April 25, 2006
Myanmar's Hidden AIDS Epidemic
Patients at an AIDS clinic in northern Myanmar.
Editor's Note: We're pleased to announce that this dispatch marks a more formal collaboration with our partners at PRI's the World. From now on, we'll be posting regular written dispatches from the World's team of far-flung radio reporters and cross-linking to their corresponding radio reports. To listen to Orlando de Guzman's two-part investigation into the AIDS crisis in Myanmar, visit the World's Web site.
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The doctor opens a thick photo album containing pictures of his patients and slowly flips through its sticky, mold-covered pages. The album is a macabre portfolio of tropical maladies: skin lesions that have gone septic, meningitis, TB, tumors left to grow to the size of grapefruits. In one photograph, a man with a gangrenous infection lies unconscious. His leg is chained to a bed.
"This man is a political prisoner," the doctor says. "The authorities waited until the last moment to take him to the hospital. He's now dead. He was chained like this, like an animal, even though he was dying."
The doctor, sensing my queasiness, skips a few pages and goes straight to pages that he'd bookmarked for me to see.
He shows me snapshots of AIDS patients he has treated in Myanmar [formerly known as Burma]. Many are in advanced stages of the disease. Their bodies are covered in fungal infections and untreatable sores. They quickly succumb to TB, hepatitis and diarrhea infections, he explains, because they don't have anti-retroviral drugs or even basic antiseptic drugs. Most of these patients are poor, abandoned by their families and left in the care of the country's crumbling health-care system.
What made the doctor speak out are the words of Martin Luther King Jr. "The words really encourage me: 'The ultimate tragedy is not the oppression and brutality of the bad people, but the silence of the good people.' So I feel I am responsible to talk the truth."
The hospital where he practices is on the frontline in the battle against HIV AIDS in Myanmar. But it lacks the most basic supplies. Patients and their families must bring their own soap, bandages, sheets and even drinking water.
After a few nervous meetings with me over the course of a couple of months, the doctor agrees to break his silence, with the condition that I don't identify him or his town. He risks being locked up in Myanmar's many gulags for speaking with a journalist without prior government approval.
What made him decide to speak, he says, are the words of Martin Luther King Jr. "The words really encourage me: 'The ultimate tragedy is not the oppression and brutality of the bad people, but the silence of the good people.' So I feel I am responsible to talk the truth."
The truth, he says, is that he treats hundreds of AIDS patients, yet he's forbidden to speak about them. "We can't say there are HIV patients ... that they need help. They don't know where to die, you know?"
The doctor says he has to make the painful decision to dismiss the sickest -- to free up their beds for new AIDS patients who continue to flood the hospital. "The hospitals need beds. So if they [the patients] can walk, they hire trishaws or other transport, and they are dropped off somewhere else. By the roadside. So that's how they end up."
Close to tears he tells me,"These people should have a proper place to die. They didn't have anyone. I talk for them. On behalf of them. So that they have a proper treatment, proper care, a proper funeral. So that they have their rights."
Talking about rights in Myanmar is extremely dangerous. Many have gone to prison for it. And this secret encounter with the doctor has made me realize that the story of AIDS in Myanmar is as much about human rights as it is about health.
The Shwedagon Temple in Yangon is a sacred place for Buddhists. Its stupa is guilded with more than eight tons of gold.
It's an observation shared by many health experts, among them, Dr. Chris Beyrer. He's an epidemiologist at Johns Hopkins University's School of Public Health in Baltimore. He has been studying Myanmar's AIDS epidemic for more than a decade, and what he sees is extremely worrying. "You essentially have the perfect storm. The perfect set of conditions for an explosive and sustained HIV epidemic," says Beyrer.
Myanmar's military junta, which has ruled the country since 1962, has created the fertile conditions for the spread of the virus, says Beyrer. "The lack of freedom, the lack of scientific information, freedom of speech, freedom of assembly, these very fundamental rights that have been denied the Burmese people, have made the spread of HIV more likely and more grave."
The true toll of HIV AIDS in Myanmar may never be known. The country's AIDS epidemic is the least studied in the world, according to health experts. The most reliable data available, from a 2000 World Health Organization study, estimated that some 300,000 people were infected and some 48,000 people had died the previous year from AIDS. But for that same year, the military government reported only 850 deaths.
The first outbreaks were detected in the late 1980s among heroin addicts sharing dirty needles. Around the same time, neighboring Thailand had its first outbreak. But unlike Thailand, which launched a massive and successful public health campaign in the early 1990s, the Myanmar junta didn't even acknowledge there was a problem until 2001.
The Joint United Nations Program on HIV AIDS estimates the infection rate to be at 1.3 percent of the population. Other surveys put the infection rate at double that.
Myanmar is the second-largest global supplier of heroin, after Afghanistan. Official complicity in the drug trade has made opium impossible to eradicate, and it has become clear that the AIDS epidemic in Myanmar is most acute wherever there is an abundance of heroin. In the hills in the state of Shan, northeast of Yangon, I met with opium poppy farmers who say that local military officers tax them for every pound of opium they produce.
