Addressing the HIV/AIDS Epidemic in Burma; Dilemmas of Policy and Practice Running Title: HIV/AIDS Policy in Burma Chris Beyrer MD, MPH, Hnin Hnin Pyne PhD The Departments of Epidemiology (CB) and Health Policy and Management (HHP), Johns Hopkins University School of Hygiene and Public Health.
3077 words
Key Words: Burma health policy HIV/AIDS heroin trafficking human rights |
Summary The people of Burma (Myanmar) currently face a severe epidemic of HIV infection. Estimates of the HIV burden are crude, but range from 400,000 to 700,000 persons infected by 1997. After initial outbreaks among injecting drug (heroin) users, HIV rates have risen rapidly among heterosexual men, and among women and infants. HIV infection has spread widely across the country and among most ethnic groups. HIV/AIDS education, drug treatment, prevention, and care programs remain markedly inadequate and under-resourced, a situation due at least in part to the profound impact of Burma’s unresolved political crisis on both domestic and international health activities. Since 1988 the country has been ruled by a military junta, SLORC, which has censored all media, ignored the results of democratic elections, and committed widespread human rights violations. Hence, Burma’s political crisis has generated several dilemmas for HIV/AIDS policy and practice. Policy options for local groups, donors or international NGOs are limited; choose not to engage with SLORC and so not to work in Burma; attempt to engage the junta on mutually acceptable grounds, should these exist; cooperate with the junta and accept that such cooperation may be used by the regime in seeking international legitimacy. Several examples exist for each of these approaches. The National League for Democracy (the party chaired by Aung San Suu Kyi, which won the 1990 national elections) position on HIV/AIDS programs has been that education and prevention are priorities, and they have invited the consultation and participation of donor agencies, NGOs, and regional governments in achieving these goals. Their activities are currently sharply curtailed by the military, however, and are unlikely to have significant impacts in the short term. They may, however, have the greatest likelihood of success in the long-term in addressing Burma’s health and humanitarian crises.
Introduction
--Aung
San Suu Kyi The people of Burma (Myanmar) currently face a severe epidemic of HIV infection. Measures of the HIV burden are crude, and Burma’s national statistics known to be incomplete and unreliable, but estimates range from 400,000 to 700,000 persons infected by 1997.(1,2,3) After initial (and ongoing) outbreaks among injecting drug users, HIV rates rose rapidly among heterosexual men, among blood donors, and are now rising rapidly among women and infants.(2) HIV infection has spread widely across the country and among most, if not all, of the countries’ many ethnic groups.(4) While little data exist for the country’s far west, HIV rates in the central , northern, and southern regions are all high and rising. The Joint UNAIDS of the United Nations has identified the four hardest hit countries in the Asian region, they are, in order of HIV prevalence; India, Thailand, Burma (Myanmar), and Cambodia.(5) There is increasing awareness in the public health community that the Burmese epidemic is one of Asia’s fastest growing and most pervasive. Prof. John Dwyer, Founding President of the AIDS Society of Asia and the Pacific, stated in June, 1997, that "Burma is the epicenter of the epidemic in Asia." (3) An international panel convened by UNAIDS and AIDSCAP at the most recent Asia-Pacific Conference on AIDS, in Manila in 1997, rated the Burma as having "High and rising HIV prevalence, and high and rising HIV incidence," the worst of the committee’s possible scenarios.(6) Burma’s epidemic has components attributable to multiple risks and vulnerabilities: needle sharing among the country’s large population of heroin injectors; an unsafe blood supply and lack of universal precautions in health care settings; heterosexual transmission facilitated by a growing local commercial sex industry, trafficking of Burmese women and girls into the regional sex industry, untreated STDs, very low condom use and availability, and lack of sexual health information and programs.(7) In addition, Burma is increasingly recognized as one of the world’s largest heroin producing and exporting states; domestic use rates are among the highest in the world, from 2-25% of adults in a 1995 UNDCP multi-community survey.(8) Burmese heroin exports to India, China, and Thailand have fueled regional outbreaks of drug use and HIV infection in Burma’s border areas, including India’s Manipur State, Yunnan and Guangxi Provinces in China, and Thailand’s northern border provinces.(9,10,11)
HIV/AIDS education, drug treatment, and prevention and care programs remain markedly inadequate and under-resourced, a situation due at least in part to the profound impact of Burma’s unresolved political crisis on both domestic and international health activities. Since 1988 the country has been ruled by a military junta, SLORC, (The State Law and Order Restoration Council; now the National Peace and Development Committee) which has censored all media, ignored the results of democratic elections, and committed widespread human rights violations. These human rights violations, and the rapid escalation of opium poppy cultivation and heroin exports under SLORC, led to the imposition of economic sanctions (The International Emergency Economic Powers Act, IEEPA) against the regime by the United States in July, 1997. Other donors have also limited development and humanitarian assistance. There is a standing UN resolution calling for restoration of democracy in Burma, which the junta has ignored since 1990. Domestic resources for health expenditures have been exceptionally low; fully 60% of reported government revenues have been for military expenditures.(12) The National AIDS Program budget was estimated at US$ 50,000 in 1996 for a country of perhaps 45 million persons.(13) Burma’s political and humanitarian crisis has generated several dilemmas for HIV/AIDS policy and practice.
