In 2010, the Population Services International (PSI) program, Sun Quality Health (SQH), and its sister network of village health workers, Sun Primary Health, performed more than 2.1 million client consultations in Myanmar. John Hetherington, who has managed the network since 2007, talked to CHMI (Center for Health Market Innovations) about how--in the second-poorest country in the Asia-Pacific region--SQH has assembled one of the broadest service packages of any social franchise network operating today in an attempt to provide high quality, well regulated priority health services to local people.

CHMI: You offer a wide range of services under the Sun Quality Health brand. How do you select the services the brand will include?
John Hetherington: With a backbone of 1200 doctors in more than 200 townships, we can be entrepreneurial. We first ask, is there a need not being met? And is there an opportunity for a network of providers to offer that service? In Myanmar, the largest health concerns - malaria, family planning, pneumonia, diarrheal disease, TB - are either too expensive to treat, or doctors don't provide the right quality service. As in many places, we started with reproductive health and family planning, where there is a natural fit for social franchising.

Why is it that so many social franchising programs start by offering family planning?

JH: I think family planning is unlike other services because everyone from 15-49 is potentially a client - meaning, they are theoretically all fertile -- and this makes it different than addressing diseases which require many more inputs to be efficient, targeting, testing, etc., particularly in Asia, where many of the big diseases tend to be concentrated epidemics. With FP, you have the potential to offer (almost) anyone you interact with something that can be of service to them. You have the potential for large scale impact without the precise geographical targeting that you would need to treat an epidemic.

Without using the media to market to clients, how does your franchise attract clients?

JH: Advertising for medical services is illegal. Here, as in many countries, there are lots of people who go to their local doctors when they are ill or think they are ill. Many of these doctors have practiced for 20-30 years without continuing medical education. These are the doctors we retrain, so [with their clients] we have a captive audience, in a way.
How do you set prices?

JH: We set prices in a way that they are not a barrier to the poorest person we want to reach in the given target. We make services available at a price people are expecting--50 cents to a dollar for a malaria treatment, versus the five to six dollars it would cost otherwise. If we were not subsidizing these services, doctors would not provide them, or they might give patients the wrong drugs--give an injection, for example.

Speaking of which, how do you ensure quality?
JH: Social franchising is more complex to manage than other channels of social marketing--you need higher levels of training, monitoring and supervision.

On our staff, we have close to 80 doctors that, on average, visit each of the 1200 clinics every six weeks. They observe service delivery and answer the franchisee doctors' questions. We also send mystery clients to assure that the level of service quality remains intact. We use vignettes in training.

These techniques ensure that [franchisees] are not gauging people with prices or giving the wrong treatment. However, we don't own these clinics. We hope the training around good hygiene, infection prevention, client relationships, and counseling improves overall practices, since we don't monitor health areas outside the SQH basket of services.

Is it difficult to get providers to participate?

JH: No - their business increases. Their reputation is better, they have more services to offer, and their customers can get an IUD for 50 cents instead of 50 dollars.
In Myanmar, the public sector is not able to serve the needs of most people; 80-90% of people go to the private sector for health care. This is not unique. The private sector, while used by everyone, is atrocious in most places. With proper management, however, it can be made to do less harm--and even do very good work.
I have had surrealistic conversations with some country officials or [global health policy makers] where someone asks [a policy maker], what is your national protocol for first-line treatment for malaria? Yet, if you look at the data, 99% of people go to a pharmacy and buy drugs off the shelf. Some have to have a philosophical shift to understand this.

Describe your relationship with the Myanmar government.

JH: There is always a give and take between an NGO and the government. We have a longstanding relationship with the government in Myanmar and some of our staff are former civil servants. [Officials] appreciate that we are improving the quality of services by providing continuing medical education where there is none, and reporting on treatments not captured by the national health management information system.
The health minister has also seen the impact of Sun Quality Health. It's not minor--it's providing something like 25% of all family planning services, and we are detecting and treating more than 12% of all TB cases nationally.
We heard you are now offering screening for cervical cancer, which is very unusual even though 80% of cases occur in the developing world.

