Which of these two options would a rational person choose?
1. Live normally but die an early death, or
2. Live longer, but starting tomorrow, life becomes a living hell for the rest of your (longer) years.
I would be extremely surprised if anyone can claim to be rational and still pick #2. Yet our Health Ministry, by their impenetrable logic, expects people to choose the second.
As I mentioned in the essay Horny straight guys’ choices,
Health Minister Khaw Boon Wan’s chief message at the [Aids] conference was to do more to promote early testing. “Our current challenge remains early identification of those who are infected,” he said in his keynote speech. “More than half of our new cases are diagnosed when their infection has reached an advanced stage.”
It was also revealed by his ministry that 80 percent of hospital patients opted out of HIV testing when offered this upon admission. Of the 20 percent who agreed to be tested, 50 individuals were found to be HIV-positive. How many of the untested were also HIV-positive is anyone’s guess. There is no doubt that there is a significant pool of asymptomatic, undetected HIV infections in the population.
Yet, doing so is contraindicated by the consequences should the result turn out positive (and confirmed by additional tests), for then:
1. You are mandatorily reported to the ministry once you seek treatment locally;
2. You may be put on medication that costs up to S$1,000 – S$2,000 a month;
3. Even if you have lots of money in your Medisave account, you can use only $550 per month from it;
4. You are almost certain to lose your job if your employer finds out;
5. You cannot travel to work or study in some countries which bar HIV-positive persons from long-stay visas;
6. Your family and friends may avoid you;
7. You may suffer depression;
8. You may never have sex again because by law you have to inform all future sexual partners that you are HIV-positive even if you have every intention to use a condom.
Who is going to freely choose this life? Yet our Health Ministry does not see it, and keeps bleating about the need to get tested. That bleating almost sounds like a diversionary tactic to hide the fact that they are doing very little in terms of practical, meaningful measures to mitigate the above-named consequences. Let’s look more closely at two areas: Money and law.
The government refuses to subsidise the cost of medication. Singapore is one of the few countries in the world that take this hardline position. Many countries, not as wealthy as Singapore, with sovereign wealth funds not as bulging as ours, do so out of a sense of moral responsibility to their citizens. But not this government, which only a few days ago saw the prime minister boasting that our “social safety net is working well” and that the government will keep finding ways to improve it (Straits Times, 3 Dec 2020, Govt to keep boosting social safety net: PM)
In Singapore, healthcare payments have three tiers.
1. Medisave — a compulsory saving scheme deducted from a person’s salary. Although it is technically one’s own money, there are all sorts of rules regarding withdrawals from one’s personal Medisave account. As mentioned above, there’s a spending limit of S$550 a month buying HIV medication.
2. Medishield — a nationwide health insurance scheme, but it is useless for HIV needs, because the terms specifically exclude HIV-related treatments. However, please pay your premiums on time.
3. Medifund — government-endowed money meant to help the neediest by way of grants.
It was only in February this year, after many years of lobbying by activists, that the government finally agreed to help patients via Medifund. A press release from the ministry said:
From 1 February 2010, the Ministry of Health (MOH) will extend Medifund assistance to needy Singaporeans who require HIV treatment, including medications. MOH will inject $8.5 mil of Medifund to the hospitals to support this extension.
This decision is in response to feedback from some VWOs and doctors treating HIV patients, that some of these patients would require additional financial assistance to cover their treatment.
The Medifund assistance will be subject to means-testing and proven financial needs.
— Ministry of Health, 15 January 2010, Press release.
By October, 1,500 people had climbed on board, which is about half of the 3,000+ persons living with HIV/Aids in Singapore. That sounds encouraging, except that there are a few not so well-known facts:
1. To pass means-testing , you have to show not only that you are totally broke — no more money in the bank — but so are other members of your immediate family. This accords with the government’s ideology that the family must be the first line of support. Don’t bother approaching Medifund for help until your parents and siblings are broke too. As Paul Ananth Tambyah said at the Aids Conference, “you have to sell your house, your car and your children” before you qualify for Medifund.
