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15 Sep 2006

HIV and stigma in singapore - part 2

Stigma greatly compromises the effectiveness of any HIV prevention work anywhere. In the second of his essay, Dr Tan Chong Kee looks at successful examples of pragmatic public health policies worldwide and what Singapore - both the government and the people - can do. Part 2 of 2.

Read part 1 here.

What is the rest of the world doing about it?
There are simply too many examples of pragmatic public health policies and successful intervention from all over the world. I will quote only a selected few here:

Developed by the Australian Federation of AIDS Organisations (AFAO) in 1998, the above poster was part of a wider campaign designed to increase the visibility of HIV positive Asian gay men, to raise awareness of HIV+ gay Asian men's needs in the gay and lesbian community, the positive community and the broader Asian community and to challenge discriminatory attitudes within these communities.
In Australia: there was close collaboration between state and community-based organisations with "early participation, at all levels of decision making, of the community most affected, the gay community The AIDS Action Committee in Sydney, with majority gay membership, formed in response to the quickly political nature of the AIDS issue. The was to be the nucleus of the AIDS Council of New South Wales." (Bloom 1993)

In Brazil: "One of the primary missions of Brazil's National STD/AIDS program (NSAP) is to make HIV medications available free of charge to all citizens who need them through the country's public health care system. This effort was initiated in the early 1990's with limited distribution of the AZT capsule, and was strengthened with a 1996 presidential decree that guaranteed that all HIV-infected citizens would have free access to essential medication to combat HIV. The distribution of protease inhibitors began between December 1996 and January 1997." (AIDS drugs policy - Ministry of Health Brazil)

In Thailand: "The National Human Rights Commission will propose a bill to provide basic human rights protection to more than 500,000 people living with HIV/AIDS. It is hoped the law will ensure fairer treatment and better understanding for people suffering from the disease which is transmitted mainly via sexual activity and drug use." (Wipatayontin 2006)

In Vietnam: Peer educators among the highly mobile construction workers in Ho Chi Minh City were empowered to help spread safe sex norms. The study found that they "were able to reach a higher proportion of the workers than the visiting health communicators; they had a lower dropout rate; and the cost per person contacted was lower than that of the visiting health communicators. Sexual values of the construction workers improved significantly in the peer educator sites only. And finally, a diffusion effect in the peer educator intervention sites occurred among workers not directly exposed to the education activities." (U.S. Agency for International Development 2003)

In Tanzania: "... teachers and health worker implemented a two-to-three-months program of AIDS-related information, small group discussions, and role-play to improve primary-school-age children's knowledge, attitude and practices. Follow-up 12 months later show that attitudes towards people living with HIV/AIDS had significantly improved" (UNAIDS 2002, Klepp et al 1997).

In Nigeria, evaluation of "HIV prevention education for high school students" showed "delayed initiation of sexual intercourse, reduced number of sex partners, and increased use of condoms." (Alford, Cheetham, Hauser 2005)
What can we do?
Both the government and the people can do many things to counter stigma in Singapore. There are three things that citizens can do immediately:

The first is for everyone to talk to your family, friends, MP and Ministers. Tell them that stigmas do exist in Singapore; that they exact huge social costs and we need to stop it. Tackle each of the stigmas concretely. For example, if you have a friend who has teenager children, talk to them about teenage sexuality, the lack of safe-sex education in school and the need for parents to fill in that gap themselves now. Talk to as many people as you can, and in turn, ask them to talk to their friends, family, MP and Ministers as well. Talking to one another is the first and most critical step towards change.

Second, civil society groups such as AWARE or AfA can continue to launch de-stigmatising campaigns even though no other PLWHA wants to come out. The experience of Asian & Pacific Islander Wellness Center in the San Francisco Bay Area shows that when people around the PLWHA "come out" about their relationships to and support of PLWHA, it is even more powerful. John Manzon-Santos, executive director of Asian & Pacific Islander Wellness Center, puts it this way:

UCLA AIDS Institute: ''Elizabeth Taylor [who co-stared with Rock Hudson in Giant, 1956, above] is recognised as the Joan of Arc of AIDS activism. It has been twenty years since Dame Elizabeth took the hand of the dying Rock Hudson - on camera, before the whole world - and, through that single, simple, humane and heroic gesture, brought the agony of AIDS into the light. She has kept the world's attention focused on the HIV pandemic ever since, by turning the public's insatiable curiosity about her into an immensely effective vehicle for her essential message - which is that the epidemic will not end until there is a cure.''
"Rock Hudson's coming out about being HIV+ brought HIV into mainstream consciousness in the U.S. But when Elizabeth Taylor rallied to his side in front of the media, she showed other Americans how to embrace their friends and loved ones who are HIV+. Even more profound for Asian Pacific Americans, when Actor Russell Wong spoke with compassion to journalists assembled in San Francisco for our First Annual National Asian & Pacific Islander HIV/AIDS Awareness Day on May 19, 2005: "my brother has been living with HIV for the last eighteen years," he modelled how family members can practice unconditional acceptance and help stop the silence and shame around HIV in Asian and Pacific Islander communities. The very creation of a high-visibility Awareness Day provided an opportunity for this family living with HIV to talk about the risks, and ultimate benefits, of such a public disclosure (personal conversation with author)."

There is no need to wait for another Paddy Chew in Singapore. We should instead focus our energy on persuading the people around our Singaporean PLWHAs to come out and help their loved ones. If it is too difficult for family members to come out, then friends, co-workers and caregivers can take the lead. If de-stigmatising PLWHA is too difficult to get pass government censors, then work first on addressing the stigmas faced by the family when one of their members is HIV+. Even if this might play into the "innocent victims" discourse, exercising care in the choice of the message can mitigate this risk.

Finally, civil society groups need to collaborate to address each of the HIV-related stigma. Women's groups like AWARE are already tackling sexism and sex phobia. Gay and lesbian groups are already tackling homophobia. Why not collaborate and address these stigmas together? New partners among healthcare professionals need to come forward and add their voice more prominently against the stigma surrounding disease and death, as well as against the other stigmas. Everyone can also address the state-imposed stigma surrounding civil society organisation. Local religious leaders have been appearing for many years at the annual vigil on World AIDS Day organised by AfA. Instead of just reciting a prayer once a year in a park, why not persuade religious leaders who believe in compassion to speak up during the other 364 days of the year about compassion towards our fellow human being? In doing this work, we need to realise that it is not just narrowly focused on HIV/AIDS, but is part of a larger process to make Singapore a better place for everyone.

There are also many things that the government can do. First, it can collaborate with local NGOs to create a non-discrimination best practices brochure. Second, it can take the lead and either mandate or encourage all ministries and government-linked companies to undergo an HIV/AIDS education that includes a de-stigmatisation component. Third, key officials such as the Prime Minister can speak and personally demonstrate non-judgmental compassion for PLWHA. Fourth, it can run or fund the running of a national de-stigmatisation campaign, or at the very least stop banning privately funded campaigns. Finally and most crucially, it can review which of the current policies are discriminatory and implement new ones.

Before concluding this essay, I want to discuss one important piece of experience gained by HIV agencies in the USA: general messages are much less effective than targeted messages in promoting safer sex. It is very important to run focus groups and personal interviews to find out the social norms that drive unsafe sex among various groups, e.g., youths, gay men, unregistered sex workers, etc. These focus groups can also give feedback on the effectiveness of public messaging that targets their communities and help design more effective messages.

Given the strength of stigmas in Singapore, people will be more willing to tell the truth if the person doing the study is from their own community. Thus, we must empower PLWHAs and collaborate with them. They can help in the studies by volunteering to lead the focus groups and conduct personal interviews.

There is no shame for the government and society to go through the stages of denial, blame, and punishment with regards to HIV/AIDS. Most other countries in the world went through similar stages. As early as 1987, Mann has already pointed out that stigma, discrimination, blame and collective denial were potentially the most difficult aspects of the HIV and AIDS epidemics to address, but also that addressing them was key to overcoming it (Mann 1987, Nyblade et al 2003). What is important now is how quickly each country recognises their own prejudices for what they are and finds the moral courage to adopt pragmatic public health policy solutions to stop the spread of this disease.

To quote a noted researcher, Prof Parker of Columbia University: "The most effective and powerful responses to the epidemic have taken place precisely when affected communities have mobilized themselves to fight back against stigmatization and oppression in relation to their lives" (Parker & Aggleton 2003, Altman 1994, Daniel & Parker 1993, Epstein1996, Parker et al 1995, Stoller 1998). For affected communities to mobilise in Singapore, there is an urgent need to tackle the state-imposed stigma against advocacy work.

