Plagued by Inaction

Abstract

While the international community stands by idly, thousands of Burmese tragically fall victim to a health crisis with far-reaching implications.

In an impoverished rangoon suburb, at the frontline of Burma's losing battle against AIDS, is a shabby, one-room private clinic that serves more than 500 HIV-positive patients. Its only doctor, who requests anonymity for fear of arrest, does not dispense life-saving antiretroviral (ARV) drugs. A month of ARVs costs 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 that, for half the price of ARVs and often for free, she dispenses by the spoonful from a recycled Ovaltine 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.”

“We have no money—so no treatment,” says Daw Khin Maw, who along with her husband U Htein Lin tested positive for HIV several years ago. Their youngest daughter, two-year-old Ei Kyu San (seated) is negative. They have been too fearful to test six-year-old Phyo Htet Oo (standing), so his status remains unknown. They receive no support from the government. Daw Khin Maw sold her shop, and they now rely on her mother and siblings for support. “I don't support sanctions or the humanitarian boycott because I can't get the medicine I need,” she says.

Most of her male patients are truck drivers and migrant laborers; the women are largely sex workers returning from neighboring Thailand or, increasingly, part of Burma's own sex industry, which has thrived under the military dictatorship that has ruled the nation since 1962. With scanty scientific evidence, the doctor claims her treatment boosts her patients' CD4 counts (a way of measuring 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–leaving behind infected partners and parentless children. “We have so many orphans living with grandparents or other relatives,” she says.

Between 170,000 and 610,000 people in Burma live with HIV/AIDS, reports the Joint U.N. Programme on HIV/AIDS (UNAIDS), with a current rate of infection of around 1.3 percent. Other surveys put the infection rate at double that. These are hardly African levels (in sub-Saharan Africa, 7 percent of the adult population lives with HIV), but rates are increasing dramatically, and Burma's generals are doing nothing to stop the trend. 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 intravenous 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 health care 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 and coauthor of a recent report on the spread of serious infectious diseases in Burma. 1

This scourge is not just a national tragedy, but also a grave and growing regional threat–including to neighboring 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 U.N. Office on Drugs and Crime. Genetic fingerprinting of the virus has proved that Burma's heroin users and sex workers have spread the disease throughout Asia, the New York-based Council on Foreign Relations (CFR) reported 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 down to Indonesia–come from a single country,” wrote CFR senior fellow Laurie Garrett, the report's author. “This evidence suggests that [Burma] 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.” 2

Burmese heroin addicts in the Chinese border town Ruili. Fourfifths of China's HIV/AIDS cases can be traced back to Burma along heroin-trafficking routes, estimates the U.N. Office on Drugs and Crime.

Perplexingly, however, the international community has found this health threat less than compelling. Last August, the Global Fund to Fight AIDS, Tuberculosis and Malaria–an independent financing body created by the United Nations–withdrew funding from Burma worth almost $100 million over five years. The fund blamed travel restrictions (it can take weeks for foreign aid-workers to get permission to leave Rangoon) and other obstructions by the junta, which remains firmly in power despite harsh U.S. sanctions and softly-softly Asian diplomacy.

But another potential epidemic could galvanize the world into making new diplomatic efforts to tackle the 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 100 outbreaks of bird flu were reported across the country, with an official from the U.N. Food and Agriculture Organization (FAO) saying the situation was “more serious than we imagined.”

The Bush administration is worried. Post-Katrina, it is terrified of botching its response to avian influenza, says Beyrer. “They want to get it right,” he says. The virus has the potential to put the health of long-suffering Burmese on the U.S. radar in a way AIDS never could, since Burma has the potential to become an incubator for human-to-human bird flu. “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,” Beyrer says. “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 and arrested. “If we ignore it, it will destroy entire races.” The following year, the U.S. 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, Burma's entire budget for combating HIV/AIDS was just $22,000–though it spent millions annually on weapons for its 400,000-strong military–reported the Brussels-based International Crisis Group (ICG). This is a nation of more than 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.” 3

HIV is not the only disease ravaging Burma. It also has one of the world's worst tuberculosis (TB) 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, more than half of all Asia's malaria deaths in 2005 occurred in Burma, where the disease is the leading cause of death in children under 5 years of age. Poverty and malnutrition compound the problem: a quarter of Burmese live on less than a dollar a day, and a third of children under 5 years old are malnourished.

