No Boundaries

Managing The HIV/AIDS Pandemic

By Roxana Saberi

The world is beginning to understand how disease connects with global security.

Epidemics can destabilize governments. A poor medical infrastructure can allow minor health issues to become major outbreaks. Preventable diseases thrive during war, and the immunizations and vaccines we all take for granted become low priorities for hungry families seeking basic shelter.

Meanwhile, every infectious disease in the world is just a plane ride away from our hometowns.

In Thailand there are efforts to slow the spread of one global security threat: AIDS.

With a bit of English and an array of short skirts, Pattaya's red-light district in Thailand attracts its share of native Thais and foreigners alike. Here, block after block, salesmen promise a variety of peepshows for the low, low price of 500 baht (roughly $13).

This in-your-face sex industry is splashed across the beach resort town, around 90 miles southeast of Bangkok. Despite the very public image of the industry, sex workers here and across the country have been trying to repair their reputation as a one-stop-shop for AIDS.

Learning From the Past

In the late 1980s, Thailand emerged as one of the epicenters for the growing HIV/AIDS pandemic. But in recent years, the country has slowed the spread of the virus. From 1991 to 2003, Thailand's annual rate of new HIV infections dropped from its peak of 143,000 to around 19,000.

Patrick Brenny, the UNAIDS coordinator for Thailand, said the decline was largely due to increased use of condoms and reduced brothel visits.

"The trend of the epidemic in Thailand, again, that was ten years ago, there was a very successful response to the epidemic, there was a large level of political mobilization, there was effective prevention in terms of the use of condoms in brothels, the famous 100 percent condom program," Brenny said. "That was very successful because the epidemic was primarily concentrated in commercial sex workers and their clients."

The challenge now is to ensure that Thailand's past successes don't lead to complacency and inaction.

Thailand's Ministry of Public Health says it realizes the country can't afford to become complacent. It has helped put on programs like an AIDS awareness concert in Bangkok on Valentine's Day, for example, to make the health concern a public issue.

Ministry spokeswoman Nitaya Chanruang Mahabhol said her government is well aware that a health crisis in one country can be a threat to other countries as well. Infectious diseases do not respect international borders. Last year, she said, Thailand donated a million condoms to neighboring Burma.

"There's no need to be in heaven while some of your neighbors are fighting like being in hell," she said.

Fear of Resurgence

In his air-conditioned office off a busy street in Rayong, about an hour's drive from Pattaya, Boripat Domnom looks the picture of health. But Boripat's routine of downing four antiviral pills a day reveals the changing faces of Thailand's AIDS victims.

"I learned that I was infected with HIV in 1993 after my wife delivered our second baby at a hospital," Domnom said. "Later on, our baby died in only 3 months. I was wondering about this. Therefore I had a blood test. The result was HIV positive. At that time, I didn't believe that I had been infected. I still continued my life as normal."

Brenny suggests that Boripat's story shows Thailand is still vulnerable to a resurgence of the epidemic—this time, spreading beyond sex workers and their clients.

"The difficulty with the epidemic now is that it's matured into the population and so most of the people being infected today are housewives or partners of those who used to go to sex workers and are people who aren't part of the general population, the youth for example," Brenny explained.

US-Thai Cooperation

Evidence suggests there is reason to worry about a relapse in the spreading of the disease. The UN says the rate of HIV-infected drug users is rising and the use of condoms among youth, homosexuals, and sex workers has decreased.

National HIV infection rates across Asia are low compared to Africa. But because Asia is so populated, even low national HIV prevalence means large numbers of people living with the virus. If Thailand and its neighbors falter, the impact would be far-reaching—hitting areas as distant as the United States. It is a risk Washington does not want to take.

In Rayong and Chonburi, two provinces with some of the highest rates of HIV in Thailand, the US government is helping the Thai government conduct the largest trial of any AIDS vaccine in the world. The idea behind this program is to reinforce Thailand's treatment and prevention programs with a potential miracle drug that could reduce the rate of new HIV infections.

In Search of the Miracle Drug

Thousands of 18- to 30-year-olds have volunteered to receive injections of a combination AIDS vaccine over three and a half years, a project called the "Prime-Boost HIV Vaccine Phase III Trial."

Critics say the test is a waste of time and money because one of the two vaccines failed in previous human tests in the United States. But a sense of urgency is spurring on supporters of the project. Around 70 Thais are infected by the virus every day. Organizers say even a partially effective vaccine-reducing the average rate of HIV infection by half—would be a victory.

Project organizers like Dr. Supachai Rerks-Ngarm admit each drug by itself is not effective but may succeed in combination.

"So I don't believe until we prove it, that it doesn't work," Dr. Rerks-Ngarm said. "This is the way of research. Research means finding new way of doing things."

Dr. Supachai points out there are numerous strains of the HIV virus around the world. But he believes the combination vaccine, which does not include the live HIV virus, may produce new results in Thailand.

The vaccine project is just one of many ways the United States has been working with Thai authorities over the past 15 years, when the robust HIV epidemic first emerged here.

The Global Threat

The US government and the United Nations recognize HIV/AIDS as a global security threat, contributing to the conditions of failed states and civil war. In 2001, then Secretary of State Colin Powell told the UN that "no war on the face of the earth is more destructive than the AIDS pandemic."

The CIA has warned that infectious diseases such as HIV/AIDS put American tourists, workers, and soldiers abroad at risk. Responding to these warnings, President Bush launched an Emergency Plan for AIDS Relief in 2003 to increase spending on HIV/AIDS around the world.

