Southeast Asia's Rising Storm
In the northern Thai province of Chiang Mai, Manat Khanadee is dying of AIDS. Manat, 31, frequently visited prostitutes ever since the age of 17, an act so culturally widespread that he thought nothing of it. "I thought AIDS was far away. I thought they only had it in Bangkok and overseas, not here," explains Manat.1
His previous attitude reflects the widespread ignorance about AIDS in Thailand and in the rest of Southeast Asia, which here included Thailand, Myanmar, Philippines, Cambodia, Vietnam, Indonesia, and Malaysia. This ignorance has facilitated the spread of this deadly disease across Southeast Asia within the last few years.
"I thought AIDS was far away. I thought they only had it in Bangkok and overseas, not here." |
Although the HIV/AIDS epidemic hit the region of Southeast Asia much alter than it spread through the rest of the world, the epidemic has rapidly expanded throughout Southeast Asia within a brief period. At the Third International Conference on AIDS in the Asia Pacific held in Thailand this past September, the World Health Organization (WHO) reported that by the year 200, Asia's share of the new HIV infections could exceed 25 percent of the world's total.2 Asia will then replace Africa as the epicenter of the AIDS epidemic. Estimates have suggested that last year, for the first time, the number of people infected with the HIV virus, was larger in Asia that in Africa. By the turn of the century, more people will be infected in Asia than in the rest of the world combined. Asia alone has 4.3 million cases of HIV infections, an increase of one million from the previous year. About 750,000 of these cases occur in Thailand, but the disease is also spreading like wildfire across Myanmar (formerly Burma) and Cambodia. Other regions, such as Indonesia and the Philippines, risk similar explosions. |
The main routes of HIV transmission in the region are sexual relations and intravenous drug use. Another prevalent route is the transmission from mother to child during the prenatal period. Women may soon face the highest risk of infection because they often leave the responsibility of practicing safe sex to their partners.3 In Thailand, the first country in the region hit by the epidemic, the disease initially affected the homosexual population and intravenous drug users. With the increased prevalence of the disease, however, heterosexual relations have become the predominant mode of transmission, many of which include prostitutes. In Myanmar, investigators have identified intravenous drug use as the main mode of HIV transmission. The transmission of the epidemic in this manner has evolved through the changing pattern of drug abuse: from smoking opium to smoking heroin and finally to injecting heroin, frequently with a shared needle.4
The Costs of the Epidemic
Failure to control the growth of the epidemic at an early stage will result in damaging and costly consequences for Southeast Asia. Deaths due to AIDS could exacerbate the current regional labor shortage. In Thailand, the workforce, originally expected to expand at a rate of 7.8 percent between 1993 and 2000, now grows at a rate of 6.7 percent.5 This reduction in the labor force could hinder the Thai economy by pushing wages up. The reduction could also hinder efforts to boost the education and skill level of the workers. Skilled workers, already scare in number, are at risk of contracting the disease. Contractors are currently saying that they cannot find enough workers and have started bringing in illegal immigrants from Myanmar to supplement the depleted labor force in northern Thailand.6
| The people who will bear the heaviest toll from the disease are those who can least afford it: poor families of AIDS patients who not only lose their main wage earners, but also have to bear the cost of caring for them. In families that have lost wage earners to AIDS, living standards plummet, savings disappear, assets are sold, and children are taken put of school to earn money and take care of their sick parents and siblings. Since most of the people with AIDS are in their 20s and 30s, they die leaving behind children and parents without financial support. For example, Thailand will have more than 95,000 orphans under the age of 15 by the year 2000.7 Presently, members of the extended family take in most of the orphans but as deaths multiply, more and more people may have to turn to the government or alternate sources for help. | Among the developing countries, Thailand spends the most for AIDS prevention programs. |
The accepted practice of prostitution and initial ignorance about HIV in Thailand allowed the virus to spread quickly from isolated communities of intravenous drug users, homosexuals and prostitutes to the general population. This trend is repeating itself in other Asian countries where poverty has driven large numbers of women into the sex trade. The routes frequented by Thai truck drivers have become hot zones for the epidemic, and numerous Chinese and Burmese women have taken the virus home after working in the Thai sex trade.
While prevention has been the key message in recent anti-AIDS programs, such as the one in Thailand, the disease has itself proven to be a stern teacher in heavily affected areas. While Ying, an 18 year-old liquor delivery man. attends the funeral of one of his friends, he reveals, "I used to go to brothels all the time. I was a real tiger. But I stopped about a year ago."8 Even though he fears hi is already infected with the disease, he is too scared to get tested. Since his wife is pregnant, he accepts that he will learn of his status after the hospitals test her.
