine that it is due to an (un)happy combination of what I have mentioned earlier.

  4. 5 Poker Player 16 September 2011 at 00:01

    “The government refuses to promote condom use. ”

    How on earth does a country where Catholics and Muslims together are a minority end up with this problem? It says more about Singaporean non-Catholics and non-Muslims than about Singaporean Catholics and Muslims.

    • 6 religion 22 September 2011 at 01:19

      Oi! Don’t throw the ‘religion’ spanner into the works! I am not a Catholic nor a Muslim. What are you trying to jibe? Trying to stir up ‘religious’ unhappiness?

  5. 7 ET 16 September 2011 at 02:35

    From the way you describe them, the medical/financial policies around HIV in Singapore sound, at best, like reckless endangerment of life.

    There is always the suspicion, though, when it comes to Singapore, that there are certain zealous, supposedly religious people with influence who see HIV (and indeed other illnesses such as cancer) as a sort of punishment by a vengeful god, believe that people should suffer the consequences of their own actions, and who seem in the case of HIV to want them to suffer the maximum possible, because, (shock, horror) it is usually sexually transmitted, and therefore particularly dirty and sinful.

    If it turns out that the policy (as described) is a deliberately debilitating one because of influence by such people, then it is more than just reckless, it is absolutely immoral and tantamount to genocide. This is what happens in some fundamentalist Christian African countries, though there generally only gay people are deliberately deprived of HIV medicines and education.

    • 8 Leuk75 18 September 2011 at 22:01

      ET, I share the same suspicion. There is this obsession with sex being a dirty thing and that HIV sufferers “deserved it” cos they get it mainly from sex or dirty needles.

      Well if that is true, then diabetes sufferers “deserve” it for bad eating habits, not exercising enough, overweight etc and should be punished by losing the eyesight and getting the legs amputated. Like we keep telling people to abstain, stay faithful, then we should tell everyone to stop eating sweets, ban all fried food etc.

      By the way, estimated that Singapore has 8-10% of people diagnosed as having diabetes. See which is more of a problem. For that matter, might as well make insulins non subsidisable. Wonder what is the ministry’s standpoint on deciding what should be considered life saving and hence subsidised.

  6. 9 wikigam 16 September 2011 at 09:16

    1) Based on moh 2010 HIV/ADIS statistics, S/N :4 “In 2010, more than half (54%) of the new cases already had late-stage HIV infection when they were diagnosed. This was similar to the pattern in previous years”

    why the rate is so high as 54% ? Is singapore the 1st world medication country ?

    Just make a call to CDC to make an appointment to see doctor for HIV consultant ! the waiting time is same as make an apointment in polyclinic to see a dentist.

    http://www.moh.gov.sg/mohcorp/uploadedFiles/Statistics/Update%20on%202010%20HIV%20figures.pdf

    • 10 yawningbread 16 September 2011 at 09:31

      Exactly – that 54 percent were late-stage cases only proves that the call for testing is not working. People get to a clinic only when symptoms appear. Why is the call for testing not working? I explained it in the article. Wouldn’t failure have called for a policy change? Yet there is none.

      • 11 Robox 20 September 2011 at 02:04

        I wonder if the HIV education-related reason for this phenomenon could be due to HIV infection still being thought of as a death sentence. Thus those who had engaged in unsafe sex might actually test late because they fear finding out the truth about their HIV status and the feared impending death.

        If so, then this is my own bit for public service.

        1. HIV is not a death sentence; today it is treated as the chronic disease that it is.

        2. Testing regularly while one is healthy is highly recommended. Should the worst fears come true and one tests positive for HIV, medication at the correct time – which might not be right away, can mean that your life span is restored to normanl.

        I propose that HIV education incorporate this into their efforts.

  7. 12 np 16 September 2011 at 09:27

    bit more background about how baan gerda started…google for ‘wat prabat namphu’ & ‘paul yves wery’.

  8. 13 Thor 16 September 2011 at 10:28

    What you spoke about reminded me of an article I read in TRE or TOC who was diagnosed with terminal illness who stopped all treatment as he did not want to wipeout the medisave of his relatives. There seems to be a deliberate moral judgement with attendant consequences. Unwed mother, divorced family, AIDS patient – society does not approve and you will receive no help. Ultimately, I keep asking myself, does this government really care for it’s citizens?

    • 14 Vane 16 September 2011 at 20:08

      I thought its was rather obvious when you see the government asking so much of its citizen yet when their pay comes to scrutiny they become really defensive about it.

    • 15 Robox 20 September 2011 at 01:56

      @Thor:

      “Unwed mother, divorced family, AIDS patient – society does not approve and you will receive no help.”

