For the last three years off the fifteen I worked in the US my clinical life was consumed with setting up a unit at Yale University to study and treat patients with the mysterious Acquired Immune Deficiency Syndrome (AIDS), the cause of which was eventually discovered to be a unique retro-virus called, logically enough, the Human Immunodeficiency Virus, (HIV). In those early years all the patients I treated died from their infection. By the time I returned to Australia (1985), HIV had been established as the causative agent and the epidemic was spreading out of control in the US, Africa and much of Europe. Throughout Asia, however, there was a nonsensical apathy about AIDS as the belief spread that Asians must have natural immunity to the disease.
We knew that semen, blood and breast milk could transmit the virus from one person to another as these fluids normally contain specific immune cells (’T cells’)in which the virus could live and multiply. Looking at Asian cultures it was not hard to guess that Thailand, with its very relaxed attitude to sexual activity would be a ‘sitting duck’ for the virus and soon this prediction was verified.
I was very vocal about my AIDS concern for Asia (and Australia) and was invited to join an action group to raise awareness of the issue in Asia which included leaders from the Thai red cross, UN AIDS, the WHO’s body set up to fight the global epidemic, and most importantly as it turned out, representatives from the United Nations Development Fund (UNDP).
At then time I was complete novice about any UN programs and which ones had influence in ASIA but I soon learnt that UNDP was held in high regard (because it funded many diverse programs in the developing countries of ASIA) and could get our group access to Government ministers and agencies in countries throughout the region. After a preliminary meeting in Manilla where we got financial support from the Asian Development Bank, we visited over the next three years a dozen or so Asian countries and that is how I found myself in Myanmar in 1988 for the first of three visits that ended with my being banned from the kingdom in 2002!
HIV was mainly being spread in Asia as elsewhere by men who had sex with men, female sex workers and the sharing of needles by intravenous drug users, activities that were (and largely still are) illegal activities in Asian countries. A major tactic to minimise the spread of the infection was to increase condom usage.
The promotion was not so difficult in Thailand and we even had monks giving out condoms as they walked the streets. It was well known in Thailand however that condoms imported from Europe and the US, though readily available, were too large for most Thai men so this Immunologist used to laboratories and hospital wards finds himself visiting a Thai brothel where some 60 women were literally on display each carrying a numbered placard so those inspecting them through a glass wall could decide whom they wished to ‘hire’.
With Thai red cross officials we met with the management and the girls at the end of a shift with a promise of money (provided by UNDP and the Thai government) if they would measure and document the size of their customer’s penises! The girls were delighted at the prospect of the extra money and the research was broadened to involve similar setups. I can only imagine with difficulty the conversation the girls must have had with their men but useful data was acquired even though, predictably, the girls frequently reported that as they started their scientific ‘measurements’ there was nothing to measure!
It was condom usage that resulted in UNDP arranging for us to visit Myanmar. In fact this was an excuse for us to get to Yangon to see if we could discover what anti-AIDS programs were in place. While the regime gave out no data it was well known that the country had many infections and that most were acquired bu IV drug users. The centre of the epidemic was the ‘Golden Triangle’ region where Thai, Chinese and Myanmar borders intersect. We had heard from dissidents that IV drug users were harshly punished in Myanmar and that the government was hostile to the idea of working with NGO’s that other countries had demonstrated could actually reach out to drug users and sex workers and influence behaviour.
Back to condoms. It was well know that locally available condoms in Myanmar were of such poor quality that they often were very likely to contain holes.This did not encourage use. A private sector initiative from the US had UNDP agreeing that it would try and have quality condoms, made readily available throughout the country and provided at no cost to Myanmar,. We arrived to see if we could persuade the government to accept the offer and at the same time see if we could discover more about the ‘underground’ NGOs that needed support. UNDP organised a two day conference for us to meet with their local representatives and clinicians involved in HIV efforts.