Thailand: Leading the Way
Until the AIDS epidemic broke out in 1988, Thailand and is neighboring countries were unconcerned about the disease. once faced with the AIDS epidemic, however, the Thai government quickly launched an aggressive prevention program in 1990 to promote the use of condoms, one of the most effective methods of preventing HIV transmission during sexual intercourse. AIDS prevention is now accorded the highest priority in Thailand, and officials have formed a national AIDS prevention and control committee that is chaired by the prime minister. Thailand’s strategy has led to a broad consensus on the importance of taking action to curtail the disease.
To monitor the epidemic, Thailand has established the world’s most comprehensive national HIV surveillance system which reports twice a year on HIV prevalence in all risk groups in all provinces of the country. Although the government realizes that commercial sex is intrinsic to Thai society and will remain so in the short run, it has decided to mandate and enforce a policy of 100 percent condom use in brothels. Preliminary evidence shows very high rates of condom se and subsequent reductions in the incidence of STDs. Starting in 1993, the prime minister’s office also launched national media campaigns to promote changes in he sexual culture and the sexual norms of the population.
Among the developing countries, Thailand spends the most or AIDS prevention programs. Spending in 1992 totaled $45 million, more than 75 percent of which was from government funds.9 The Ministry of Public Health, which started distributing free condoms in brothels, now gives away about 60 million condoms annually. The government also launched an extensive campaign to enlighten the public about the disease. AIDS education starts at the level of elementary school, where students are taught about the virus and its transmission. Due to the campaign, there have been noticeable changes in societal behavior. Condom use is up and visits to prostitutes are down. Condom usage in the country topped 170 million last year, up from 10 million a decade ago.10
In certain ways, Thailand has been fortunate. Its prevention efforts are supported by a relatively efficient and extensive bureaucracy that extends through the village level, a strong and pervasive media, and an educated and literate population. Thailand is also better equipped than other developing nations with the economic resources necessary to carry out such a task. This year, the government’s anti-AIDS budget is 1.7 billion baht (US $68 million).11
Myanmar: Falling Behind
Unfortunately, few
other countries in the region enjoy the same circumstances as
Thailand. In Myanmar, an estimated 400,000 people are HIV
positive, but the government lacks the necessary financial and
intellectual resources to do much about it. Condoms are not
freely available in the country, and intravenous drug use is
widespread. In the north, where seedy tent cities surround
several jade and gem mines, it is the norm for men to use their
wages to buy sex thereby
Most hospital nurses believed that AIDS was a disease exclusive to foreigners and that it could not be passed between Cambodians. |
exacerbating the spread of the disease. In addition, because of the tension between the government and the rebel ethnic groups, the law has little influence in many of the ethnic minority areas where the disease has hit especially hard.
Moreover, little has been done in Myanmar to fight the ignorance regarding the disease. In a population of 43 million, one percent of the entire nation has already been infected. The country’s medical infrastructure is very poor and only 30 percent of the blood supply is tested.12 Due to the acute shortage of medical instruments, needles are not readily available and many tend to be reused. Evidence from a variety of hospitals and doctors indicates that many deaths due to AIDS are being misdiagnosed as results of other illnesses such as malaria or tuberculosis.13 In addition to inadequate testing facilities, the social stigma of AIDS also contributed to such misleading diagnoses.
Because of the cast extent of poverty in Myanmar, many of the rural village women cross he Thai-Myanmar border to work the Thai sex trade. Approximately 70 percent of Thai commercial sex workers are HIV positive.14 When these women return to Myanmar, they often do not know that they are infected. Since rural villagers do not have access to condoms or to reliable information regarding the disease, preventive measures cannot be taken.
HIV infection rates among intravenous drug users in various high risk areas exceed 90 percent. According to a United States Agency for International Development (USAID) AIDS specialist, an infection rate that exceed 10 percent for intravenous drug users in developed countries is already considered extremely serious.
Unlike Thailand, the government in Myanmar does not perceive AIDS as a top priority and does not acknowledge that this serious epidemic is starting to make it way into the general population.
Cambodia and Vietnam: AIDS as a Foreign Disease
Cambodia is also in the midst of the epidemic without the money or the expertise to do much about it. After a generation of civil war, Cambodia is one of the poorest nations in the world, with most adults earning little more than the equivalent of a dollar a day. The government cannot provide most of the people with basic necessities, let alone an effective AIDS education program.
