The AIDS time bomb

By ELIZABETH PISANI
1740 words
12 June 1996
Asia Times
English
(c) 1996 Chamber World Network International Ltd

Buddhist monk Phal Houn works in a growth industry – he claims he can cure AIDS. But he and others unwilling or unable to grasp the reality of the country’s commercial sex culture will make matters even worse in Cambodia, where the AIDS virus is now believed to be spreading faster than anywhere else on earth.

"Look, here’s another one." Phal Houn casually tossed over to a stranger the test results brought in by a terrified Vietnamese girl who shuffled forward on her knees between her two female minders. The white slip of paper from the Pasteur Institute confirmed that the girl was infected with HIV, the virus that will eventually lead to AIDS and her death. "Stick your tongue out. No fever? Good. Drink my medicine every day and you’ll be fine in six months. Oh, and don’t eat meat, fish or eggs."

Health professionals are scandalized by such charlatans. "Youngsters here already think they are invulnerable. If they believe AIDS is curable, they will never change their behavior," said one advisor to the national AIDS program. Cambodia has almost everything it takes to ensure a rapid spread of HIV. Decades of war and neglect have razed the health system to the ground. The sudden opening of a command economy to the free market has created both a need for money and a huge gulf between those who have it and those who don’t.

The Haves are keen to spend money enjoying themselves in a way they could not through the years of war and oppression. The Have-nots – education, basic skills and employment prospects are among the things they don’t have – need to make money any way they can. Taken together, these factors are fertile ground for prostitution.

An active sex industry spreads all sexually transmitted diseases (STD). Most are easily treated, except in countries like Cambodia where there is no basic health infrastructure to speak of and where private sector drugs are often useless counterfeits. So common STDs go untreated, and that vastly increases the chance of catching the most frightening sexual disease, HIV. "You couldn’t have a test tube better set up for the spread of the HIV/AIDS epidemic," said a prevention specialist.

After dark, Cambodia’s towns and cities light up with the pink neon that indicates sex for sale. "It has become our social norm," said Hor Bunleng, coordinator of the Ministry of Health’s National AIDS Office. "Men gather in groups to go out drinking. The rich ones go to a dancing hall and pick up a girl. The poor ones go straight to the brothel."

Whoring is a pastime that occupies all social groups from a very early age. Hor Bunleng, who said he has treated secondary school pupils as young as 13 for gonorrhea, estimates that around 70 percent of Cambodian men regularly have sex with prostitutes. Others believe his figure is conservative. "The Cambodian man between 16 and 45 goes to prostitutes regularly. That’s just how it is," said Annie Macarry, a doctor with the World Health Organization (WHO) global program on AIDS. "Then he goes home and infects his wife. Simple as that."

Accurate figures on HIV infection are notoriously hard to come by. They are often skewed by the way they are collected, and who they are collected from. The best indicator of the prevalence of the virus in the general population – rather than in high-risk groups such as prostitutes, drug users or soldiers – comes from testing pregnant women. Last year, some 2.64 percent of pregnant women tested for the HIV virus in Cambodia were found to be infected, and early indications are that the picture has grown bleaker since then. The WHO estimates that between 50,000 and 90,000 Cambodians are already infected with the virus and some 3,000 to 4,000 are probably suffering from AIDS. With a population of around 10 million, Cambodia is believed now to have a higher infection rate than neighboring Thailand, where the disease has been established far longer.

"This is worse than anything we saw in Africa. In fact, it is worse than anything we have seen anywhere in the world," said an expert from WHO’s regional headquarters. "One can only be pessimistic." Cambodia-based colleague Macarry is more emphatic still. "This is going to be worse than Pol Pot." When Pol Pot’s Khmer Rouge ruled the country, a sixth of the population died by violence or of disease or starvation. Things are especially bad among high-risk groups. Around one in 10 of Cambodia’s soldiers is infected, and persuading them to practise safe sex is an uphill battle. "All a soldier wants to think about when they come back from the field is enjoying themselves. They feel strong. They feel invulnerable. They don’t want to think about things like disease and condoms," said Monique Munz, a health consultant who has worked to set up an AIDS program with Cambodia’s Defense Ministry. In any case, soldiers have a tendency to think short term. "If you survive the dry season offensive and you know that next year you are going to get sent right back out to fight the Khmer Rouge, to see more of your friends killed and maimed, perhaps to die yourself, are you really going to worry so much about something that may kill you years from now?" wondered Ly Solim, HIV/AIDS project officer at Save the Children (UK).

