The Coming Plague

by Laurie Garrett

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.

  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.72 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, ‘If you don’t see the body in the coffin, you don’t shed a tear.’ Rapid spread of the virus is possible—is ignored—because 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.73

  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.74 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. 75

  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 Japan76 and Germany. And local Thai men showed no signs of slackening their demand. A 1989–90 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.77 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,78 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.

  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.79 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.80

  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.81 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 s
outhern 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 1987.82 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.83

  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.84

  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 1989–93 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 sophisticated—and costly—health care systems.

  Still, it seemed at first glance unimaginable that AIDS could make a dent in Asia’s economic boom. Only a handful of countries (the Philippines, Papua New Guinea, Burma, and Cambodia) experienced negative GNP growth during the 1980s, and many Asian countries had growth rates that were five to seven times greater than those of the United States and Switzerland.85

  Like Africa, however, much of Asia was simultaneously undergoing other disease emergences that could be expected to compound or synergize with HIV/AIDS. These included dengue, hepatitis (A, B, C, D, and E), multiply drug-resistant malaria, tuberculosis, drug-resistant cholera, and virtually every known sexually transmissible microbe. Though no one knew how to calculate the additive or multiplicative economic impacts the interlocking epidemics might have, it was clear, biologically and epidemiologically speaking, that interconnections existed.

  In mid-1993 the GPA estimated that 1.5 million residents of South Asia were HIV-positive, most of them Indian or Thai citizens. For Thailand, specifically, WHO estimated that 450,000 people were infected by late 1992.86

  But WHO’s numbers were surely overly conservative. Newer data demonstrated that the rate of expansion of the country’s epidemic, far from slowing as many hoped, was accelerating alarmingly.87 The only hopeful slowdown in Thailand’s plague was seen among injecting drug users in Bangkok, who readily snapped up sterile syringes when they were made available.88

  Mechai Viravaidhya estimated that Thailand’s cumulative AIDS death burden by the year 2000 would be 470,000 to 560,000 adults. Based on an average productivity loss of $22,000 per dead worker, that could inflect an indirect loss of $7.3—$8.5 billion on the Thai economy. Direct treatment costs for those people would be between $61 and $167 million out of a total annual Ministry of Health budget of just over $40 million.89 In 1992 a single day of AIDS hospitalization in Bangkok cost an average of $298.73; Thailand was in the unfortunate position of having reached Western standards of curative medicine and hospitalization while its populace still earned Third World wages. By 1992 Thai officials were predicting that the epidemic would push the nation’s health and medical advances backward, as an overwhelmed system collapsed under the economic costs and the sheer load of AIDS cases.90

  Drawing on slightly different estimates of both the forecast epidemic size and indirect costs, WHO predicted a total economic burden from AIDS of $9 billion for Thailand by the year 2000.91 And the GPA told World Bank officials as early as October 1991 to expect a possible economic downturn in South Asia during the latter half of the decade: it was a view shared by the Thailand Development Research Institute in Bangkok.92

  The U.S. Census Bureau issued dire forecasts for Thailand, based on HIV-prevalence rates as of early 1994. The Bureau predicted that by 2010 Thailand would have experienced such severe devastation due to AIDS that the country’s population growth rate would have plummeted to—0.8 percent (from a pre-AIDS predicted +0.9 percent); there would be 25 million fewer people in the country than would have been the case in the absence of AIDS; life expectancy would take a nosedive from what would have been 75 years to a mere 45 years; child mortality rates would more than triple (reaching some 110 per 1,000 children born); and the nation’s crude death rate would soar from about 6 deaths per 1,000 to more than 22 per 1,000.93

  Though few analogous economic analyses had been done for India, Burma, the Philippines, or other Asian countries in the grips of HIV, there was a clear consensus in international public health circles by 1993 that the pandemic would, at the very least, exert a Thirdworldization effect upon the health care systems, tourist industries, and government-funded social service sectors of hard-hit countries. Worst-case scenarios forecast sharp declines in both agricultural and industrial productivity with resultant declines in GDPs.94 The United Nations Development Program and the Asian Development Bank predicted in late 1993 that the HIV epidemic would increase general levels of poverty and, by the year 2000, cause local famines in key areas.

