The Coming Plague (87 page)
Authors: Laurie Garrett
The HIV-1 strains were all quite similar and matched closely to a strain of the virus found in South Africa. Given the large number of Indian-descended people living in South Africa and their frequent travels back to India, this was not surprising. But it was astonishing, the researchers said, to discover so little genetic difference between HIV-1 strains in Bombay, Goa, Manipur, and other locations separated by thousands of miles.
“We conclude that these [HIV-1] strains must have been introduced into
India very recently and are spreading
very
rapidly,” the German research team said.
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India very recently and are spreading
very
rapidly,” the German research team said.
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HIV-2 also showed little genetic diversity in India, again indicating that the virus had arrived in the country very recently. Further, all HIV-2 strains appeared to be descended from a common ancestor, indicating that a single infected individual brought the virus from West Africa; its emergence and spread within Indian society occurred with extraordinary speed.
By comparing HIV-1 and HIV-2 incidence rates throughout India in early 1993 with the amount of genetic diversity seen in the various viral strains, the Frankfurt research team estimated that India's epidemic was growing by 1 million new infections a year. If Congressman McDermott's estimate of 1 million infected Indians was correct for 1991, and the Frankfurt growth rate held true, the world's oldest continuous civilization would be confronting about 10 million HIV cases in 2000.
But, of course, epidemics couldn't be expected to grow at a stagnant rate over time because the more people infected in a society, the greater the potential for additional infections. Thus, growth rates themselves grew with time. When officials at WHO plotted India's AIDS forecast they were reluctant to put precise figures on the nation's future epidemic. But they were able to compare its growth rate with Africa's: while the slope of Africa's pandemic arched upward at a gentle angle for the 1990s, India's forecast was a sharp line soaring up at a 60-degree angle.
“This is threatening to clear the world,” Kenyan AIDS physician Mboya Okeyo said. “Africa first. Then India, then Southeast Asia. Then, who knows?”
In 1993 Subhash Hira moved back to Bombay. Having witnessed the emergence of AIDS in Zambia he was now determined to do all in his power to slow the deadly virus's race across his homeland.
If India's epidemic was racing, Thailand's was moving at supersonic speed. Thai Ministry of Health studies showed that HIV-1 infection rates in nearly every sector of society were well below 2.5 percent in 1989. Eighteen months later double-digit infection rates were the norm all over the country.
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Something particularly strange and troublesome happened in Thailand: two separate lineages of HIV-1 emerged, each exploiting entirely different population groups. Among Bangkok's heroin injectors there appeared a B-class virus that looked genetically like a typical American HIV. But a very different HIV emerged in Thailand's prostitute and heterosexual populations, one that closely resembled a virulent virus seen in Uganda. The two strains moved on separate paths in Thailand, and as of 1993 there was no evidence of cross-mixing of their genetic material.
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So Thailand, biologically speaking, had two separate epidemics, both of which grew at unprecedented rates.
The Thai situation demonstrated the folly of dismissing the threat of an emerging microbe merely on the basis of initially small numbers of cases.
And it showed, once again, the links between human rights and the emergence of microbes new to a particular society. In the beginning of its epidemic the Thai government took many of the toughest steps advocated by hard-liners elsewhere in the world. A special HIV quarantine unit was established in Lard Yao Prison in Bangkok. When, by June 1989, tests indicated that up to 44 percent of the female prostitutes in Chiang Mai were HIV-positive, the government issued decrees in an attempt to crack down on the brothels. As rates of infection soared among heroin addicts, the government ordered Thai police to come down hard on the drug trade and narcotics injectors. Infected foreigners were deported.
And it showed, once again, the links between human rights and the emergence of microbes new to a particular society. In the beginning of its epidemic the Thai government took many of the toughest steps advocated by hard-liners elsewhere in the world. A special HIV quarantine unit was established in Lard Yao Prison in Bangkok. When, by June 1989, tests indicated that up to 44 percent of the female prostitutes in Chiang Mai were HIV-positive, the government issued decrees in an attempt to crack down on the brothels. As rates of infection soared among heroin addicts, the government ordered Thai police to come down hard on the drug trade and narcotics injectors. Infected foreigners were deported.
Thailand also took positive steps that drew praise from WHO, including establishing the first national HIV sentinel surveillance program in the developing world. By carefully and continuously monitoring levels of HIV infection in key subpopulations of Thai society, the Ministry of Health kept close tabs on the nation's burgeoning epidemic.
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It may well have been the best-documented HIV emergence in any society in the world.
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It may well have been the best-documented HIV emergence in any society in the world.
Despite these efforts the virus spread at record speed throughout the Southeast Asian nation, primarily via its enormous sex industry. As word of the new plague spread, few Thais took steps to protect themselves. Denial, Thai health official Dr. Chai Podhista said in 1992, was the number one problem.
