Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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416 Surgery and Healing in the Developing World
but the ruling regime has consistently denied the extent of the problem; it has denied
the existence of prostitution, which is rampant and growing. Until a few years
ago, condoms were illegal in Burma; even now, they are restricted and unaffordable.
In 1996, Burma’s National AIDS Program budget was estimated to total $50,000
US dollars. There have been virtually no public information campaigns on AIDS
prevention.
Moreover, the lack of resources devoted to health care combined with many
years of repression have driven countless medical professionals out of the country.
Independent medical organizations that once existed, such as the Burma Medical
Association, have come completely under central control, with politically suspect
members kicked out.
A second problem in the past has been that Burma’s ruling military has generally
denied that the AIDS epidemic exists. Senior officials have repeatedly stated that
reports of the extent of HIV infection, as well as of drug use and of prostitution, are
part of an outside plot to discredit and destabilize their country. Very recently, one
of the military junta leaders, Khin Nyunt conceded for the first time that the problem
is real, and researchers have obtained from the government its first relatively
honest survey data, revealing, for example, that a majority of sex workers and IV
drug users in Mandalay are HIV positive. But it is still far from clear if the government
as a whole is committed to discussing the problem openly.
Finally, and perhaps most important, some government policies have contributed
to the spread of the disease, both within Burma and across its borders to Thailand,
China and India. Since there is no free press and the government is deeply
suspicious of any activity beyond its ability to control, ordinary citizens can do little
to spread information against the disease or to organize themselves to fight it. Widespread
corruption and official tolerance encourage the drug trade within Burma.
Then there is the military’s fight against ethnic minority peoples on Burma’s frontiers—it’s
so called “four cuts” policy—which involves forced population transfers,
village and crop destruction, and terror tactics including rape and executions. These
policies have pushed hundreds of thousands of civilians off their land. Perhaps most
important from the point of view of the AIDS epidemic, they have driven thousands
of women across Burma’s borders into the regional sex industry.
Studies among sex workers in Thai brothels where Burmese women predominate
have found HIV rates of 50-70%; similar rates are now being reported for
brothels inside Burma. There have been press reports that Burmese sex workers
returning home have been imprisoned in camps by the military; in some cases,
women who appear healthy have been sold back into prostitution by the officers
who run these camps. In recent years, the military government has given considerable
autonomy to its regional commanders. In the Shan State, along the Chinese
border, the regional command openly runs gambling casinos that offer sex services
(Chris Beyrer, 1999).
Every one of my public health colleagues along the Thai-Burmese border has
thought about working inside Burma. There are a small handful of NGOs operating
within the country, as well as several UN agencies, though under many restrictions.
Each struggles with the ethical dilemma of how to help the innocent people of the
country without getting too involved with the authorities who are responsible for
their suffering. For some governments, the answer is “constructive engagement”—
providing direct assistance to the military regime and urging it to invest in the welfare
of its people. For now, international organizations like the World Bank and