  Such dire economic forecasts, whether they concerned the projected impact of AIDS on Africa, Asia, or Latin America,95 were always intended to draw the attention of wealthy donor states. The nations of North America, Western Europe, and, to a lesser degree, Japan and the Soviet Union had always been forthcoming with cash when a crisis struck, even if the quantities were more symbolic than substantial. If the cash was offered at interest, Africa and Latin America might cringe, but Asia had an excellent debt-repayment record.

  Throughout the world hope for a global AIDS bailout rose as Berliners clawed away at the wall that had physically divided their city for three decades. What began with dockworkers in Gdansk in the early 1980s built slowly for years in pockets of antiauthoritarian resistance that spanned from Prague to Riga, from Vladivostok to Berlin. Once the Berlin Wall fell there was no turning back: the ideal and reality of communism were dead. And with the end of communism came capitalist dominance and Western victory in the Cold War. Threat of global thermonuclear annihilation suddenly seemed quite remote. Politicians all over the world spoke of a Peace Dividend. And suddenly the world had surplus cash, they claimed, and long-neglected social programs could now be subsidized. For a few moments in history, it seemed, people around the world were remarkably optimistic.

  But no Peace Dividend appeared. People craned their necks looking for it, soon spotting a shadow emerging on the horizon. Excitement yielded to despair and frustration as they recognized the shadowy Dividend for what it was: international recession.

  After all the celebrations and dancing in the streets of Prague and Berlin settled down, the West got a good, hard look at what lay behind the Wall, inside the long-sequestered world of communism. And they discovered that Stalinists from Uzbekistan to the Baltics had been juggling the books for decades. The East was broke.

  Worse yet, its populations, which had long had nearly every aspect of their lives controlled by the state, were ill prepared to build strong civic societies. With their economies in a shambles, cynicism quickly overcame the brief sensation of elation for most Europeans.

  Reunification of the two Germanys was concretized on October 3, 1990, amid fetes and fireworks, but by the end of that year official unemployment in the former GDR had soa
red from zero to more than 350,000 adults.

  Overnight the former Cold War multitrillion-dollar spending became a latter-day Marshall Plan for reconstruction of the ex-communist world. Ten billion dollars shifted from coffers in Bonn to national bank vaults in Moscow in a single day. And that was just one of many West-to-East transfers.

  Not only was there no Peace Dividend, there was newfound, long-term structural agony. Even the booming Asian economies felt the pain as demand for autos, electronics, and consumer goods dropped in Europe and North America.

  While much of the world watched the demolition of the Berlin Wall during the fall of 1989 with astonishment and elation, Hans Seyfarth-Hermann dashed about Checkpoint Charlie tossing condoms at the crowds of East Germans as they poured through. The bewildered East Germans snapped the packets out of the air and examined what looked like matchbook covers. They read this brightly colored inscription: “You will see many tantalizing things during your visit to West Berlin. Enjoy yourself, but remember, we have AIDS.”

  Inside each putative matchbook was a latex condom. Political openness, it appeared, could carry a price tag. If it was true, as the old Stalinist leaders claimed,96 that AIDS hadn’t made its way yet into most of Eastern Europe, the fall of the Wall would surely put an end to the political barriers that had allegedly kept the microbe at bay.

  Seyfarth-Hermann and fellow AIDS activist Julian Eaves were in a Berlin gay bar called the Dark Cellar the night of November 9, 1989, when they overheard Germans speaking in a startling accent. The two of them realized that the men were from Saxony, part of East Germany, and that they were filled with excitement that night, Eaves later recalled, “trying to enjoy the wild life in the big city.” Eaves and Seyfarth-Hermann recognized that their Saxon gay counterparts knew nothing about AIDS and safe sex. They also were sadly aware that some West Berlin gays, sick and tired of “latex sex,” might take advantage of the Easterners’ ignorance.