JH: Our franchising director at the time, Dr. Nyo Nyo Mihn learned a couple of years ago at a medical quality conference funded by one of our donors that you can screen [for abnormal cells] with acetic acid and treat abnormal cells with cryotherapy using Co2 in low resource environment, all without electricity. PSI's innovations fund allows us to be entrepreneurial without massive amounts of money, so we are now beginning training.

Some people in the health ministry are concerned that private sector doctors should be doing something they consider to be a hospital service. But almost no one is doing cervical screenings anywhere, so again, there is a choice of doing nothing, or doing something in partnership with the health facilities that are actually being accessed by people.

We are also piloting a basic package of anti-retroviral therapy with 100 clients, which hasn't yet been done in social marketing.

You also provide TB screening and treatment.

JH: Starting this intervention in 2004 was our biggest gamble. A recent study showed that the TB prevalence in Myanmar is five to six times higher than what was previously estimated. Now, our franchise does more than 12% of all case detection and treatment in the country.

Recently, in a village meeting, a woman spontaneously came up to us in tears. She told us she had been dying from TB and the treatment she got from a government clinic wasn't working for her. A PSI health worker told her to go to a [Sun Quality Health] doctor. She said, 'I'm healthy now and you saved my life'. I was thinking, that's one person, and there are 17,000 people every year getting that service that would otherwise die, and give TB to eight other people.

Yet, you still have people outside the country saying you can't work ethically inside the country, and the regime here can also be xenophobic. We can negotiate between those two things--the government doesn't see [the program] as impinging on their sovereignty and the opposition doesn't see it as giving succor to the regime. This model would be interesting to use in other difficult political situations, perhaps in Zimbabwe.

Organization: the Population Services International (PSI)

Learn more about Social Franchising

Weblink: http://healthmarketinnovations.org/blog/2011/may/26/how-engage-private-sector-doctors-deliver-high-quality-and-affordable-priority-care


    国际人口服务组织(the Population Services International),Sun Quality Health (SQH)组织与其姐妹组织--Sun Primary Health乡村健康工作者网络于2010年在缅甸全国提供超过210万次健康咨询服务。于2007年接管该项目的John Hetherington接受健康市场创新组织(Center for Health Market Innovations-CHIMI)的采访,介绍SQH如何在缅甸--这个亚太地区最贫穷的国度之一,基于目前可利用的社会特许经营网络,集合最广泛的服务为当地人群提供高质、管理完善的医疗服务。

CHMI:贵机构以Sun Quality Health为商标提供各种各样的服务,你们是如何选择将要提供的服务类别的?








CHMI: 说到这里,你们如何保证医疗质量?



CHMI: 让医护人员加入这个项目是否困难?




缅甸卫生部部长也看到了Sun Quality Health项目的影响力。我们的计划生育服务占该服务全国总量的25%,我们也对全国12%的肺结核病例开展追踪治疗,这并不是个小数目。

Asia Report 翻译

组织: the Population Services International (PSI)-- 国际人口服务组织

了解社会特许经营(Social Franchising

原文链接: http://healthmarketinnovations.org/blog/2011/may/26/how-engage-private-sector-doctors-deliver-high-quality-and-affordable-priority-care

作者:Alex Delamare


    当Thida Win因在街边从事性交易而感染艾滋病后,她转而向其他性工作者,而非医疗机构寻求帮助。

    几乎完全是由性工作者开展的"顶端"项目为Thida Win提供治疗,使她避免了来自社会对艾滋病和性工作的双重污名化。





    "顶端"项目发起人和主管Habib Rahman表示为大家提供一个不受社会禁忌约束、能够与同仁共同讨论问题的空间是这个项目的主要目标。







    Myint Myint在离婚之后进入一家按摩院工作,之后她立刻感染了艾滋病毒。她表示顾客们(其中大部分是卖豆或卖鱼的小贩)对于使用安全套都表现的非常迟疑。

    联合国艾滋病规划署缅甸事物官员Soe Maing表示:"缅甸艾滋感染呈下降趋势,关键受影响群体的感染率也在下降,但是基数仍然非常高。"



    该项目由国际人口服务(Population Services International)组织于七年前展开,目前雇员来自全国19个市镇,总人数达350人,其中95%为女性性工作者和男男性行为者。


    Thida Win第一次参与性交易的时候还是一名大学在校学生,她表示婚姻和抚养下一代的经济负担使她不得不继续从事性服务。


Asia Report 翻译

原文链接: http://news.yahoo.com/s/afp/20110522/hl_afp/myanmarhivhealthsocial_20110522185905

By Alex Delamare (AFP) 

YANGON -- When Thida Win contracted HIV after selling her body on the Yangon streets, it was her fellow sex workers that she turned to, not Myanmar's crumbling health service.