Despite all of this, Burma receives less humanitarian aid than almost every other poor country. Even Cuba–which, like Burma, is the target of sweeping U.S. sanctions–gets double the per-capita aid. The Global Fund's withdrawal was a serious blow. Under the 5-year program, some 5,000 of Burma's estimated 45,000 patients were due to receive ARVs; the money 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 U.N. Development Programme chief in Burma, told the Los Angeles Times in December. 4 And not just people in Burma, as the Global Fund 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 China. Its HIV infection rate is also rising. In 2005, it saw 25,000 deaths and 70,000 new cases, transmitted primarily through intravenous drug use and sex, according to a joint survey by China's Ministry of Health, the World Health Organization (WHO), and UNAIDS. Yunnan, which borders Burma, is among the worst-hit provinces. The so-called Burma Road, a trade lifeline that 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.

That's why analysts like Garrett argue that AIDS must be addressed in national and regional security terms. “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 explains in an interview. “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.”

For David Fidler, an expert in international law and public health at Indiana University, Burma's AIDS epidemic falls into the category of “microbialpolitik,” the international politics of infectious disease control. He believes intervention in Burma is justified under the “responsibility to protect,” a developing principle in international relations and law. While usually cited in relation to genocide and crimes against humanity, responsibility to protect could and should apply to infectious diseases, Fidler argues. “Look at the massive amount of human suffering that takes place because of pathogenic microbes,” he says. “For me, that provides not only a moral but perhaps a legal basis for not only the United Nations and the WHO, but also more importantly regional organizations like ASEAN [Association of Southeast Asian Nations] or APEC [Asia-Pacific Economic Cooperation] to engage with the Burmese government.”

There are “obviously complexities” with this approach, Fidler admits, “but look what happened with SARS.” Severe acute respiratory syndrome, a serious form of pneumonia, first emerged in southern China in 2002, killing nearly 800 people and infecting more than 8,000 in Asia, North America, and Europe. Chinese officials tried unsuccessfully to cover up the outbreak. “You essentially had the international community, led by the WHO, calling China on the carpet because its behavior was creating cross-border and transboundary harm to the rest of the world,” Fidler says. “That's exactly what's happening with tracing those HIV strains back to Burma.”

Fidler cites other precedents, such as cross-border environmental pollution, which is regulated by “treaties and all kinds of precautionary principles,” and says there is no reason why the same principles could not also be applied to AIDS and Burma. Add these existing principles, along with the responsibility to protect, “and you have more than enough of a moral and legal basis for engaging in diplomat intervention against the government of Burma,” Fidler concludes. “The harder question is political. How much leverage does anybody have over this regime?”

Refugees suffering from tuberculosis (TB) in the Sho Klo camp. About 40 percent of Burma's population is thought to be infected with TB, with about 97,000 new cases being diagnosed each year. Among patients with HIV, an estimated 60 to 80 percent also have TB, making it the most common AIDS-associated infection.

Up till now, not a lot. In December 2004, 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.” 5 That moment came, sort of, a year later. In a closed-door meeting described by the media and other U.N. officials as “informal,” senior U.N. official Ibrahim Gambari briefed the 15-member Security Council on Burma's deteriorating record on human rights and health, including its AIDS epidemic. But despite U.S. and British arguments that the junta poses a clear threat to international peace and security, Burma has stayed off the council's official agenda–thanks to the efforts of Burma's diplomatic patrons, China and Russia.

Still, says Garrett, this U.N. briefing was “significant,” although its impact on Burma's generals is hard to gauge. “Do they even care what the U.N. 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 Pyinmanaa, nearly 200 miles north of Rangoon, apparently prompted partly by the advice of soothsayers–junta chief Gen. Than Shwe is deeply superstitious–and partly by paranoid but longstanding fears of a U.S. military invasion.) Other analysts are cautious about reading too much into the U.N. briefing–or indeed, into Gambari's three-day visit to Rangoon in May, during which he met both General Shwe and imprisoned democracy leader Aung San Suu Kyi. “Is there going to be a serious amount of commitment from the Security Council to challenge Burma on a whole range of issues, not just HIV/AIDS?” Fidler asks. “It could just be more empty talk from the United Nations.” He believes diplomatic intervention by regional groups, such as ASEAN, might be more effective now that S ARS and bird flu have “sensitized” Asian leaders to the threat posed by emerging infectious diseases.

