Marshall has produced one of the best articles on HIV in Burma/Myanmar in the last year.
He wishes Laurie Garrett, author of the famous ‘smoking gun’ mixed metaphor, had been left out. This time she has come out with a Bandaid metaphor and follows up with a remark on the aid dilemma: “This is ugly stuff.”
********************************
AIDS: Burma’s shadowy mass export
Andrew Marshall
Irrawaddy
July 2006,
Will ignorance, incompetence and international indifference allow a treatable disease to decimate a Burmese generation and engulf eastern Asia?
In an impoverished Rangoon suburb, at the frontline of Burma’s losing battle against AIDS, is a shabby, one-room private clinic which serves more than 500 HIV-positive patients. Its only doctor, who requests anonymity for fear of arrest, does not dispense life-saving anti-retroviral drugs (ARV). A month of these drugs costs the equivalent of about $40, more than a month’s wages for an average patient. Instead, the doctor has concocted her own treatment, a dark, pungent paste made from local herbs and fruits which, for half the price of anti-retrovirals and often free, she dispenses by the spoonful from an old jar. “Most patients can’t afford Western medicines,” she explains. “I try to give them cheap and effective traditional medicine. My drugs are very effective and have no side-effects.”
Most of her male patients are truck drivers and migrant laborers; the women are mostly sex workers returning from neighboring Thailand, or, increasingly, from Burma’s own sex industry, which has thrived under the military dictatorship which has ruled this nation since 1962. With scanty scientific evidence, the doctor claims her treatment boosts her patients’ CD4 counts (a way of testing the immune system’s strength) and prolongs their lives for “three or four years.” But she also admits that “eight or nine” of her patients die every month—tuberculosis, malaria, typhoid, or diarrhea usually provide the coup de grâce, she says—leaving behind infected partners and parentless children. “We have so many orphans living with grandparents or other relatives,” she says.
In 2005 an estimated 360,000 people in Burma were living with HIV, according to the Joint United Nations Programme on HIV/AIDS. These are hardly African levels yet, but rates are increasing dramatically and Burma’s generals are doing nothing to stop them. Among ethnic minorities such as the Shan, an estimated 9 percent of men are HIV-positive; so, in some areas, are a staggering 96 percent of injecting drug-users. These rates are exacerbated by public ignorance, widespread poverty, burgeoning prostitution and drug abuse, lack of medicines, and the collapse of a once-respectable healthcare system under military misrule. “You essentially have the perfect storm, the perfect set of conditions for an explosive and sustained HIV epidemic,” says Chris Beyrer, director of the Johns Hopkins Bloomberg School’s Center for Public Health and Human Rights in the US, and co-author of a recent report on the spread of serious infectious diseases in Burma.
This plague is not just a national tragedy, but also a grave and growing regional threat—including to regional superpower China. Burma is the world’s second-largest producer of opium after Afghanistan, and four-fifths of China’s HIV/AIDS cases can be traced back to Burma along heroin-trafficking routes, estimates the United Nations Office of Drugs and Crime. Genetic fingerprinting has also proved that Burma’s heroin-users and sex workers have spread the disease throughout Asia, reported the New York-based Council of Foreign Relations (CFR) last July. “With the exception of one serious outbreak in China, virtually all the strains of HIV now circulating in Asia—from Manipur, India, all the way to Vietnam, from mid-China all the way to down Indonesia—come from a single country,” said CFR senior fellow Laurie Garrett, the report’s author. “This evidence suggests that Myanmar may be the greatest contributor of new types of HIV in the world.” This genetic evidence is a “smoking gun, fingering Burma,” Garrett continued. “The Burmese HIV contribution to much of Asia poses a clear security threat to the region.”
Perplexingly, however, the international community seems to have found this health threat less than compelling. Indeed, last August the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria announced it was withdrawing funding from Burma worth almost $100 million over five years. The Fund blamed travel restrictions and other obstructions by the junta which, despite harsh US sanctions and softly-softly Asian diplomacy, remains firmly in power.