Six of us arrived at Yangon airport and were ushered straight through customs by non-verbal soldiers to an awaiting bus. We were give a schedule that explained we would be staying in the home of a retired Admiral and would be transported the next day to meet the senior official assigned to us who happened to be a very young Minister for the Navy! If you have been to Myanmar you will, I am sure have noticed as we did, the hundreds of brick Georgian residences that line the huge lake that is the major geographical feature of Yangon. The houses were meant for Sussex or Devon not Yangon but the colonial Brits obviously wanted a bit of the old country around them.
We were met by our housekeeper come gardener come security agent who ushered us to very sparse accomodation. It was all very strange, exciting but a bit scary, not a smile had been visited on us. We were clearly not welcome.
The next day we were taken to a huge red brick complex and settled in a room to await the minister and his translator. We had a bunch of condom samples and details of the very good deal on offer. We waited nearly 90 minutes before this ‘kid’ shows up. We delivered our sermon without interruption or questions. After this he said thank you and that we should meet at the same time tomorrow for a decision.
This we duly did but no minister this time, just the translator/spokesperson. He had the condom samples with him and told us that the Minister would accept the donations (hurrah) but that the inserts with instruction re usage were in fact deemed pornographic and could not be distributed! Ridiculous of course and totally impossible to comply when the condoms would have been available from pre-packaged vending machines. The deal was scrapped but far more serious issues were to be encountered later during that visit and in return visits and these will be described in part two of this contribution.
At the end of the 80’s with HIV infections surging throughout Asia it was frustrating that conservative governments would not countenance the mass broadcasting of frank information about the sexual activity and IV drug use that was causing so many infections and deaths. There was a deep distrust of movements to have NGOs composed of educators from the effected populations engage in the dissemination of information. IV drug use, sodomy and prostitution were all illegal activities. This was particularly difficult in Myanmar.
Under the guise of a ‘clinical meeting’ my delegation did meet with university students and representatives of the marginalised groups who were doing their best to minimise risky behaviour. It was clear that IV drug use was the major behavioural risk in Myanmar. We tried to convince government agents that using NGO’s to reach marginalised groups to tackle infection was known to be effective. There was no interest then, though over the coming years ,gradually some semi-offical support was given to NGOs.
We left Myanmar depressed after our first visit and moved on to Malaysia. No trouble meeting the Minister for Health there who was anxious for us to believe that all the HIV problems in Malaysia were associated with the influx of Thai prostitutes whom he declared “should be hung in a public square” Hypocrisy was abundant. That evening we were waiting outside our hotel for a car to take us to a dinner meeting and got chatting with a group of uniformed US Airmen visiting to arrange for spare parts for the Malaysian airforce. They told us ‘wink, wink’’ that the Ministry had arranged for them to be accompanied by girls who ‘’would give them a good time”!
As for frank education of the populace ? As we left the KL airport there was a huge Billboard declaring that, “Marriage protects you from AIDS”. While in KL I gave lecture re HIV in the town hall, and talked frankly about infected T cells in semen etc. At question time a young lady popped up and asked me “What happens to your T cells when you get married?”
My second visit to Myanmar occurred in 2000 when a number of Asian activists re HIV were invited to join a public march through the streets of Yangon for World AIDS day, December 1, 2000. This was risky move by the locals who reasoned that with a few international visitors and perhaps some media coverage the March would not be banned. We tried to get permission for Aung San Suu Kyi to join the march but that was not allowed.
A few hundred marchers participated without harassment from local Police. We then retreated to the University Campus where students had assembled wonderful exhibitions re the prevention and treatment of AIDS. Rebellion was in the air. Intelligent young people determined to force democratic changes in their country. Importantly, I thought it seemed that self-help within the groups at risk of developing AIDS was being tolerated unofficially.