Policy Options and Dilemmas HIV/AIDS policy options for local groups, donors or international NGOs are limited; choose not to engage with SLORC and potentially not to work in Burma; attempt to engage the junta on mutually acceptable grounds, should these exist; attempt to cooperate with the elected leadership and the leaders of Burma’s ethnic nationalities, if possible; cooperate with the junta and accept that such cooperation may be used by the regime in seeking international legitimacy. Several examples exist for each of these approaches, though rigorous analysis of programmatic outcomes, where available, would likely suggest that under the current regime, none have been able to impact significantly on the rapid spread of HIV in the country. The International Committee of the Red Cross, ICRC, withdrew its staff and funding from Burma in 1995, after the regime repeatedly refused to allow ICRC to monitor the health status of political prisoners.(4) ICRC did this publicly, and stated their reasons for withdrawal to the media and the international donor community. In contrast, UNICEF continues its activities in Burma, while complying with SLORCs dictates to avoid involvement of the National League for Democracy (NLD) and its members in its activities. In 1995, for example, UNICEF Rangoon agreed to produce an HIV/AIDS education pamphlet in collaboration with the NLD. The pamphlet included a message from Aung San Suu Kyi, Burma’s elected leader, and frank prevention messages for youth. The pamphlet was produced but never released, after objections from the junta. Suu Kyi then requested that UNICEF give her party the materials for distribution among the youth wing of the party. This request was denied, and the pamphlets remain embargoed. (Personal Communication with the author, N.L.D. officials, Rangoon, 1997) Several international NGOs, including Medecins du Monde, Medecins San Frontiers, and World Vision, now have HIV/AIDS programs in Burma, and all have signed Memorandums of Understanding (MOU) with the junta. While the content of these MOUs has not been made public, it is known that meeting with the NLD, or cooperating with its members, is not tolerated by the junta.(14, 15) Each of these programs has been cited by SLORC in defense of the regime at the annual UNHCR review by the Special Rapporteur on human rights in Burma.(14, 16) While some of these groups have mounted promising HIV/AIDS programs, their activities are currently small-moderate in scale, and none is attempting country-wide programs. At least one, World Vision, currently collaborates with the junta’s civilian arm, The Union Solidarity and Development Association (USDA), which all international groups agree is controlled by the junta, and has been widely implicated in human rights abuses and the intimidation of democratically elected leaders. (Southeast Asian Information Network, Chiang Mai, 1998). Another approach, taken by several groups and media organizations, including the Democratic Voice of Burma, Voice of America, The BBC, and the National Health and Education Committee of the Union of Burma, has been to work "cross-border" directly engaging in HIV prevention and education activities without the permission of the junta. The radio media groups provide the only uncensored HIV/AIDS information currently available to the people of Burma. While unable to work in much of the country, these organizations have been able to reach vulnerable border groups, and to provide educational information without collaborating with SLORC. This policy approach attempts to address Burma’s health and humanitarian crises without empowering the junta. While currently small in scale, these organizations do have the support of many ethnic minority organizations and political groups opposed to the junta. Practical dilemmas for groups working with SLORC or the agencies it controls (these include USDA, the Myanmar Red Cross, and the Myanmar Medical Association) have been problematic; how to ensure human rights for staff, program participants and research subjects in a context in which citizen’s rights are not assured; how to address the severe lack of resources in an aid-limited setting; how to promote HIV/AIDS prevention and harm reduction activities with a government widely held responsible for 40-60% of the world’s heroin supply; how to engage the elected leadership of Burma in prevention activities given the limitations on their activities imposed by the junta. While some of these dilemmas are perhaps unique to Burma, similar situations have been faced in other settings, including engagements in health in Apartheid era South Africa, and the current dilemma over HIV/AIDS funding in Cambodia after that country’s recent coup d’etat. In the case of Burma, however, there is a political entity with a popular mandate to speak for the diverse peoples of the country; the NLD chaired by Aung San Suu Kyi, which won the 1990 national elections.(17) Their position on HIV/AIDS programs has been that education and prevention are priorities, and they have invited the consultation and participation of donor agencies, NGOs, and regional governments in achieving these goals. Their activities are currently sharply curtailed by the military, however, and are unlikely to have significant impacts in the short term.