The Fund’s Burma program ends in about October, but a new European Union-led disease-fighting scheme is now due to take over (see separate panel, Europe Fills the Vacuum, Page 22).
But another potential epidemic could finally give Burma’s AIDS crisis the attention it demands, and galvanize the world into new diplomatic efforts to tackle a brutal regime: avian influenza. In early March the H5N1 virus was detected among poultry near Mandalay, Burma’s second largest city. Within a month, more than a 100 outbreaks of bird flu were reported across the country, with an official of the UN’s Food and Agriculture Organization saying the situation was “more serious than we imagined.”
The Bush Administration is worried. Post-Katrina, it is terrified of botching the response to avian influenza, says Chris Beyrer. “They want to get it right,” he says. The virus promises to put the health of long-suffering Burmese on the US radar in a way AIDS never could. “Here’s a country that now has more than a hundred outbreaks, doesn’t have a laboratory infrastructure, has really closed down the public health system, won’t allow open access to areas by international organizations, and borders Bangladesh, India, China and Thailand,” says Beyrer. “Hello? This is your worst nightmare.”
Burma’s secretive rulers did not publicly admit their country had an HIV problem until 2001. “HIV/AIDS is a national cause,” declared intelligence chief Gen Khin Nyunt, who has since been purged. “If we ignore it, it will destroy entire races.” The following year the US State Department warned: “Unless checked, the disease threatens to destroy a generation of young Burmese, much as it is destroying several societies in Africa.” Yet by 2004—and while the regime spent millions of dollars annually on weapons for its 400,000-strong military—its entire budget for combating HIV/AIDS was just $22,000, reported the International Crisis Group. This in a nation of over 50 million people. The ICG stressed that the epidemic “could undermine the basis for economic development and health services in the country for decades to come. This situation is urgent enough to require immediate action by all who have the power to make a difference.”
Educational programs are few and far between in Burma, and largely funded by the few foreign aid agencies allowed to operate in Burma. Popular awareness of HIV/AIDS has been raised mainly by the increasingly hard-to-ignore number of deaths: few neighborhoods, rural or urban, remain untouched by the epidemic. People living with HIV/AIDS are socially shunned. A magazine editor tells how his brother was evicted from his apartment building when the landlord discovered he was infected. In rural areas, villagers refuse to bathe or wash clothes in the same rivers which HIV sufferers use. In the countryside, bodies are often burnt on pyres of tires, in the belief that only the intense heat of burning rubber will kill the virus and prevent the corpse from infecting others.
The junta has not only delayed tackling HIV/AIDS, but also obstructed private attempts to do so. Last August, citing licensing irregularities, the junta ordered the closure of a popular clinic called Golden Heart in the northern town of Monywa. Funded by private businesses, the clinic provided free medi cal treatment to hundreds of poor people, especially to HIV patients. The authorities were jealous of the clinic’s success, a Monywa resident told the Democratic Voice of Burma radio station. “They can’t provide a single thing to the poor,” he said. He added that clinic staff had been threatened with six-month prison sentences, and donors with three-year sentences.
The xenophobic regime also places harsh restrictions on overseas aid agencies. “The junta basically regards all foreign aid-workers as spies,” says a European diplomat in Rangoon. To secure travel permits for non-Burmese aid-workers to leave the capital Rangoon takes three weeks, often much longer. “We joke that we’re all under city arrest,” says Willy de Maere, the Rangoon chief of the Asian Harm Reduction Network, which distributes free syringes to injecting drug users.
The Burmese are now doing what they can to help themselves. Many sink into debt buying anti-retroviral treatments. “Some people have sold their houses and land to buy ARVs,” says a Mandalay doctor. “We have to do something ourselves, whether or not the Global Fund is here,” adds a Rangoon social worker. With her friends and colleagues, she is raising funds to build a home for children orphaned (and, in some cases, infected) by HIV/AIDS. “There are hundreds of children [affected by AIDS],” she says. “We might be able to house 20 or 30. It depends how much money we raise.” Without foreign backers, she is struggling to raise the $7,000 required, or pay for the children’s medical treatment; it is enough for now to give them a roof over their heads, she says. Fearful of government meddling, the social worker says the home will be built without revealing its actual function to health or social welfare officials, for fears they will halt the project. The key is to get the home up and running, she explains. “Then we can tell officials, ‘Recognize and help us—or take the children and treat them yourself.’ This they won’t do.”