Dr. Jordan Tappero, the director of the US Center for Disease Control in Thailand, said the United States realizes HIV in Thailand poses a real threat to Americans.

"There are other infections that pop up because of HIV infections, the most common example being TB," Dr. Tappero said. "I think if you asked yourself the question: if 50 percent of Americans were going to have a life-threatening illness over the next decade, would we consider that a catastrophe, a crisis? I don't know anyone who would answer no to that at all."

Education for Prevention

Many Thais are also taking the fight against AIDS into their own hands, trying to limit the spread of the virus to the general population.

At the all-boys' Suan Kularb high school in Bangkok, Nakorn Santhiyothin is trying to teach her students that they are not immune from the virus. Her method isn't based only on books or biology lessons, but on hands-on exercises. Today one student is holding a plastic model while another is struggling to wrap it with a condom.

For these boys, the giggles heard throughout the classroom don't weaken the stark reality they've come to know too well.

"Previously," said one student, "I thought it was not a related issue to teenagers. Currently, teenagers are more promiscuous. Some teenagers have got the virus as they do not prevent themselves at all. They don't think that they are in danger. They don't use condoms!"

The US-based Program for Appropriate Technology in Health, or PATH, helped develop the curriculum aimed at bringing health knowledge to students. The NGO wants to expand this lesson plan and extend it to schools across the country to teach students that abstinence is good. But if abstinence is not chosen, the organization says, students should at least know how to protect themselves.

But PATH is facing opposition from conservatives in government who point to the Bush administration's emphasis on abstinence and feel graphic lessons like these validate teen sex.

Hope Without Despair

At a Buddhist temple in Bangkok, Thais toss coins into a row of metal pots, wishing for happiness and health. Miles away, as Boripat Domnom carefully counts the pills of his antiviral cocktail, he says he wishes to replace despair with hope.

Boripat has opened his own nongovernmental organization—the Network of People Living With HIV/AIDS—where victims and others can learn about the virus. And he hopes countries, including the United States, will continue to support programs that make expensive AIDS drugs more affordable to the developing world.

He hopes, above all, that countries will be able to work together to prevent the rapid spread of AIDS—or as he puts it, to prevent the beauty of life from fading into a disaster for humanity.

Familes Fragmented

Julia Taft ran the crisis prevention bureau at the United Nations Development Programme.

"I'm seeing some of the countries that are going to be virtually imploding—where, for instance, there's rampant HIV/AIDS which is decimating the productive age groups of 18 to 40.

"These people are dying in dramatically high numbers," she said. "So the structure of government is being threatened because they don't have people who can actually do professional jobs. The families are being fragmented."

The scourge of infectious disease can have both very local and very far reaching implications.

"There's good globalization and there's bad globalization," said Jan Eliasson, the Swedish ambassador to the United States and president-elect of the UN General Assembly.

If you, for instance, have a disease—SARS in Asia—or if you can even imagine small pox breaking out, either independently or by terrorists, then you have a new disaster with enormous movement of people around the world. So with globalization, the fact that we are on one planet makes us truly interdependent. That means that a problem for one is a problem for all."

More Than a Local Problem

Johanna Mendelson-Forman, a senior program officer at the United Nations Foundation, said there is growing understanding of how infectious disease travels.

"Anyone who travels even between two continents, or anybody who crosses the border between Canada or Mexico, recognizes there has been an elevated interest in health and its relationship to preventing epidemics from spreading," Mendelson-Forman said. "Whether it's this Avian flu or whether it's SARS."

Because of this, infectious disease is beginning to be seen as something more than a local health care issue.

Bob Orr, the UN Assistant Secretary-General for Strategic Planning, recently helped draw up a list of recommendations for Kofi Annan that listed infectious disease as a very real global security threat.

"No country—whether it's the United States, Europe, North Asia—is safe if the national health systems in Africa, in South Asia, and other regions of the world can't cope with the infectious disease in those regions," Orr said.

"In this regard, we were lucky, if you will, that SARS happened in Asia—that there were health systems with international assistance that could contain the SARS epidemic. If SARS were to emerge in Africa, for example, it would have been around the globe before anyone could have done anything about it. So threats that start in some regions emanate to others and, therefore, a threat to one is a threat to all."

"Fantastically Complex"

"The fact is, none of us has been as sensitive to these fantastically complex interconnections as we need to be and as exist," said Jeanne Kirkpatrick, US ambassador to the United Nations during the Reagan administration. "It's something we all need to work on in my opinion.

"Collective action is very complex too. You know, it's not just collective, it's complicated. I think we need to face those interconnections and those problems in a lot of different ways.

Orr agrees.

"Because these threats, by their very nature, do threaten us all, the idea that any single government or even any single small group of governments could address them is, on the face of it, false," he said.

"Because our threats are now universal, our collective action needs to be universal. This is what's new. It's not just a small alliance of countries that can build a NATO to protect and enhance security. That mechanism is still useful and needed, but now the kinds of threats—the nonstate actors, the terrorism, HIV, AIDS—these kinds of threats are universal. You can't use an alliance to stop that, unless it's an alliance of every country in the world. That's what's new."

"Security Check: Confronting Today's Global Threats" is part of the 2005 Public Radio collaboration "Think Global," May 16-22. The documentary is produced by Simon Marks, Keith Porter, and Kristin McHugh. It is a Stanley Foundation production in association with KQED Public Radio. The full program includes segments on civil war in Uganda, loose nuclear material in Russia, small arms in Colombia, and an exclusive interview with Secretary-General Kofi Annan.

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