Internal Policies of the SLORC (State Peace and Development Council) that impact on HIV/AIDS in Burma: Are their policies and practices of the ruling junta that directly impact on HIV/AIDS? It could be argued that a number of current explicit or policies or documented practices of the junta are of significant import to the epidemic. At least two steps have had a potentially positive impact, several others negative ones. Positive steps include the 1993 decision to make condoms, previously illegal in Burma, legal for sale and distribution.(1) While Burma continues to have very low rates of condom availability and use, condoms are now sold openly in the country’s markets. Until 1994, donors were required by the junta to exchange all aid monies at the official bank rate, then approximately 6 kyat to the U.S. dollar.(4) Because the actual value of the kyat was perhaps 120 kyat to the dollar on the country’s extensive illegal currency market, this amounted to a huge loss in the value of donations, and enabled the junta to collect perhaps 90% of donations in direct foreign exchange. The reversal of this policy allowed donors to spend funds at actual kyat market values, and this had a significant impact on donors’ ability to operate in Burma. Policies with clear negative impacts are several, and relate to risks from injection and sexual risk. Burma continues (as does the U.S.) to criminalize the non-medical use of needles and syringes.(18) These so-called "drug paraphernalia" laws discourage injecting drug users from carrying their own needles, and have facilitated Burma’s culture of "tea-stall" injection sites, where addicts can get both heroin doses and syringes, the latter typically used my multiple addicts without sterilization between uses. The recent joint venture enterprises, including a bus transport company in the Shan states, with Khun Sa, the Shan opium magnate, and other indicted (by the U.S.) narcotics figures have established the tolerant relationship of the junta to economic enterprises based on narcotics revenues.(19, 20) This policy has created a safe business climate in Burma for laundering drug revenues, with predictable consequences for domestic heroin availability, already among the highest in Asia.(8). Spill-overs of the Burma heroin industry are causing problems for other countries in the region, notably India and China. The road leading out of the western Chin hills and into India's frontier state of Manipur carries increasing volumes of heroin. Manipur, closed to the world through years of ethnic insurgency, now has one of India's worst heroin addiction problems, and by far the highest HIV rate of any state in that country.(9) Ethnic peoples on both sides of this border are heavily affected, and heroin is reaching India's cities and her youth. The Burma spill-over into China, has led to an epidemic among injectors in 3 border districts of Yunnan Province, which accounted for approximately 60% of China's entire HIV burden in 1996;(11) making control of Burma's heroin trade an issue of national importance for her, as well as for India. The continued use of civilians for forced labor projects, forced porterage for the military, and forced sexual service for soldiers by ethnic minority women in several states, most notable the Shan states, have led to a further tide of refugees into Thailand.(15, 21) Women and girls fleeing these human rights abuses continue to become part of the extensive sex trafficking industry in Thailand and further afield.(22) These women are at extraordinarily high risk for HIV infection, particularly those from rural and tribal areas, who may have little awareness of the risks of HIV infection, or indeed of the infectious nature of some diseases. While the junta has defended forced labor as "voluntary" and a part of Burma’s tradition of merit-making for the public good," the dangerous conditions and high morbidity and mortality of forced and impressed laborers has led to many thousands of illegal crossings each year.(21) Recent reports have confirmed the existence of camps in the Shan States which the junta has established for Burmese women and girls returned from the sex industry in Thailand.(23) In 1996 many of these women were being housed in leprosy colonies; a disastrous public health policy.(7) In 1997-1998, interviews with women who had escaped, or been sold out of these camps by SLORC officials for the domestic sex trade, have revealed a system of several internment camps. HIV infected women who appear asymptomatic have been sold into prostitution out of these camps, with proceeds going to SLORC commanders.(23) Censorship of all media is one of the junta’s central domestic policies. As the Burma scholar Martin Smith as argued, this censorship has had profoundly negative impacts on the health of the Burmese people.(12) Because HIV/AIDS is a new and complex disease, information is one of the cornerstones of prevention world-wide, so it could certainly be argued that this policy can only have increased the population’s vulnerability, through, fear, ignorance and misinformation.