      I thought the examples you cited were very interesting in that they all reveal a common thread: those who betray “family values” – a project that has its origins in the US Christian Right – are denied proper access to the health care they need.

      I wonder if this might be called “family values medicine”. Or Christian medicine.

      • 16 religion 22 September 2011 at 01:33

        I think there is NO NEED to try to stir up shit when there is no shit to start with. Don’t try to link up THOR’s comments to such far-right religious groups. What do you mean by “they REVEAL a common thread”? Was there anything hidden in the first place?

  9. 17 wikigam 16 September 2011 at 15:54

    1) Bloomberg BusinessWeek March 4 , 2010 reported :

    “….Francoise Barre-Sinoussi, winner of the 2008 Nobel Prize in Medicine for her co-discovery of the virus that causes AIDS, criticised Singapore for the lack of free treatment of HIV, saying this added to the stigma and burden of being HIV positive, and very likely drives the disease further underground.

    http://www.fridae.asia/newsfeatures/2010/03/05/9712.singapores-hiv-aids-treatment-dilemma-multi-pronged-strategy-needed

  10. 18 wikigam 16 September 2011 at 16:01

    How ironic – as Singapore promotes itself as a medical tourism hub, at the same time it’s sending patients to its neighbours to get affordable medication. Why Singapore Govt cannot ? , or don’t want to take care of thier own citizens ?

    • 19 Chow 17 September 2011 at 20:20

      Uhhh, well being cynical I will say that the difference between those two is that as a medical tourist hub you make profits whereas universal healthcare is generally a drain on the budget.

  11. 20 Teck Soon 16 September 2011 at 20:34

    Malaysians who are diagnosed with HIV get free medication. They also just abolished their ISA. Our neighbours move ahead; Singapore lags behind.

  12. 21 the little K 19 September 2011 at 08:59

    I know of a young guy who still goes around having unprotected sex (and not telling people about this status) even after he was diagnosed positive. It’s really up to the individual. No matter how much support or help the people around them (or government) wants to provide, it boils down to the individual. This guy I know got it from very irresponsible behaviour, and he’s not going to change, no matter how much people warn him or tell him about it. Even if it’s a criminal offense, he’ll take no heed until he gets himself into trouble. For this group of irresponsible personals, do they really deserve any help?

    • 22 yawningbread 19 September 2011 at 23:23

      This approach you have adopted in your argument is one that is commonly used to stop further consideration of a programme meant to help those in need. Basically, the tactic is (1) to focus on ONE anecdotal example of a person in need being highly irresponsible and undeserving, then (2) implicitly tar everybody else in the same vulnerable population with the same brush, and (3) voila, sympathy vanishes for the entire group.

      The same tactic is used by conservatives to argue against unemployment support (“I know someone who used the cash to buy liquor and get drunk!”), help for single mothers (“I know one who went to buy drugs for herself instead of milk for her baby!”), or subsidised hospital care (“This woman stayed 65 days and refused to be discharged because the hospital was more comfortable than her home!”).

      Even in your own example, so one guy is irresponsible and goes on to infect, say, 85 girls. Are we going to deny the 85 a sensible HIV policy and affordable treatment, based on one anecdotal case?

    • 23 Robox 20 September 2011 at 01:51

      @the little K:

      Do those who are HIV negative also have an obligation to ensure that they have protected sex? What were they doing having unprotected sex? Had they never heard of HIV?

  13. 24 wikigam 21 September 2011 at 11:17

    “….why cancer patients in prison have full access to drugs and is free of charge but not HIV inmates….”

    http://www.facebook.com/note.php?note_id=10150365455099343

    1) Is It “Equality” or “In-Equality ” was written on our pledge / law ?

  14. 25 wikigam 26 September 2011 at 13:49

    1) with refer to the statistics ” Total number of HIV infections and ADIS death between 1986 to 2008 malaysia”

    ..Malaysia as an example that permitting the usage of generic HIV drugs as first line medical treatment had yielded a downward trend on HIV statistics over the years, whereas Singapore is currently on the upward trend…

    http://theonlinecitizen.com/2011/09/using-generic-drugs-to-fight-hiv/

    2)As refer to below link ,the Chart shows the United States from 1987 to 2002 the number of deaths among AIDS patients, including 1995, due to the advent of HAART and mortality rates began to decline.

    3) Why singapore still stay in the ” upward trend’ ? is it immoral authority set up the “MDP” policy to the HIV infected person ? if not , why HIV inmate have in-equality treament ? Who should responsibility on this ? MHA/ SPS /CDC / MOH /PAP ?


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