OCTOBER 16, 2000 VOL. 156 NO. 15

John Stanmeyer. A three-year-old boy plays beside the coffin prepared for his mother, who died of AIDS contracted from her late husband.

Back to No Future
Once a model for how to control AIDS, Thailand now is losing the battle. Blame changing sexual habits and cuts in state spending
By ROBERT HORN Bangkok

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Nearly 400,000 Thais owe their lives to Senator Mechai Viravaidya. When AIDS began exploding across Thailand in the late 1980s, Mechai, then an economist active in family planning issues, began his now famous campaign to get people to use condoms to stop the spread of the disease. He handed them out to prostitutes in red-light districts. He blew them up like balloons in front of startled housewives. Thais began calling condoms "mechais" and Mechai "Mr. Condom." Appointed to the cabinet in 1991, he helped launch what the World Bank called "one of the few international examples of an effective national AIDS prevention program." Although nearly 1 million Thais have been infected with the HIV virus, the institution estimates the number is 395,000 lower than it would have been without the program.

But tragically, Thailand is slipping backward. Changes in local sexual behavior mean new groups are now at higher risk. Demand for treatment from the growing numbers of infected people is taxing scarce resources. And perhaps most critically, the Thai government since 1996 has been steadily cutting its AIDS expenditures. "This is one case where stupidity is proving to be worse than corruption," Mechai says. According to a draft of a World Bank report scheduled for release at the end of this month, the current AIDS budget of $34 million is 28% less than it was four years ago. Public spending on prevention has declined by half. As a result, the report says, HIV infections, which had been declining overall, are now increasing among several risk groups, including pregnant women, children, sex workers and soldiers. Volunteers at counseling centers and outreach groups say that AIDS is also rising among teenagers, housewives and office workers. Mechai says that, aside from the heavy economic and personal tolls of caring for ever-larger numbers of AIDS sufferers, "losing so many people who can make valuable contributions to our society will be devastating for our future."

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Thailand's approach to the crisis is being watched closely by other Asian nations, which will face a similar situation in coming years. Thailand was the first country in the region to be hit by the epidemic, with the initial cases recorded in 1984. Now 55,000 Thais develop AIDS every year, and the strain on health services is mounting. "We have not lessened our commitment to fighting aids," insists government spokesman Akaphol Sorasuchart, "but we have some tough choices." If the choices are tough for Thailand, imagine what they will be like for poorer countries such as Vietnam, Burma and Cambodia, where infection rates are still on the rise. The same can be said for China, which has an estimated 500,000 heroin addicts in Yunnan province alone. Akaphol says that the budget was cut largely to consolidate programs that were being duplicated by various agencies. Mechai disagrees: "The government can spend millions on F-16s, but can't find money for aids. It's a national disgrace."

The face of AIDS in Thailand is changing, says Phakamas Ardpoon, who supervises telephone counselors at Access, an AIDS outreach group. "Before, most of our calls were from men," she says. "Now it's mostly women concerned that they may have been infected by boyfriends or husbands." Thailand has one of the world's most visible sex industries, with perhaps as many as 1 million prostitutes out of a population of 61 million. But Thai men, fearful of aids, are patronizing prostitutes less and having more affairs with office women, salesgirls and friends. Most of the men, according to AIDS researchers, are not using condoms. "It's not just a matter of money," says Senator Jon Ungpakorn, who founded Access. "Our prevention strategies haven't been keeping up with the situation." What AIDS information campaigns there are, he says, aren't doing enough to target those involved in non-commercial sexual activity, and when they do, the messages are so repetitive and frightening that many people tune them out. "There is something like AIDS fatigue in Thailand," he says. "The challenge for AIDS groups is to find new, effective ways to get the message across."

As they search for that message, the death toll mounts and medical facilities can't keep up. In Bangkok's portside slum Klong Toey, those turned away from hospitals often end up with Father Joe Maier. A Redemptorist priest who came to Thailand 33 years ago, he tends to those sick and dying of AIDS in his 45-bed hospice. A new facility with 150 beds is under construction, but if he had 500, Father Joe says, they would all be full. "If you want to fight aids, it has to be total war," he says. "The entire community must be involved, because AIDS affects the entire community. This is not a fight we can leave to big drug companies or the government." Father Joe certainly isn't waiting for them to take the lead: about 95% of his funds come from private donations.

At the hospice, no one knows how much longer 11-year-old Nong Bhoei has to live. She was born with HIV in Klong Toey, where violence and drug addiction are rife. Her mother, a janitor, and father, a trucker, hadn't known they were infected. When she was nine, Nong Bhoei awoke one morning and watched as her mother, then suffering from full-blown aids, hanged herself. Wanting nothing more to do with his family, her father abandoned her at Father Joe's hospice. She weighed just 12 kg at the time. A private donor is paying for her treatment with antiretroviral drugs. She's up to 22 kg, although her ghost-white skin is still dappled with maroon blotches. Surrounded by wards filled with the skeletal figures of those dying from the same disease she has, Nong Bhoei somehow manages to smile. "I want to go school," she says. Usanee Kanngeon, who cares for the 16 HIV-infected children at the hospice, says she may get her wish. If her infections keep healing and she puts on a bit more weight, she may be able to attend secondary school next semester. "She's a fighter," Usanee says. "But there is no way to know if her health will continue to improve. When they get ill and go, they go so quickly."

Nong Bhoei is part of what's known as the sixth wave. When AIDS first hit Thailand it started with homosexuals, then spread to drug users. The third wave infected prostitutes, while the fourth swept over their customers. They, in turn, infected wives and girlfriends, the fifth wave. The sixth consists of the children of those women. But few believe this is the final wave. "The situation is only going to get worse," Usanee says. "We should be getting more government support, but we're not." Government spokesman Akaphol says the state's resolve shouldn't be measured just in terms of money. "The AIDS budget is less, but it's being spent more effectively," he says. The only thing measurable is that the tide of death is rising across Thailand once again.

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