As in most of the other nations in the region, ignorance is widespread, even among doctors and nurses. A recent study showed that most hospital nurses believed that AIDS was a disease exclusive to foreigners and that it could not be passed between Cambodians. A mere five percent knew that the virus could be transmitted through intravenous drug use.15 This ignorance may help explain why Cambodia presently has an estimated 90,000 infections as opposed to zero recorded cases five years ago.
In Vietnam, an anti-AIDS campaign is under way, but health workers must first overcome the widespread ignorance about the disease, including the perception that AIDS can only be contracted from foreigners.
Philippines: Catholic Church Opposition
Even though the WHO estimates that only 18,000 Filipinos are infected with HIV, some epidemiologists find the estimate to be too low, given the number of brothels and massage parlors found in Manila and other Philippine cities. Whatever the accurate figure may be, health workers believe that the Philippines is headed for disaster because of rampant prostitution and because of opposition from the Roman Catholic Church to anti-AIDS educational programs.
With 90 percent of the population being Catholic, Jaime Cardinal Sin, the impassioned Catholic leader in Manila, has blocked all attempts by the government to organize a national anti-AIDS program. He has described the anti-AIDS program as "intrinsically evil."16 In fact, church leaders have also been known to set boxes of condoms on fire at anti-government demonstrations.
Indonesia and Malaysia: Conservative Islamic Nations
As the world’s fourth most populous nation, Indonesia has a population of 190 million people. The government has suggested that as many as two million people could be HIV positive by the year 2000. With Islam being the predominant religion, religious conservatives denounce anti-AIDS campaigns as an effort to encourage promiscuity. The country’s highest Muslim authority has demanded that the government limit the sale of condoms only to married couples.
Unlike AIDS, ignorance is a curable disease. |
Malaysia, also an Islamic country, is led by a physician-turned-politician, Prime Minister Mahathir Mohammad, but his government has been reluctant to offer any kind of comprehensive anti-AIDS program. In the last three years, the number of HIV infections in Malaysia has jumped from an estimated 2,400 to nearly 30,000. Ironically, the president of the Malaysian AIDS Council is the |
Prime Minister’s 38 year-old daughter, Marina Mahathir, who criticizes Asian governments who do too little to avert a health disaster: "I think there’s a fear of having to deal with some sticky issues. You have to talk about sex, and all the conservative elements of this society don’t want to talk about it."17
Given the lethal nature, ease, and speed with which the disease can spread, there is no time for delay. In about five to ten years, experts say Thailand may be lucky enough to have escaped relatively unscathed compared to its neighbors. The other Southeast Asian nations, however, face tremendous obstacles in their fight against AIDS, the biggest of which is an ignorant population. Using Thailand as a model, countries should consider instituting comprehensive AIDS education programs in order to erase the stigma of AIDS as a foreign disease. Unlike AIDS ignorance is a curable disease. Unfortunately, religious conservatism cannot be overcome just as easily. The governments of Southeast Asia must play an active and commanding role in installing AIDS prevention programs or else these conservative beliefs may lead each nation into a health disaster.
As an official in the Thai anti-AIDS program says, "They don’t know they’re sitting on a time-bomb. At least we heard something ticking and we did something about it."18
| Notes: 1. Gordon Fairclough. "A Gathering Storm." Far Eastern Economic Review. September 21, 1995. p.27. 2. "Health: AIDS Updates 415-418." Asiaweek, October 6, 1995. p.18. 3. Ibid. 4. Myo Thant. "The Economic Implications of AIDS in Southeast Asia: Equity Considerations." Economic Implications of AIDS in Asia. David Bloom and Joyce Lyons eds. p. 139. 5. Fairclough. p.27. 6. Ibid. 7. Ibid. 8. Fairclough. p.30. 9. World Development Report 1993: Investing In Health. p.100. 10. Fairclough. p.30. 11. Ibid. 12. "HIV/AIDS in Myanmar." World Vision-Myanmar. August 2, 1995. p.2. 13. Ibid. 14. Ibid. p.3. 15. Philip Shenon. "AIDS Epidemic, Late to Arrive, Now Explodes in Populous Asia." New York Times. January 21, 1996. p.8. 16. Ibid. 17. Ibid. 18. Fairclough. p.30. |
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Ms. Win, SM'98, is an economics major at Yale College.