2. The grant is only for six months.
Yes, 1,500 people have been helped, but it also means that 1,500 extended families had been reduced to penury before that. Perhaps the government was moved to help when faced with the prospect of 7,500 desperate suicides.
Some readers may recall another piece of “good news” just a week ago.
The price of drugs that can help prolong the lives of HIV-positive patients has been slashed by about two-thirds at one clinic – thanks to Medifund.
Associate Professor Leo Yee Sin, clinical director of the Communicable Disease Centre (CDC), said it has led to a far larger number of patients buying the drugs from the CDC. This has allowed the centre – which treats 70 per cent of Singapore’s HIV sufferers – to negotiate lower prices from its suppliers.
‘This price reduction…is able to cut the price by at least threefold. It’s a very significant reduction,’ she said, adding it could pave the way for cheaper HIV drugs at the other public hospitals.
The antiretroviral drug treatment Combivir, which used to cost $629 a month in the middle of this year, now sells for $161 at the CDC. Stavudine, which used to cost $434 a month, now costs $68.
Patients used to pay $900 to $1,500 for a cocktail of drugs, but now pay between $200 and $600.
— Straits Times, 30 Nov 2010, HIV patients can now pay less for drugs
Did you notice the wonderful piece of propagandistic writing in the very first sentence: “slashed by about two-thirds at one clinic — thanks to Medifund”?
Firstly, I’m not sure what Medifund has to do with it, because the rest of the article says the clinic selling these cheaper drugs is the Communicable Disease Centre (CDC). Might it be that the newspaper got it wrong? Secondly, I have since found out that the price reduction was not due to any astute negotiations by a government buyer, but simply because the patents of these older drugs have run out, and prices are falling anyway!
But hey, no reason not to pile on the praise for our “caring” government!
Older drugs doesn’t mean they are less effective, as Roy Chan, President of Action for Aids, told me. These drugs are proven, their side effects are known and they constitute an effective first line of treatment.
But what about those who need stronger drugs? Pay the full price, no subsidies available.
Admittedly, whether subsidising medication or giving out Medifund grants, both can be costly to the state. However, as I noted in the lemon-yellow sidebar above, so are cancer drugs and we have no hesitation subsidising them.
Possibly the fear of institutionalising a “subsidy mentality” is what stops the government from helping out with the cost of HIV medication. But what is the effect? People avoid testing because they know the cost of medication is ruinous. But since they avoid testing, their HIV-infection remains unmanaged (because undiscovered), which means they fall very sick within a few years. Then when they get diagnosed, they are hit with huge bills (including lengthy hospitalisation). The family goes broke and the state has to step in with financial aid anyway.
If the state offers to subsidise medication, people will be more willing to test early, their infection is managed, they stay productive and employable for the rest of their lives. Society continues benefit from their economic contributions and the state from their taxes. It sounds to me like the far more sensible policy even if we want to be hardheaded about it (i.e. excluding compassion from policy-making). Yet we are currently doing the exact opposite.
One more thing to bear in mind: Even when an HIV-positive person’s health and infection is successfully managed, stigma and ignorance are so widespread that most employers will get rid of a worker as soon as they discover he or she is HIV-positive. Knowing this, other countries have instituted anti-discrimination laws that make it illegal for an employer to fire an employee just because of HIV-status. Why does Singapore not do the same?
In a nutshell
The call to people to get themselves tested early is so obviously contraindicated by other discouragements, it is mind-boggling that the government does not see the contradictions. Is the government so stupid they cannot see them? Have they no understanding of how human rationality operates? Or do they not want to see it, instead trying to pin the blame for the spread of HIV onto private choices (avoiding test), absolving themselves of responsibility for counter-productive public policy (disincentivising early testing)?
Don’t get me wrong — I will affirm that it is good to know one’s HIV status and I would encourage early testing. But what I am saying here is that the government is doing everything to discourage people from doing the right thing.