HIV is not the only disease ravaging Burma and imperiling neighboring China, India and Thailand. Burma also has one of the world’s worst tuberculosis problems, with 97,000 new cases diagnosed each year and multi-drug-resistant strains flourishing. About 40 percent of Burma’s population is thought to be infected with TB. Equally staggering, over half of all Asia’s malaria deaths in 2005 occurred in benighted Burma, where the disease is the leading cause of death in children under five. Poverty and malnutrition compound the problem: a quarter of Burmese live on less than $1 a day, and a third of under-fives are malnourished.
Despite all this, Burma receives less humanitarian aid than almost every other poor country. Even Cuba—which, like Burma, is the target of sweeping US sanctions—gets double the per-capita aid. The Global Fund’s withdrawal was another blow. Under the five-year program, some 5,000 patients were due to receive ARVs, from an estimated 45,000 who need them; it would also have funded HIV testing in a country where last year only 28,000 tests were conducted. “People are going to die because of this decision,” Charles Petrie, the UN Development Program chief in Burma, told the Los Angeles Times in December. And not just people in Burma, as the Global Fund itself acknowledged in a statement explaining the withdrawal. “Together with the relatively porous borders with key neighbors, especially Thailand, this means that, without resolute intervention, these diseases”—AIDS, TB, malaria—“could soon reach catastrophic proportions, affecting the entire region. This could endanger gains in controlling these diseases in other countries as well.”
Chief among those countries is, of course, China. Its infection rate is also rising. Last year there were 25,000 deaths and 70,000 new cases, transmitted primarily through injecting drug use and sex, according to a joint survey by China’s ministry of health, the World Health Organization and UNAIDS. Yunnan, which borders Burma, is among the worst-hit provinces. The so-called Burma Road, a trade lifeline which links the Yunnanese capital of Kunming with the northern Burmese city of Mandalay, is a major transmission route, an “AIDS highway” plied by thousands of truckers every day. In short, Burma is fueling an epidemic in a country too huge and populous for the world to safely ignore.
This is why analysts like Laurie Garrett at CFR argue that AIDS must be addressed in national and regional security terms, not as only a health problem. “Currently, HIV is talked about as only a health problem, and that means that it’s relegated to the lowest tiers of priority in most governments,” she said. “And it also means that the notion of obligations of states to respond to an epidemic—not only domestically but regionally—is somehow written off, somehow ignored.”
In a December 2004 editorial, The Washington Post, citing the regional threat posed by Burma’s unchecked HIV epidemic, noted: “If ever the United Nations faced a challenge to its relevance, this would be the moment.” A year later, in a closed-door meeting described as “informal,” UN Undersecretary-General for Political Affairs Ibrahim Gambari briefed the 15-member Security Council on Burma’s deteriorating record on human rights and health, including its AIDS epidemic. But despite arguments by the US and Britain that the junta poses a clear threat to international peace and security, Burma has stayed off the Council’s official agenda due to two other permanent members, China and Russia.
Still, says Laurie Garrett, this UN briefing was “significant,” although its impact on Burma’s generals is hard to gauge. “Do they even care what the UN says or thinks?” she wonders. “Now that they’ve moved the capital it’s getting harder to have any idea of what’s going on in their minds.” Last November Burma’s generals moved to a newly built seat of government at Pyinmana, nearly 400 miles from Rangoon, apparently prompted partly by the advice of soothsayers—junta chief Snr-Gen Than Shwe is deeply superstitious—and partly by paranoid but long-standing fears of a US military invasion.