The knowledge that their fighting forces may be decimated by disease has galvanized the military into action, and the army is in the process of setting up an AIDS program. But elsewhere in the government, people are slow to grasp how far the disease has come. "If we’d had more support from the government in the first place, it might not have come this far at all," said an international organization specialist. Official obstruction has set back efforts to educate Cambodians about the disease. AIDS workers would like to move away from vague images of death to posters which actually tell people something about how the disease is spread and how to avoid it. "We know from other countries that images of fuzzy gremlins which are going to attack you and turn you into a skeleton don’t work," said Michael Calabria, the United Nations Development Program’s AIDS coordinator in Cambodia. But more explicit messages are apparently not yet on the cards. Phnom Penh municipal authorities ordered the removal of four AIDS awareness billboards in central Phnom Penh, because they offended Khmer culture. Banners put up ahead of international AIDS day had to come down, too.

"And yet, if you go 100 meters down the road from where the banners were, you can see huge numbers of sex workers right there on the street," said Hannah Phan, who runs the HIV/AIDS program at Care Cambodia. "We are tired of these double standards about our culture. People come to meetings and say, ‘We need to protect our youth’, and then go off and buy very young girls."

Some believe that it is the first, puritanical side of Cambodian culture that feeds the second, lascivious side. "Cambodians go to prostitutes for pleasure because they don’t know how to have fun with their wives. In our culture, wives just lay down and accept whatever their husbands do," said Bunleng of the Health Ministry. "With a prostitute, you can order it up any style you want."

This view is confirmed by Kien Serey Phal, director of the Cambodian Women’s Development Association. "I have spoken to women who have five and six children and who have never seen their husband’s penis," she said. "I ask them, well, how do you have sex? and they say they just close their eyes, otherwise they would be ashamed."

The sexual reluctance of Cambodian women, which Kien Serey Phal said held even for sex workers, is a big boost to the large numbers of Vietnamese prostitutes who work in Cambodia. Studies, most of them rather unscientific, show that between one-third and half of Cambodia’s prostitutes are Vietnamese and that they are more likely than Cambodian girls to have become prostitutes to make money, rather than because they were kidnapped or sold by relatives to brothel owners.

"Vietnamese girls consider prostitution their profession. They work hard to provide better services and they make more money," said Hor Bunleng. He asserted that HIV infection among Vietnamese girls was lower than among their Cambodian counterparts, partly because they are more likely to seek health care for other STDs. "Cambodian girls are rejected by their society; they give up hope and they don’t care about protecting themselves."

Ethnic variations aside, HIV infection among prostitutes appears to be skyrocketing. Initial results from a series of surveys currently being carried out by the WHO show that infection among prostitues has jumped as high as 58 percent in the northern town of Battambang from 38 percent a year ago. In Siem Reap, near Angkor Wat, almost half of prostitutes tested were HIV positive, up from well under a third. Encouragingly, condom use in brothels is also rising quickly (see below). But many believe that it is only when people start to see their families and friends die of AIDS that they will begin to protect themselves more methodically. They point out that while plenty of people are already dying of AIDS, few are diagnosed as such. AIDS itself doesn’t kill people. Death is caused by other diseases which would not normally be fatal but which can invade and overcome the body because HIV has knocked out the immune system, the body’s natural defense.

It is not surprising that doctors are weak on diagnosis – to this day, there is not a single course on AIDS at a Cambodian medical school. "What we really need is some well-publicized cases of high officials dying of AIDS," said one Cambodian health worker, adding that the AIDS death of one army doctor was immediately swept out of the public eye. "They think they are immune because they go to expensive nightclubs, but the girls there will infect them just like anyone else."

Elizabeth Pisani is an Asia Times correspondent based in Indochina.

Copyright 1996 Asia Times.

(c) 1996 Chamber World Network International Ltd.

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