In Singapore, a 1970's health law
becomes a weapon to fight SARS

  New York Times
June 11, 2003


THOUGH its tools were thoroughly modern thermal scanners, Web cameras and electronic bracelets Singapore's most potent weapon in its battle against SARS may have been a 27-year-old law originally designed to protect the island's inhabitants from old-fashioned diseases like cholera.

When the first cases of severe acute respiratory syndrome appeared in Singapore, the government dusted off its powers to impose quarantine, something it had not done since independence in 1965. Faced with several potential problems, Parliament raised the penalty for violating quarantine to as much as $5800 and six months in prison.

It then required those quarantined to appear regularly before Web cameras installed at their homes and to wear electronic bracelets if they failed to do so.

Civil libertarians condemned the measures, but experts say it was similarly intrusive legislation, public awareness campaigns and improved sanitation and medicine that helped Singapore beat a host of older diseases endemic to its tropical neighborhood, including malaria, typhoid, hepatitis and leprosy.

"In your country, individual rights always take precedent over community rights. In our country, it's the other way around," said Goh Kee Tai, chief of the communicable diseases branch at the Ministry of Health's epidemiology and disease control division.

Singapore has a siege mentality about disease, much as it does about other security issues, because it exists in a microbiologically turbulent region. A crowded port 1 degree above the equator, Singapore is an ideal habitat for pathogens. Mosquitoes can breed year-round here, and travelers bring in a steady supply of bugs new and old.

Singapore's strategy for fighting disease is modeled largely on the procedures of the Centers for Disease Control and Prevention in the United States, said Dr Goh, relying on physicians and hospitals to report diseases so that outbreaks can be pinpointed and then fenced in rings as quickly as possible. But its ability to identify and contain such outbreaks has been backed up by laws many Americans would find objectionable.

"The thing that tends to be different in Singapore is that rules imposed tend to be stricter than other places," said Dr Gurinder Shahi, a local biotech entrepreneur and former official at the International Vaccine Institute.

The results are compelling. The average life expectancy in Singapore in 1965 was 66 years, on par with Argentina. Singapore had one of the world's highest rates of tuberculosis. Malaria was widespread. Just 38 years later, Singapore's life expectancy is higher than the United States'. Singapore is so clean that public health officials worry that its citizens have low resistance to even mild outbreaks.

In 1968, Singapore gave teeth to anti-malaria efforts with a law allowing health inspectors to enter premises without a warrant to look for mosquito breeding spots. Failure to eliminate the problems can now cost violators up to $50,000 in fines and six months in jail. Under these anti-mosquito laws, the authorities can fumigate homes and can force residents to submit blood samples and be treated.

By 1982, these efforts, combined with urbanization, had wiped out most of the malaria mosquito population and the World Health Organization declared Singapore malaria-free. Travelers occasionally reintroduce the parasite, however, so authorities continue to control the population of mosquitoes. As a result, people often rush to close windows to block clouds of pesticide that rise when workers fumigate city shrubbery.

Authorities have also been given the power to intrude to fight other diseases. Because lepers tended to hide from public view, for example, a leprosy law gave officials the power to enter suspected dwellings without warning and remove the people for treatment. Leprosy was virtually eliminated by 1992, and the law was rescinded.

Spitting, believed to aid the spread of tuberculosis, has been outlawed here since British colonialists tried in vain to quell what the port's Chinese immigrants once considered as natural as breathing. Chinese immigrants believed that keeping phlegm in the throat was unhealthy and that spitting could ward off bad luck or ill will. Spittoons were common around Singapore, and in his memoirs Lee Kuan Yew, the former prime minister and statesman, recalled how with difficulty the government tried to eliminate the practice after independence.

In 1984, the government began a major effort to eliminate spitting. After warning that it would begin enforcing the anti-spitting laws, the government fined 128 people for spitting that first year and another 139 in 1985, up from just 1 in 1983.

With evidence showing that the virus that causes SARS is spread through droplets from the nose and mouth, the government has mounted a new campaign against spitting. Last month, authorities took 11 men accused of spitting in public into custody and paraded them in court before fining them $300 each.

Changing the unhealthful habits of its largely immigrant population has been the purpose of much legislation. In 1970, Singapore passed what Dr Goh considers one of the most significant pieces of health legislation, the Environmental Public Health Act.

Among many other things, the law drove the ubiquitous street vendors indoors. Until then, hawkers were considered intrinsic to Singapore life, peddling curry, meat and noodles from pushcarts, using filthy water and dumping waste in the sewers.

"Getting them off the street was a big deal," said Dr Shahi. The effort helped reduce the incidence of cholera, salmonella, hepatitis and typhoid.

Public health regulation has also affected Singapore's taste for pork, a staple of the local Chinese diet. Pigs were once raised locally and sold fresh in wet markets, but the government phased out pig farming in the late 1980's.

That virtually eliminated the incidence of Japanese encephalitis, a disease that passes from pigs to humans via mosquito. Most pork, after that point, was imported from neighboring Malaysia.

The linchpin in Singapore's health defenses, the legal basis for its timely response to SARS, was the Infectious Diseases Act of 1976, which required physicians to report cases of certain infectious diseases to authorities. Over the years, this list of diseases has been expanded to include AIDS and now SARS.

The law also allowed authorities to require testing of suspected carriers and restored the quarantine provisions adopted in the early 1900's.

Then there is what Dr Goh calls the paradox of dengue. Incidence of the disease has risen in Singapore despite efforts to eliminate places the dengue mosquito breeds. Unlike the malaria mosquito, which breeds outdoors, the dengue mosquito is an indoor breeder.

As new buildings and homes replaced the swampy areas and construction sites where malaria had been fought, the dengue mosquito made itself at home.

Dr. Goh said strict health controls had led to public complacency: most people trust the government to keep bugs at bay.

In the end, the only answer to dengue, Dr Goh said, is a vaccine. "Law enforcement is a last resort," he said. "It's a deterrent."