Discussion: HIV/AIDS and Human Rights in Burma Burma in 1998 can be characterized by a political culture marked by state violence and corruption, chronic civil war and insurgency, and an explosive and recent epidemic of HIV infection. These realities may be linked, indeed, they may be inseparable. An examination of global HIV/AIDS epidemiology in the developing world suggests that this situation may not be unique. Uganda in the recent past could be used to make the same argument, as could Haiti under its violent and chaotic military rule; other examples could include Congo/Zaire, Rwanda, Burundi, and Cambodia. These are countries that have shared the misfortune of having HIV affect their populations during periods of civil strife under incompetent governments, when civil society, human rights, and health care in general were profoundly endangered. Supporting such regimes, and lending them legitimacy through donation of HIV/AIDS monies, may assist in prolonging the political and social situations which have led to explosive HIV spread. The Burmese junta is actively seeking such legitimacy, and recently defended itself in the December, 1995, U.N. hearings on human rights violations in the country by listing the number of international agencies and NGOs collaborating with them on HIV/AIDS programs, among others. While researchers and prevention experts may bear no ill intent, and indeed may struggle to establish ethical standards for their own projects in countries like Burma, there are larger ethical issues at stake. Burma has lost so many of her health professionals, educators, and civil servants not because of poverty or lack of support for social programs, but through repression, imprisonment, and murder. The junta itself has helped create the lack of needed professionals. To support such regimes, particularly, as Aung San Suu Kyi has said, when we ourselves come from countries which tolerate basic freedoms and human rights, is, if we accept this premise, illogical in itself, whatever "good" we believe we are doing by our presence. A new paradigm for understanding the relationships of public health problems and political realities may be required if we are to address challenges like the spread of HIV/AIDS in countries in turmoil. While humanitarian assistance and strict ethical standards for international involvement must remain priorities, the integration of human rights and political realities into public health discourses and analyses is needed. At the last Asia Pacific meeting on AIDS, a call was made to "de-politicize" AIDS in Burma.(3) Perhaps the precise opposite approach is called for; to recognize and attempt to respond to the crucial impact political and social realities have on the dynamics of this, and other, diseases. In Burma citizens are denied freedom of speech, of assembly, of a free press, of the right to vote, the right to organize independent non-governmental organizations, and to criticize the junta and its policies. Arbitrary arrest, incarceration without trial, and extra-judicial execution have all been documented against SLORC.(15, 24) Can the rights of people with AIDS be addressed in any meaningful way without taking into account the wider reality of human rights under this regime? To phrase the question differently: can a political body with such policies be expected either to respect the rights of people with or without HIV/AIDS, or to enact effective HIV/AIDS programs?
Conclusion: Dialogue or Devastation Upon her 1995 release, after six years house arrest, Aung San Suu Kyi stated that Burma faced either "dialogue or utter devastation." The junta continues to refuse dialogue, and Suu Kyi’s prediction of devastation, of which Burma’s HIV epidemic is certainly a part, seems only too likely to be coming true. Is there a way forward? The NLD position has been that engagement of the elected leadership and the leaders of Burma’s ethnic nationalities is essential to the resolution of Burma’s political and humanitarian crisis. If we agree with this position; the only one which has the support of Burma’s electorate, then organizations and groups which seek to assist the people of Burma have really only one option--to include the NLD and its local supporters in HIV/AIDS prevention and control programs. If doing so endangers their ability to work in the country, difficult decisions will have to be made. But to comply with the junta and further undermine the democratic aspirations of the Burmese people is highly unlikely to support real improvements in the health of the Burmese people, to affect the burgeoning heroin sector, or to reduce the already catastrophic effects of HIV/AIDS. |
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19.
Reuters. "Khun Sa thrives after rebuilding empire."
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