David Fullbrook
Precise data about the AIDS and the human immunodeficiency virus (HIV) that causes it are scant in the secretive military-run country, which until recently banned all local reporting on HIV and AIDS cases for reasons of national security. But many independent public-health experts believe that Myanmar is heading in a dangerous direction, a public-health risk large enough potentially to have adverse effects on domestic and regional security.
“The current epidemic in Asia, with exception of the blood-transfusion ones in China and Japan, is really a [Myanmar] epidemic,” said Laurie Garrett, senior fellow for global health at the Council on Foreign Relations in New York. “It is in the interests of Asian states to see Myanmar’s HIV epidemic as a national-security threat.”
Myanmar’s official headline HIV-infection-rate data surprisingly suggest the epidemic is slowing, with 1.3% of those aged between 15 and 49, or about 350,000 people, testing positive for the disease in 2005, down from a 2.2% incidence rate five years earlier, according to the National AIDS Program Myanmar as quoted in the latest report by UNAIDS (the Joint United Nations Program on HIV/AIDS).
Another apparent cause for cautious optimism comes from pregnant women, among whom infection has remained steady at about 1.5% in urban areas throughout the decade. The situation in rural towns and villages is hard to gauge because the public health-care system is in a critical condition, struggling to function on meager funding. Among army recruits, incidence eased to 1.6% in 2004 from 2.1% a year earlier, according to Myanmar government data.
Yet there are concurrent reasons for grave concern. Among people aged 15-24, or the country’s future doctors, bureaucrats, commanders, entrepreneurs and parents, the infection rate is a high 2.2%. One in three sex workers tested positive for HIV in 2005, against one in four in 2004, according to the Department of Health and the National AIDS Program.
These high incidence rates could actually be much worse, however, because of shoestring budgets for monitoring and the ruling junta’s obsession with secrecy, even over crucial public-health issues. Myanmar has not held a reliable national census since the results of colonial-era surveys were destroyed in 1942.
Some countries that in comparison take their AIDS problems seriously and are deploying large budgets and able officials to combat the disease doubt the veracity of Myanmar’s official data. Chinese Health Ministry officials said in November that Myanmar’s infections are probably four or five times what their data indicate. China reported in October that its number of cases had jumped 30% to 183,733 from 144,089 at the end of last year.
Likewise, Taiwanese public-health officials told reporters in November that they believe Myanmar’s infections are three times as high as the military government admits, according to a news report in the Taipei Times. Health officials and researchers usually take stock of the HIV situation around this time of year in preparation for World AIDS Day.
“I think what we can say for now is that [Myanmar’s] figures are likely a very significant underestimate, and the true numbers of infected individuals is much, much higher,” said Dr Voravit Suwanvanichkij, an epidemiologist with the Johns Hopkins Bloomberg School of Public Health in Chiang Mai. UNAIDS last year described the situation in Myanmar as “one of the most serious AIDS epidemics in the region”.
Yet according to Myanmar’s official figures, new-incidence rates are rapidly declining without substantial spending on the public-awareness campaigns that have successfully changed behaviors and encourage condom use in other countries, including Thailand.
“The folks at John Hopkins recently published an estimate that [the Myanmar government] spent less than US$50,000 [on countering HIV and AIDS] in the last year,” said Garrett of the Council on Foreign Relations in New York. “I’ve heard other folks say that through secondary mechanisms such as the UN that it might be up to $2 million nationwide.”
Meanwhile, international money, medics and experts brought in to the reclusive country to track and combat its HIV/AIDS problem have recently been called back, apparently because of the military government’s suspicions that foreign aid workers were too sympathetic toward the political opposition.
In August 2005, the Global Fund for HIV/AIDS, Tuberculosis and Malaria canceled its $37.5 million program in Myanmar, blaming tight government restrictions on its movements that made working nearly impossible. Medecins Sans Frontieres pulled out of the country’s war-torn Karen and Mon states last March for similar reasons.