The Top project, run almost entirely by those in the sex trade, gave her treatment, a place to be herself away from the dual stigma of HIV and prostitution -- and eventually a job.

"I am now a health worker for my community and I can forget I am positive. I am so proud to work for the programmes, I will work for them for my whole life," the 33-year-old told AFP.

Top and similar projects are a vital resource in army-dominated Myanmar, where a chronically underfunded health service, large itinerant populations and poor education fuel one of Asia's worst HIV epidemics.

Nearly one in five of Myanmar's estimated 60,000 sex workers were infected with HIV in 2008.

A United Nations report from August last year said legal constraints and discrimination made it hard to reach those in the trade, which is illegal. Surveys suggested police even used condoms as evidence for arrest.

Top founder and director Habib Rahman said providing a place free from taboos and letting people share their problems with contemporaries was a key aim for the project.

Rahman said many women enter sex work without knowing about the risks.

"In general in Myanmar I do not think there is any sex education in school," he said.

The project recruits former and current sex workers to help educate others about HIV, spreading the message from a position of trust within the community.

"We cannot tell anyone to stop selling sex even though they are positive but what we do is tell them how they can keep healthy and protect the client by using condoms," said Rahman.

He said Top's part-time "peer educators" who chose to continue in the sex trade were encouraged to always use protection, while full-time employees were instructed to stop selling sex altogether.

Myint Myint contracted HIV soon after being recruited to work in a brothel following the break-up of her marriage. She said her clients, mainly local bean and fish traders, had often been reluctant to use protection.

HIV transmission in Myanmar occurs "primarily through high-risk sexual contact between sex workers and their clients", as well as men who have sex with men and their partners, according to the UN report.

It said while injecting drug users have the highest HIV prevalence, at 36 percent, they are also likely to pay for sex and "this interaction may refuel the sex-work-driven epidemic".

Years of neglect by the ruling generals -- Myanmar spent just 0.9 percent of its budget on health in 2007 -- have left foreign donors facilitating most of the country's HIV treatment.

A new government, which came into power after controversial November 2010 elections, has raised hopes of more investment from overseas donors -- but not the state, which is expected to spend around 20 percent of outlay on the army this year.

In 2009 the UN estimated 240,000 people in Myanmar were living with the virus and while there have been improvements, the situation remains worrying with prevalence rates the third highest in Asia after Thailand and Papua New Guinea.

"The HIV epidemic in Myanmar is on a decreasing trend and among the key population groups it is also reducing -- but it is still really quite high," said Soe Naing of UNAIDS in Myanmar.

He said some state provision for HIV treatment does exist in big cities, "but of course the standards and situations are not ideal. People are reluctant to go to them because of privacy issues and quality".

Top clinics provide everything from testing and counselling to routine medical care.

Last year it gave treatment and consultation to 11,770 female sex workers and 10,727 men. It also accounted for 40 percent and 82 percent of all HIV tests for those groups respectively in the country.

The programme, which was formed by Population Services International (PSI) seven years ago, now employs 350 people -- 95 percent of whom are from the sex worker community and men who have sex with men -- in 19 towns and cities.

In Myanmar, where the US estimates around a third of people were below the poverty line in 2007, money worries are likely to continue to drive people into sex work.

Thida Win, who was still a university student when she first sold sex, said the financial burden of marriage and children only pushed her further into the trade.

"I got my degree with sex work, I supported my family very well with sex work," said the chemistry graduate, who said her earnings still help support seven family members.

Weblink: http://news.yahoo.com/s/afp/20110522/hl_afp/myanmarhivhealthsocial_20110522185905

Tin Soe was just four when he realised he was different to other boys in his neighbourhood, but growing up in conservative and army-ruled Myanmar, he struggled to be accepted as gay by his relatives.

"My granddad's sister said that if I became a monk my sexuality would change. So I was a monk for three months, but my sexuality never changed," the 30-year-old said, asking for his real name to be withheld.