Many countries in all regions of the globe have already made the transition and showing encouraging results in their fight against HIV/AIDS. The Singapore people need to decide if this is an issue that they can ignore and leave it to the government to handle, or to become empowered and do something about it themselves. The Singapore government will need to decide if it wants its public health response to HIV/AIDS to be about ideology, or about effective intervention. This is an urgent question because every day we wait and give in to irrational emotional responses disguised as high moral standards, the more we risk people dying prematurely and the virus becoming intractable.

I would like to thank my research assistants, Nurhaizatul Jamila Bt Jamil for searching and organising news articles from the local media, and Amutha Meyyappan for accessing and photocopying books and journal articles. I would also like to thank Prof Khoo Hoon Eng and Prof Roy Chan for reading and commenting on the initial drafts.

Footnotes and references for this essay can be viewed in PDF format by clicking here.

Dr Tan Chong Kee holds a Ph.D. in Chinese Literature from Stanford University in the United States and is one of Singapore's best-known figures in civil society activism.


Reader's Comments

1. 2006-09-16 09:25  
this is by the the most comprehensive article on how to tackle the problem of AIDs in Singapore. well done! i hope that singapore can learn from the examples of other countries and start similar programs..
2. 2006-09-16 10:43  
Congratulations on your work, Dr Tan.

I wish my home country, South Africa, which may have the worst per capita HIV prevalence in the world, and cannot be quoted as a result of government policies which are driven by a persistent and stubborn ignorance about HIV/AIDS, would heed your words.

Good luck to Singapore in overcoming the impediments of an ignorant and unfeeling paternalistic government control over the citizenry. Time for a little open-minded decency in government, I think.

The closet works as a tool of manipulation and control. Coming out with the support of family and friends can be so healthy, whether it is about orientation or illness.
3. 2006-09-16 14:23  
Lets face it guys, no matter how hard we fought this battle, we can never win.
4. 2006-09-16 22:36  
Sounds kinda quaint now I know BUT..."winners never quit & quitters never win" & "If at first U don't succeed try try again" also " lifes battles don't always go to the stronger or faster man, but soon or late the man who wins is the man WHO THINKS HE CAN"..living life in tepid hope is a kind of mental stagnation, I beleive that 'hope' was one of the evils released from Pandora's box, how ever BELEIVING is the word to wrap our minds around, freedom can come, cures can come, justice and liberty can come, beleive in possibilities and they will come, I have no time for the faint hearted, stregnthen your resolve & just get on with it.
5. 2006-09-17 13:25  
In fact in Singapore there is still part which need to improve, not only which above mention but as what I concern most places still very concern people who being infected by HIV.

Example for those who are working in Singapore as permit holder have to go back to their own country one they are being tested postive. Permanently they will barred from entering Singapore. This rule same goes to some of the major country. Far as i did my research only Thailand which do not require for further check up for HIV test for work permit or lenght of stay in Thai.

Most country they didn't do much subsidary of medication. In fact what I had recently found out, Malaysia in fact doing a subsudary of medication bout 50% for Malaysian. Some University provided free examination of HIV test for their Viral Load and CD4 dount. Some require payment but only small amount.

In Thailand there is Red Cross where provide all these service which give more opportunity for world to felt free doing HIV testing because full details will be provided by email and all your particular is full of confidential.

Anyway with posted this mail I do hope there is more people who are affected stay strong. Life is still wonderfull ahead of us.
Comment #6 was deleted by its author
Comment #7 was deleted by its author
Comment #8 was deleted by its author
9. 2006-09-17 19:28  
I agree that we must thank Dr Tan for his effort in this two part article. I had never come across something so frank and unbiased.

We should advocate to remove the stigma associated with HIV rather than fighting for our rights in Singapore. We will have no rights as long as HIV is still being percieved as a disease associated with Homosexuals.The mentality will never change because our government is homophobic and uses HIV as tool to curb our activities.

Bill Clinton once said in a World's AIDs conference that the first step to curbing HIV is to remove the stigma attached to the sufferers. I strongly agree to that.

Hope our community will be serious about HIV. From conversations I had with my friends about their sexual activities, our HIV statistic only shows the tip of an iceberg. The truth should manifest itself in another 5 to 10 year's time.