“We have an expression in Thailand,” Podhista explained. “It goes, âIf you don't see the body in the coffin, you don't shed a tear.' Rapid spread of the virus is possibleâis ignoredâbecause there hasn't yet been mass death. And there won't be for a few years. Hundreds of thousands of people are all getting infected at once, in a clandestine epidemic. Years from now when they all get AIDS the entire Thai society will go into a state of shock.”
In early 1990 a variety of nongovernmental organizations waged impressive AIDS education campaigns, particularly among female prostitutes, and by late 1990 more than 90 percent of the prostitutes working in Chiang Mai were using condoms. But for the majority of the women it was too late: they were already infected.
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At the most crucial moment in its emergence into Thai society, HIV was handed a social gift: human chaos. In February 1991 there was a coup in Thailand, bringing a military junta to power.
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AIDS programs came to a grinding halt; the flow of nearly all foreign aid, including monies earmarked for HIV control, stopped abruptly. AIDS programs generally fell apart, and the military regime responded to the HIV threat with the sorts of repressive actions that typify juntas: conducting raids on brothels, shutting down those that failed to provide adequate bribes, and rounding up children, alleged slaves, and foreign men and women working in the houses of prostitution.
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AIDS programs came to a grinding halt; the flow of nearly all foreign aid, including monies earmarked for HIV control, stopped abruptly. AIDS programs generally fell apart, and the military regime responded to the HIV threat with the sorts of repressive actions that typify juntas: conducting raids on brothels, shutting down those that failed to provide adequate bribes, and rounding up children, alleged slaves, and foreign men and women working in the houses of prostitution.
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During this time there was little apparent change in the sexual appetite of male customers. Foreign sex tourists continued to flock into Thailand from all over the world, particularly Japan
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and Germany. And local Thai
men showed no signs of slackening their demand. A 1989â90 survey showed that more than a quarter of randomly queried Thai men had sex outside their marriage that year, most of them with male or female prostitutes.
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A year later no apparent change was observed, and upon compulsory entry to the Thai military more than 97 percent of the twenty-one-year-old recruits admitted to having frequented brothels.
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and Germany. And local Thai
men showed no signs of slackening their demand. A 1989â90 survey showed that more than a quarter of randomly queried Thai men had sex outside their marriage that year, most of them with male or female prostitutes.
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A year later no apparent change was observed, and upon compulsory entry to the Thai military more than 97 percent of the twenty-one-year-old recruits admitted to having frequented brothels.
As more and more of Thailand's prostitutes became infected, and concern about AIDS rose, brothel owners began actively recruiting virgins and young girls. This allowed them to market safety for their male clientele, though, of course, it remained extremely risky for the women/girls. Various studies indicated that between 1991 and 1993 the demographics of Thailand's female prostitute population shifted dramatically, particularly in the northern Chiang Mai area, which bordered on Burma. The average ages of the prostitutes plummeted (to include nine- to twelve-year-olds), and the number of Burmese women working in the brothels soared, topping 40 percent by 1993.
According to Amnesty International and Human Rights Watch, nearly all the Burmese female prostitutes were slaves, either sold outright by their parents to brothel brokers or signed on to indentured servant contracts from which they couldn't extricate themselves once they reached Thailand. Few of the girls, most of whom were under eighteen years of age at the time of their sales/recruitments, understood that they were to be prostitutes. The vast majority were illiterate, spoke no Thai, and were virgins when they reached their new brothel homes.
Periodically, Thai police would raid the brothels, round up Burmese nationals, and march them off to the border. Some women, fearing what lay in store for them on the other side, gave sexual favors to the police in exchange for allowing them to return to lives of prostitution.
But what could possibly be more horrible than the lives of sex slavery to which they had been subjected in Thailand?
In September 1988 the Burmese government was overthrown in a coup that brought the most corrupt elements of the country's business and military communities to power. Ne Win took the reins of control, running an authoritarian state that cracked down mercilessly on its citizenry while assiduously protecting the nation's opium/heroin producers. The country, which was renamed Myanmar,
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sank into chaos. Amid reports of torture and mass executions, as well as economic despair, demonstrations broke out all over Burma in 1990, led by supporters of Aung San Suu Kyi. Though she won the national presidential elections in May 1990 and subsequently received the Nobel Peace Prize, Aung was placed under house arrest. As of mid-1994 she remained a homebound prisoner of the military state.
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sank into chaos. Amid reports of torture and mass executions, as well as economic despair, demonstrations broke out all over Burma in 1990, led by supporters of Aung San Suu Kyi. Though she won the national presidential elections in May 1990 and subsequently received the Nobel Peace Prize, Aung was placed under house arrest. As of mid-1994 she remained a homebound prisoner of the military state.