My third and final trip to Myanmar uncured in 2002 when I was asked to visit for a medical conference on the management of HIV infections. By then my advocacy had given me some status among Myamar physicians and it turned out that the Government wanted my advise re a specific regional problem – Amazing. So I arrived , bringing my wife with me for this trip. We were assigned a ‘driver/minder’ who accompanied Catherine to the huge Yangon Bazaar while I was working.
For the first time I was asked by the physicians to visit the hospital for infectious diseases to examine and discuss the management of those in hospital with AIDS. There were 20-25 inpatients in the ward ,mostly men and in virtually all cases their infection was caused by sharing drug injecting material.
Many had pneumonia, viral infections in their eyes that was causing blindness. Drugs of any sort were in short supply and the X-Ray machines were antiquated, probably dangerous and certainly produced poor quality pictures. But it was when I started a ward round to examine the patients that I was really shocked.
As I approached one bed occupied by a totally emaciated man, clearly soon to die ,his mother holding his hand and sobbing, saw me approaching and quickly pulled a sheet over his ankles. Curious I exposed his ankle to find a 17 th century style metal shackle locked around this man’s ankle. The skin under the shackle was broken, infected and a huge ulcer was forming. The man’s mother was embarrassed that her dying son was so treated.
The doctors and nurses accompanying me explained that all the patients who had been IV drug users were under arrest and the staff were ordered to keep all shackled to their beds. Appeals to authorities to stop this practice with desperately ill patients were ignored. I was incensed at the cruelty involved and determined to see if could change the practice by letting the world know what was occurring.
As I let the ward, still quite shaken by what I had seen we passed an out patient area where pregnant Mum’s were attending a prenatal clinic. The one doctor handling the clinic ran up to be and in excellent English told me she had trained in Melbourne, daily had about 160 patients to see and felt helpless to help many as she did not have any ultrasound equipment. Could I ask at home for donations of ultrasound equipment. Three months later Australian radiologists had delivered her the equipment she needed. As it turns out this was only positive accomplishment from my visit.
The next day my wife and I were to fly to Kawthoung a tiny town on the southernmost tip of Myanmar which borders with Thailand. At that time the only way to get there was to fly or take a long boat journey. On this tiny peninsula Thai and Myanmar citizens intermingled freely and there had been a lot of HIV infections in this area. The Myanmar government actually asked me to visit and look at the effectiveness or otherwise of the prevention programs initiated. As it turns out in this isolated spot Myanmar had a penal colony.
As our very ancient Fokker Friendship landed we noticed a large number of people, including foreigners, jostling for positions that might see them get on the return flight. They were literally desperate to get out. As we left the airport we saw perhaps 70 or 80 men in prison garb wielding old fashioned scythes to cut the grass around the airport. They were shackled to heavy metal balls and most looked emaciated and ill. I met with the Mayor and his council as well as some of the health personnel, got sufficient information to write a report and we flew back to Yangon two days later
Before we were to leave and fly to Thailand the head doctor from the AIDS ward caught up with me a begged me not to say anything about the shackled patients, it would do no good and make his life even more difficult. However consumed by righteous indignation and still naive about influencing in any way totalitarian regimes , I arranged through the Thai tried Cross to hold a press conference on the matter and told the media of the cruelty I had witnessed. This resulted in UNDP being told I would not again be granted a visa to visit Myanmar and the head doctor in the AIDS unit being demoted!
As much as possible I have kept a close eye on the HIV epidemic in Myanmar and am full of respect for all those who continue to deal with one of the most persistent HIV epidemics in Asia. Contacts had been telling me of the dangerous spread of HIV among the Rohingya exiles in Bangladesh where heroin is readily available. What will happen to fragile but successful programs to supply anti-retroviral drugs to the HIV infected in Myanmar with the cruel, deadly suppression of the peoples demand for democracy is just one of the problems that that will be associated with the murderous disruption of life in a country subjected to brutal suppression for so long.
Professor John Dwyer is an Emeritus Professor of Medicine at UNSW and the founder of the Australian Healthcare Reform Alliance.
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