In the 1990s, while still under military rule, Thailand launched a much-emulated anti-AIDS campaign which included huge public-awareness programs and the promotion of 100-percent condom use. “Thailand was pretty close to being a police state,” notes Laurie Garrett, “but ironically waged the most successful battle against HIV that we have ever seen by any country.”
That battle was prompted by high infection rates among young Thai military conscripts. Burma is not waging a similar campaign, despite plenty of evidence that infection rates among its troops are the same or worse. Orlando de Guzman, a journalist with US-based Public Radio International’s “The World” program, interviewed a former Burmese army doctor whose job was to discharge dozens of HIV-positive soldiers. They received “no anti-retroviral drug, no care [or] support at all,” said the doctor, and their bed in a large military HIV ward was immediately occupied by new arrivals.
One partial success story in Burma is condoms. More than 40 million were sold last year, compared to only 2.6 million in 1996. The most popular brand—called Aphaw meaning “companion”—is imported and sold cheaply by Population Services International, a non-profit group based in Washington. PSI has also produced television series and films to raise awareness about condom use. This would have been almost unthinkable a decade ago: Burma is a conservative society, and condoms have long been associated with prostitutes and promiscuity. But it is still a long way from Thailand’s hugely successful “100-percent” condom campaign in the 1990s.
Complicating the global response to Burma’s health crises is a bitter and unresolved debate over humanitarian aid to the country. Vocal pro-democracy groups outside the country argue that the presence of foreign aid groups only legitimizes an evil regime. Kentucky senator Mitch McConnell campaigned for the Global Fund’s withdrawal—a withdrawal Brian Williams, the head of UNAIDS in Burma, likened to withholding food from refugee camps. Even Laurie Garrett, whose report dramatically underscored the urgency of tackling the epidemic, compares the efforts of UN agencies and foreign aid groups as “putting Band Aids on a terrible, gushing wound.” Their presence might assuage international guilt, she says, but it also removes the “burden of responsibility” from the junta. When it is suggested these arguments will mean little to sick Burmese, Garrett replies, “This is ugly stuff, there’s no doubt about it. My heart breaks for anybody who is trying to deal with HIV/AIDS in Burma right now.”
Or, indeed, with bird flu. Like AIDS, H5N1 is “a transnational issue that underscores why Burma not responding to the health of its people matters for everybody else,” explains Chris Beyrer. Surprisingly, perhaps, the junta cooperated with the Food and Agriculture Organization by, for example, promptly sending specimens to Bangkok for testing. But it waited nine days before telling its own people, and still fails to adequately relay the information that could check an avian epidemic and prevent human deaths. Reliable information about bird flu in Burma is still—as The Bangkok Post put it, choosing its simile carefully—“as rare as hen’s teeth.”
One Western government has sent 1,000 biohazard suits and other equipment to Burma. That the junta should accept such an offer from a sworn enemy is evidence that at least someone in the regime understands that Burma cannot fight bird flu alone. For example, surveillance is hamstrung by a laboratory infrastructure which is “dangerously decrepit,” notes Beyrer, who finds it striking that bird flu was first detected in Mandalay—“just about the only place where there’s a functioning laboratory.” He adds: “Chillingly, Rangoon and Mandalay are also the only places where there appears to be screening for blood donors.”
The bird flu outbreaks could conceivably persuade the junta to relax the travel restrictions which have hampered all humanitarian work in Burma. It would not be a moment too soon. The “great wave of AIDS illnesses and deaths” has yet to strike countries such as Burma, notes Laurie Garrett. A foreign aid official quoted in The Washington Post estimated that the disease will kill a tenth of young Burmese in the next decade. In the Rangoon suburb where the traditional doctor has her clinic, they are already dying “like leaves falling from a tree,” says a former resident. The doctor herself makes no mention of AIDS on death certificates, because temples in this predominantly Buddhist country often refuse to cremate its victims. “They’re uneducated,” she says of her dirt-poor clientele. “If they get [HIV], they are ashamed to tell relatives or neighbors. They hide it, and they die quickly. They die within months.”
Andrew Marshall is the author of a book on Burma called “The Trouser People,” published by Counterpoint in 2003.