The government's actions after the 1990 elections only worsened, and the nation became dangerous for all vocal advocates of human rights. Small wonder, then, that Burmese poured illegally across the Thai border by the hundreds every day, and some 300,000 were estimated to have immigrated
by 1993. It was perhaps less than surprising also that impoverished parents were willing to sell their daughters to brothel brokers.
by 1993. It was perhaps less than surprising also that impoverished parents were willing to sell their daughters to brothel brokers.
In April 1992, Commander Bancha Jarujareet of the Thai Crime Suppression Division announced that twenty-five HIV-positive Burmese brothel girls that had been rounded up by his officers and deported back to Burma were dead. According to the Thai policeman, Burmese officials injected cyanide into the women and set their bodies afloat in a border stream as a warning that Burma would take whatever steps necessary to keep AIDS out of the country.
In Burma, heroin was locally produced and could therefore be purchased cheaply with the internationally worthless Burmese currency. But syringes required foreign exchange, and the abusive Burmese state had become an international pariah, cut off economically from the rest of the world.
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By 1992, WHO estimates put HIV infection rates among Rangoon's heroin injectors at over 76 percent, but that was a conservative guess. Even if these people knew about HIV, understood how the virus was spread, and were motivated to protect themselves, they couldn't do so.
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By 1992, WHO estimates put HIV infection rates among Rangoon's heroin injectors at over 76 percent, but that was a conservative guess. Even if these people knew about HIV, understood how the virus was spread, and were motivated to protect themselves, they couldn't do so.
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Fortunately for the Thai people, their nation had, in contrast, a courageous local hero who was willing to take politically dangerous steps to slow the country's skyrocketing epidemic. Mechai Viravaidhya worked within the Ministry of Health and outside the government (depending on who was in power) tirelessly promoting condom use. Equally comfortable arguing with a brothel owner in a Bangkok red-light slum or twisting the arm of a member of the Thai cabinet during a celebrity golf match, Mechai forcefully pushed a “100 percent condom use” policy.
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But even Mechai knew that the real battle had been lost. AIDS was endemic in Thailand, and in 1993 the government predicted that 3 million adults (out of a population of 25 million over the age of fourteen) would be HIV-positive by the year 2000.
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But even Mechai knew that the real battle had been lost. AIDS was endemic in Thailand, and in 1993 the government predicted that 3 million adults (out of a population of 25 million over the age of fourteen) would be HIV-positive by the year 2000.
As was the case in Burma and India, the Golden Triangle heroin connection was having an effect on promoting HIV emergence in southern China. Though the government denied it, China had serious heroin, prostitution, and sexually transmitted disease incidences that were readily apparent to even casual observers as early as 1987.
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The most severe problem was in China's southern Yunnan province, which shared borders with Laos and Burma and had long been an opium center. Yunnan narcotics traffickers, like their counterparts in Burma, had learned how to process opium into heroin. By 1991 heroin was in ready supply in Yunnan; syringes were not. The pattern there mirrored what had occurred with HIV among heroin injectors in Manipur and Rangoon, and by 1993 the World Health Organization was estimating that up to a third of Yunnan heroin users were infected.
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The most severe problem was in China's southern Yunnan province, which shared borders with Laos and Burma and had long been an opium center. Yunnan narcotics traffickers, like their counterparts in Burma, had learned how to process opium into heroin. By 1991 heroin was in ready supply in Yunnan; syringes were not. The pattern there mirrored what had occurred with HIV among heroin injectors in Manipur and Rangoon, and by 1993 the World Health Organization was estimating that up to a third of Yunnan heroin users were infected.
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Less than a year later WHO announced that heroin was driving a terrible HIV epidemic in Ho Chi Minh City, Vietnam. Among heroin users the
HIV rate climbed from less than 2 percent to more than 30 percent in about nine months' time.
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HIV rate climbed from less than 2 percent to more than 30 percent in about nine months' time.
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As had been the case with Africa's AIDS epidemic, Asia watchers wondered aloud whether the pandemic might reverse the region's famed “Economic Miracle,” causing a Thirdworldization effect. If local epidemics continued to expand at their breathtaking 1989â93 rates, Asia could be expected to overtake Africa in HIV numbers before the turn of the century. And ironically, the fiscal cost to Asia would be greater precisely because the continent's economy had boomed so impressively during the 1980s. With greater prosperity came higher costs. The dollar value of productive capacity lost due to worker illness and death was greater in Asia (compared with Africa) simply because there was a larger highly skilled labor force and incomes across the board were higher. Direct medical costs were higher as well, because of the availability of more sophisticatedâand costlyâhealth care systems.
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