By Alan Sipress and Ellen Nakashima
Washington Post Foreign Service
Friday, December 30, 2005
RANGOON, Burma -- Dada would have killed herself but she couldn't afford a proper burial.
An orphan with a broad, sweet face and downcast eyes, she recalled the horror of learning two years ago that she had HIV. She had been a prostitute since she was 15 and hadn't saved enough for even a simple funeral, which according to her belief as a Buddhist was vital to reincarnation into a better life. So Dada kept on living.
Now, at age 23, it is what is left of this life that frightens her. Friends and other prostitutes have begun wasting away from AIDS, unable to pay the staggering cost of antiretroviral drugs, and Dada admits with an awkward giggle that she expects the same fate.
"I have no husband. I have no family," she whispered. "I have to stand on my own feet all by myself."
The secretive Burmese government had long denied that this country had a major AIDS problem, but international health experts now say it is among the worst in Asia. With antiretroviral drugs for AIDS costing about 10 times a teacher's monthly salary, few Burmese can pay for them. Fewer than 5 percent of those who need the drugs can get them free from the government and international agencies, according to U.N. estimates.
The Global Fund to Fight AIDS, Tuberculosis and Malaria, a Geneva-based foundation, had planned to expand funding to triple the number of HIV-positive people receiving subsidized medication. But in August, it canceled a program to fight the three diseases in Burma and ended $87 million in funding, because of new restrictions imposed by the military government on travel and the import of medical supplies.
The fund's decision highlights a moral dilemma over how to operate in a country that has one of the world's worst human rights records but is also on the brink of a humanitarian crisis affecting millions of people. This quandary has stoked a sharp, behind-the-scenes dispute between democracy advocates in the United States and Thailand -- who welcomed Global Fund's decision -- and humanitarian officials and many diplomats in Burma.
Critics of relief programs in Burma argue that the country's corrupt, repressive rulers make it impossible to deliver humanitarian aid and that such programs can instead bring reprisals against Burmese who participate in them. Relief efforts, they say, may only enrich the government -- which is facing broad U.S. economic sanctions -- while lending it greater international legitimacy.
U.N. officials and other humanitarian workers inside the country counter that they are able to operate independently of the government. While they acknowledge that travel and restrictions on imports at times hamper their programs, these officials say the efforts have already saved countless lives.
"If we're not able to come up with a successor fund, the termination of the Global Fund will directly lead to deaths," said Charles Petrie, Burma representative of the U.N. Development Program, which would have administered the money.
U.N. officials say the best available figures show that about 1.3 percent of Burmese adults are infected with HIV, but the actual numbers could be as high as 2.2 percent. Recent studies have found that nearly 2 percent of pregnant women are infected. The outbreak ranks among Southeast Asia's worst, along with those in Thailand and Cambodia. But control efforts lag badly.
"The first wave of death has started," a foreign humanitarian official said on condition he not be named for fear of government reprisal. "We are going to lose 10 percent of young people in the next 10 years."
Outside the largest city, Rangoon, the situation is especially dire, he said. Ignorance is widespread. When people become gravely ill, they are at times left to die in cemeteries with little water and food because others are afraid to approach them, the official said, adding that he had witnessed such an occurrence.
Until four years ago, the Burmese government barely acknowledged AIDS. But after the prime minister highlighted the disease in a speech, international agencies were able to increase funding, recording success particularly in promoting the use of condoms. Sales have more than doubled and, while usage still trails that in other Asian countries, condoms are used in more than half of encounters between prostitutes and clients, the agencies reported.
Still, the provision of antiretroviral drugs is just beginning. Only about 2,000 people are able to obtain subsidized medicine, among the nearly 50,000 people who U.N. officials estimate have advanced cases of AIDS.
Among those who may eventually seek the medication is Mary, 38, who has wispy bangs and smears the traditional Burmese cosmetic made from tree bark on her cheeks. She tested positive for HIV six years ago and her husband has already died of AIDS-related disease.
"I'm so afraid of getting sick. I'm so worried about getting care and medicine. Once I'm not able to work, I won't be able to buy it," Mary said. Like other Burmese with HIV, she withheld her full name, fearing government retribution for speaking with a foreign journalist about the disease.
Mary said she once ran a small restaurant and managed a beauty salon. After pains in her stomach grew too severe, she gave up the businesses and now does the light work of serving tea. She has already watched another friend grow weak from AIDS, scrounging enough cash to buy antiretroviral drugs for two months from a private pharmacy before the money ran out.
"He's bedridden, waiting to die," she said.
Brian J. Williams, coordinator for UNAIDS in Burma, reported that the Global Fund money would have paid for antiretroviral drugs for 5,000 more people over five years. It also would have financed HIV testing, extended a program to promote condom use among prostitutes to more than half the country and expanded services for drug users.
U.N. officials and half a dozen foreign governments are now seeking a new source of support to replace the Global Fund and another international health care program that ran its scheduled course. Without this, Williams said, international programs could use up their money entirely by June, meaning cutbacks in efforts to reach drug users and prostitutes.
"That will be a tragedy," he said.
Jon Liden, Global Fund's spokesman, said the decision to cancel its Burma program "left us with no joy whatsoever." But citing difficulties in operating under the restrictions the Burmese government imposed, he said, "We also have a responsibility to not waste the money that has been entrusted to us."
Before ending the program, Liden said, Global Fund had put in place several safeguards designed to ensure that the money was spent as planned, and had included a ban on funding government agencies. At the time, Global Fund was under pressure from democracy groups, which contend that foreign assistance ends up helping the government.
Frank Smithuis, director of Doctors Without Borders in Burma, said that rather than canceling the program, Global Fund should have delayed the funding and used it as leverage to win better government performance in health care. Instead, Global Fund joined what was "basically a boycott," said Smithuis, who has worked in Burma for more than a decade. "Entirely for political reasons, they didn't want to use that leverage."
Such political disagreements are far beyond Kyawt, 21, a prostitute with a thick head of black hair and a thin, reedy voice. Since she tested positive for HIV three years ago, she said, her overriding concern has been simply to look after herself.
Kyawt explained that she has lightened her workload and begun using female condoms all the time. Orphaned and living alone in a hostel, she said that she could not afford antiretroviral drugs and that free medicine is too hard to find.
So, she offered, "I take vitamins."
Nakashima reported from Bangkok.