ASEAN's diplomatic efforts to date, however, have been ineffectual. Burma is the “great non-joiner,” the historian Timothy Garton Ash once noted, a country so non-aligned that, in 1979, it resigned from the non-aligned movement. But Burma did join ASEAN in 1997 and was scheduled to chair the regional grouping this year. Faced with a possible U.S. and European Union boycott of meetings held in the pariah state, the junta eventually turned down the chairmanship, much to the relief of many Southeast Asian diplomats. But Burma continues to heap humiliation on ASEAN, where the old principle of noninterference in the affairs of other member-states evidently outranks a new one such as the responsibility to protect.

Last December, ASEAN decided to dispatch Malaysian foreign minister Syed Hamid Albar to press its wayward member on reform. It took three months before the junta allowed Hamid to visit. He met Burma's prime minister and foreign minister but not Suu Kyi. He cut short his trip after just one night, perhaps feeling that the familiar reassurances he left with–the junta had promised to (in Hamid's words) “prove to the outside world that it is moving toward a road map to democracy”–were meaningless.

If ASEAN is sending any message to the generals, it is a mixed one. Returning from a trip to Burma in December 2004, then-Thai prime minister Thaksin Shinawatra described the jailing of Suu Kyi–who has spent 10 of the past 16 years in captivity, cut off from friends and family and denied medical attention–as “reasonable.”

Such remarks are unhelpful, not least because Thailand–a nation with a long history of authoritarian leaders (Thaksin among them)–could provide a model for the junta next door. 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 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 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 antiretroviral drug, no care [or] support at all,” said the doctor, and their beds in a large military HIV ward were immediately occupied by new arrivals.

Burma continues to heap humiliation on ASEAN, where the old principle of noninterference in the affairs of other member-states evidently outranks a new one such as the responsibility to protect.

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 or “trusted friend”–is imported and sold cheaply by Population Services International (PSI), a nonprofit group based in Washington, D.C. 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 of 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 organizations only legitimizes an evil regime. Republican Sen. Mitch McConnell of Kentucky campaigned for the Global Fund's withdrawal. (Brian Williams, head of UNAIDS in Burma, likened the withdrawal to withholding food from refugee camps.) Even Garrett, whose report dramatically underscored the urgency of tackling the epidemic, likens the efforts of U.N. agencies and foreign aid groups to “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 Beyrer. Surprisingly, perhaps, the junta cooperated with the FAO by, for example, promptly sending specimens of potential bird flu cases 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.” 6

A quarter of Burmese live on less than a dollar a day. Burma receives less humanitarian aid than almost every other poor country. Even Cuba–which, like Burma, is the target of sweeping U.S. sanctions–gets double the per-capita aid.

Recently, the FAO provided $40,000 in emergency assistance to the Burmese government, including laboratory and personal protection equipment. That the junta should accept such an offer 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 that 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 that have hampered all humanitarian work in Burma. Equally significant, the prospect of an emerging H5N1 pandemic could prompt ASEAN countries–who lost billions in the economic impact of SARS–to finally get serious about pressuring Burma to undertake internal reforms. Beyond concerns over public health, China in particular has a vested interest in preventing Burma from imploding. Chinese leaders worry about the impact that social turmoil could have on their southern provinces. Up to a million Chinese migrants have settled in Mandalay and upper Burma in the last decade. As analyst Min Win recently told the Asia Times, “The last thing Beijing needs is thousands of Chinese migrants flooding back across the border, increasing the number of restless, unemployed Chinese peasants looking for work in the country's main urban centers and adding to China's growing social and rural unrest.” 7

Tragically for Burma, viruses move faster than both diplomats and dictators. As the authors of the Johns Hopkins report observed, “While reform in Burma has been painfully slow, disease spread can be markedly rapid.” Meanwhile, the doctor at the makeshift AIDS clinic will continue to spoon-feed herbal remedies to her impoverished patients in the suburb of Rangoon where, according to one former resident, they are already dying “like leaves falling from a tree.”

Supplementary Material

Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Myanmar

Supplementary Material

Response to HIV and AIDS in Myanmar