Our Government should shoulder the biggest blame for the HIV infections, for what they care for are votes. They are like the lalang grass, bending with respect to the direction of the wind, no backbone. They will only worry when the infection begins to affect our economy. They will definitely take drastic measures by then. Maybe the reason why they will react so late is because it will affect their hefty salary. Money makes the world go around.

On the other hand, our community should shoulder part of the blame for concentrating selfishly on their rights and not for humanity. They are to be blamed also for supporting fully the ruling party even though that the party is homophobic. One thing for sure, in the next election, five years from now, the epidemic will be worst. It may be a little too late to do something effectively. We may share the same fate as many in Africa.

God bless Singapore.
10. 2006-09-18 05:45  
The stark reality is this; the HIV storm has already started. The mechanism for a pandemic has already been put in motion.

Why do you think the government and health ministry, which is obviously homophobic, is going around big companies to launch the initiative to help organisations, familiarise, understand and seek assistance to manage a likely workforce affected by HIV? Everyone true blue Singaporean knows that the government will never do anything of this magnitude unless it knows something you don't. Eventually, dire circumstances will force the government to take offensive measures to curb deeper widespread. There's really no need to say fight on or quit, the sequence for necessary action has already begun.

Imagine, a country like Thailand can offer free HIV testing and cheap medication to everyone afflicted, including foreigners. What about so called more "progressive and richer" nations? Shame on you Singapore! What a joke!
And to think they wanna make themselves the medical hub for tourist. Please! ..take a number..you are no where even near..and rightly so too..

Look at the current hosting of the IMF/World Bank event. It is an embarassment for Singapore. The local officials cannot wait to boast of taking 5 years to prepare for this prestigious event and are steadfast in sticking to its rigid principles to impress on it security, but yet when told off by the President of the IMF that enormous damage has been done to its international reputation for the way it handled the protest activities, Singapore compromised. Hypocritical to the core.

Like I said before, what man cannot change, God will step in. This is the only way Singapore will listen. Just you wait.
11. 2006-09-18 17:50  
We, Singaporean Gays, are condemned to die of ignorance.

We are just a bunch of brainless himbos. Why do I say that ???

I have not logged in a very long time and as I scrolled through all the articles and the comments, I discovered that what gays in Singapore care for are :-

- Looks
- Gossip
- things between the legs.
- Who is top and bottom.

The article on HIV got simply a mild reaction. But articles on himbo interest get the most hits.

We sure are going to die of ignorance - HIV.
Comment #12 was deleted by its author
13. 2006-09-19 00:03  
Unfortunately, Singapore has a public policy that stigmatises PLWHA. I don't see much chance of things changing in Singapore until the government pulls it's head out of the sand
Comment #14 was deleted by its author
15. 2006-09-19 01:35  
Singaporeans may be all that on Post #8 and more, but they do not exclusively corner the market on these shallow values. It only seemed so and more cos the government makes it easier to be like that with its dictatorial policies and governance. Trust me on this, I have met far worse from countries in Asia and the Western hemisphere.

If one is truly honest and candid about the reality of the gay Asian male, one will know that many that frequent circuits and engage in orgies, are less of a kindred soul than Singaporeans. The only difference is that Singaporeans do not have the bold, originality and ruthlessness of their visiting playmates from around the globe. What himbo Singaporeans lack, they make up by copying, and poorly at that.

So as much as many things are wrong with the Singapore system and the by-product it creates, proper respect must be given to its people.
16. 2006-09-21 18:59  
Did the truth hurts? I am sure it does... Until you yourself gets the disease, then you would know the stigmas that come with it, typical of singaporean, if i dont have it , I dont care! Most plus who claim that they dont have it, or simply just lie thru their tongue are the biggest scare! They are simply afraid to go for checks and I am sure many out there have not even got their HIV status tested out yet, afraid to know the truth, afraid that one they find out, that the end of it. Some people I know, just go for STD checks, when asked about their HIV status, they lie, saying that they have taken it before.
Singaporean in general, whether its HIV, or whether how crappy the gay society can be, are living in total denial! Ever thought, fridae this is for you, people who attend your big parties in phuket have group sex, some ending up not using condoms and some I am sure get STDS from it as well, worse HIV... ever though of taking responsibilty, be it personal responsibility or others.

Yours Truly

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