In the state of Shan, one survey of a town found that a staggering 96 percent of injection drug users are HIV positive. And the epidemic is no longer confined to sex workers and heroin addicts.
One survey of a town in Shan found that a staggering 96 percent of injection drug users are HIV positive. And the epidemic is no longer confined to sex workers and heroin addicts.
"I have to say that the epidemic is getting worse," says another doctor, who practices near the old capital of Yangon [formerly known as Rangoon]. "There are new and fresh cases every day." She says her patients now include married women and children, people who do not engage in risky behaviors. And she says the military junta's public awareness campaign since the beginning has been ridiculously inadequate.
"It's only done by giving pamphlets to the public that say 'Stop AIDS' in English! Just imagine -- how many of us can read in English? That's the earliest public awareness, and it lasted five to six years."
Like everyone I met, a former Burmese military doctor, who worked in one of Myanmar's hospitals for army conscripts, agreed to speak only if he wasn't identified. His job was to do blood tests on soldiers suspected of having HIV, then immediately dismiss them from the service if they tested positive.
What continually shocked him, he says, is how little people knew about their disease. "Most of the cases, once they found out they are HIV, they seem very happy, because they will be dismissed from the army and be able to go back to their village and make a plantation and spend the rest of their lives. They don't know HIV has no cure. They don't know what HIV means."
I ask him if he feels compelled to explain to his patients what HIV is and what it means to them and their families.
But he is under strict orders to say nothing more. "If you are a military doctor, you must know your duty. Your duty is, you have to do whatever the superior commands you. To do otherwise, he says, is "very dangerous for your survival."
People gather at a sidewalk tea shop on the streets of Yangon.
On the surface, Myanmar looks like an exotic holiday spot, and when you visit its shining golden temples and beautiful, green countryside, it's easy to forget that you are in one of the world's most entrenched military dictatorships. Here, suspected activists are watched and followed. Phone lines are tapped. Meetings with foreigners are closely scrutinized. Dissidents are jailed, often in remote areas where their families cannot visit.
There is an acute fear of the state.
"In Burma, even the walls have ears," notes author Emma Larkin, in her book Finding George Orwell in a Burmese Teashop.
This Orwellian military government uses an intricate network of informants and intelligence agents to spy on its people. Ironically, many of these intelligence officers are coming down with HIV, a former military doctor told me, who has diagnosed many of them. "They are the officers that mingle in civilian society, and sex workers have to give them free services in exchange for their protection," he says.
Perhaps because of the HIV problem within its own ranks, the military government has begun to acknowledge the situation. "HIV, if ignored, will destroy entire races," once announced Lieutenant General Khin Nyunt. The former chief of Myanmar's military intelligence was purged in an internal power struggle in October 2004.
And Myanmar's Ministry of Health now lists AIDS as one of its three top-priority diseases, along with TB and malaria.
Burmese I met said they've learned to expect nothing from their nonelected leaders. They've also come to expect little from the international community, which is locked in a bitter debate over how to best help this country.
Yet in 2004, the military junta allocated only US$22,000 for its entire AIDS prevention program -- for a country of more than 50 million people. And it has stopped collecting reliable data on the epidemic, in spite of growing evidence that the virus is spreading to the general population.
Burmese I met expressed that they've learned to expect nothing from their nonelected leaders. They've also come to expect little from the international community, which is locked in a bitter debate over how to best help this country.
Many rights activists, claiming to speak on behalf of Burmese, do not want humanitarian aid to go to Burma. They say that any aid will only help prop up the regime and that the best way to effect change is to pressure the regime by playing hardball. They applauded when the Global Fund to Fight Malaria, Tuberculosis and AIDS pulled out its $98 million grant to Myanmar last year. The pullout was the result of the military government's canceling the organization's travel permits to check on projects around the country.
But those infected with HIV and those at risk of the disease can no longer wait for the politics to change. Doctors and those living with HIV are using what they have. In one of Yangon's slums, a doctor has mashed together a pungent local remedy from roots and tree bark. She doles it out to her AIDS patients from a rusty tin can. And she admits it's futile. "They don't live long," she says. "Their lifespan is only three to six months."
In another town, I met a woman who had formed a secret society of AIDS widows. "We have to do things secretly," she says, "because it's the best way to help others here. If the authorities found out, it will only bring us trouble."
Her husband died five years ago, but not before giving her HIV. She has no access to life-saving anti-retroviral drugs and has given up hope trying to get them. "I heard that some international aid agencies have distributed some anti-retroviral drugs to the district authorities," she says, "but up to now, we haven't seen any of them."
Rather than wait for foreign aid, she and her friends -- AIDS widows like her -- pay monthly dues into their secret organization from their meager earnings. The group's savings are used for hospital bills if one of their members needs treatment.
"The only thing that keeps me strong are the teachings of the Buddha," she says. "He said that we must live for others."
Orlando de Guzman currently lives in Thailand and is a freelance radio reporter covering Southeast Asia. He is a regular correspondent for Public Radio International's The World. De Guzman has also contributed to FRONTLINE/World. His broadcast story "Philippines: Islands Under Siege" aired in June 2003 and is available in streaming video on this Web site.