In November, the International Committee of the Red Cross was ordered to close all its offices outside of Yangon. Meanwhile local non-governmental groups trying to prevent infections and care for sufferers are often harassed by security forces, people aware of the situation say.
Look the other way
It took brash campaigns backed with huge sums of government spending and foreign aid to break down taboos and change behavior to help bring new infections down in impoverished Cambodia and comparatively well-off Thailand. And even there, with international assistance, those gains are tenuous as signs of official complacency are putting a new generation of young people at risk.
In absence of the prevention and public-awareness campaigns seen in Cambodia and Thailand, condom use and availability rates in Myanmar - although rising - remain dangerously low. Patchy education and awareness campaigns, though better than official denial up until just a few years ago, are not enough to keep pace with the evolving demographics of the virus’s spread.
The Myanmar government estimates that condoms are used in only about half of all commercial sex transactions. Combine that with what most observers characterize as an expanding sex industry, and more doubts are cast on the government’s overall infection-rate data.
Anecdotal evidence suggests the clientele includes a growing number of Chinese entering Myanmar, especially impoverished border areas to trade in goods and natural resources, cut forests and mine for jade and other minerals. Those human flows are creating conditions ideal for the virus to spread further, faster, including into mainland China. Improving measures in China to stem its still expanding HIV problem, health experts say, are clearly being undermined by Myanmar’s uneven efforts.
Myanmar’s infection rates are particularly acute in border areas where intravenous drug use is endemic and poverty causes shared needle use. Australia’s Burnet Institute estimates 150,000-250,000 people in Myanmar regularly inject drugs. Nationally 43% of people injecting drugs were infected with HIV in 2005, reports the National AIDS Program Myanmar, up from 34% reported by Myanmar’s Department of Health in 2004.
In the remote Shan state, which borders China and Thailand, rates for drug injectors are even higher, including, according to the Department of Health, a startling overall 60% infection rate in Lashio, a trading town along the main trade and trafficking route between the central Myanmar city of Mandalay and southern China’s Yunnan province. Meanwhile, India reports that more than 3% of pregnant women tested positive in districts along the Myanmar border in 2005.
“In some areas, the epidemic continues to rage essentially out of control, particularly in Kachin state, and without genuine attempts to systematically collect and analyze relevant information, address the issue and the factors that drive HIV vulnerability, including migration, poverty, and lack of education and health care, some regional epidemics have the potential to reach prevalence rates more closely resembling some countries in Africa,” said Dr Voravit.
In many African countries, infection rates of 5% opened the door to epidemics ripping through societies, leaving more than 25% HIV-positive. More worrying, new strains are beginning to emerge in Myanmar’s remote areas and China’s Yunnan province, health experts say.
“We have molecular data to link China’s epidemic in IDUs [injecting drug users] in Yunnan to HIV strains circulating in Burma,” said Voravit. “And we have more molecular data showing that HIV strains in IDUs from Burma and Yunnan are not only similar but very diverse, strongly suggesting an epidemic out of control, as individuals get infected again and again with multiple HIV strains.”
Health experts also note that comparatively few Africans inject drugs, yet AIDS has ravaged that continent, significantly rolling back life-expectancy rates and crippling the economies of many countries. Similar to Myanmar, many of those countries were very poor with substandard health-care systems, and rather than tackling their epidemics straight on, many African governments looked away until it was too late. Only where governments, often supported by foreign aid, have confronted the epidemic openly have infection rates slowed.
“Unless Burma’s epidemic is confronted and there is a real aggressive campaign, then the whole region will continue to receive new strains of HIV, part of the fluid movement of the black market across southern Asia in drugs, sex and labor,” said Garrett. And unless the country’s ruling generals are soon persuaded to address the country’s HIV/AIDS situation not only as a public-health problem but as a potential domestic and regional security threat, Myanmar could, a la Africa, be headed toward failed-state status.