A repressive mix of totalitarian politics, religious views and reserved social mores has kept many gay people in the closet in Myanmar, formerly known as Burma.

Gay men have developed their own language as a "gaylingual" code to both signify and conceal their sexuality, said Tin Soe, who now works on HIV/AIDs prevention in Yangon.

"We want to be secret and we don't want to let other people know what we are saying. We twist the pronunciation."

It's a world away from neighbouring Thailand, where a lively gay and transsexual scene is a largely accepted part of society, which -- like Myanmar -- is mainly Buddhist.

"More Burmese are travelling to Thailand and see things there," said a 34-year-old working in Myanmar's tourism industry. "But here gays are still looked down on, in a certain category."

Homosexuality is often linked to local religious beliefs about karma in Myanmar, Tin Soe said.

Many believe "we're gay because we did something in a past life, that in a past life I committed adultery or raped a woman. But I don't believe in that," he explained.

"It's not like Iran where they are killed, but gays are a strange story in this country."

Traditionally, the only area where non-heterosexuality has been openly embraced is the realm of "nat" or spirit worship, a form of animism that is intertwined with Myanmar's Buddhist beliefs.

Flamboyant and effeminate spirit mediums take centre stage at popular "nat" festivals throughout the year, but their acceptance here has also served to reinforce certain stereotypes of gay people in Myanmar.

Same-sex relations are technically criminalised by a colonial penal code, and while this is no longer strictly enforced, activists say it is still used by authorities to discriminate and extort.

"They use it as an excuse to make money and harass people but they don't bring the cases to court," said Aung Myo Min, an openly gay Myanmar exile and director of the Human Rights Education Institute of Burma, based in Thailand.

He said there were numerous instances of sexual violence and humiliation of gay people in public.

"Many cases are not reported because the victims keep silent out of shame and fear of repercussions."

In a country under army control for nearly five decades, broaching any kind of anti-discrimination or human rights issue is hugely sensitive.

"The man who starts to ask for rights in the gay community will be sent to prison," said another Yangon-based HIV/AIDS activist in his fifties.

The Internet offers a forum for gay men to meet, deemed safer than public cruising: Tin Soe met his boyfriend on Facebook, for example, but he said many were afraid to put their photos on gay websites.

In light of such discretion, raising public health awareness isn't easy.

In some areas, such as the big cities of Yangon and Mandalay, as many as 29 percent of men having sex with men are HIV positive, according to a 2010 report by the Joint United Nations Programme on HIV/AIDS.

"We have a lot of activists in this country but we can't campaign very openly. We will have a workshop in a hotel but without big posters and loudspeakers. We do it low profile," said Tin Soe.

While lesbianism is also largely hidden in Myanmar, Aung Myo Min said it was more acceptable to the militarised and macho culture, in which many fail to differentiate between homosexual and transgender people.

"The woman who wants to be a man is excusable," he said.

A 52-year-old in Yangon said things had improved since his teenage years, when "people would use sling shots against us," but he warned there was still a long road ahead to a truly tolerant Myanmar.

"We want to be like Thailand, where gay people have equal chances," he said.

Weblink: http://www.rnw.nl/english/bulletin/myanmar-gays-seek-thai-style-acceptance

Organization: Human Rights Education Institute of Burma(HREIB)


G.P.O Box 485,Chiang Mai 50000, Thailand.
email : hreburma@loxinfo.co.th

    Tin Soe四岁时就已经意识到他和周围邻居家的男孩儿们不一样,但由于生长在传统的军人家庭,要让亲戚接受自己的同性恋取向非常困难。"我的姑婆说当和尚能够改变性向,因此我去寺庙做了三个月和尚,可是什么变化也没发生。"一名30岁的受访者说道,并要求在采访中隐去其真实姓名。

    由于极权政治、宗教和保守的社会道德规范,许多缅甸的男同性恋者始终不敢公开自己的性向。在仰光从事艾滋预防工作的Tin Soe表示现在男同已发明了"同志语",用以标示和隐藏自己的性取向。"为了确保不让别人听到我们在说什么,我们改变了发音。"

    在与缅甸相邻的、同为佛教国家的泰国,男同和变性者群体却获得了更多的社会认同。"越来越多的缅甸人去泰国旅游,去解到那边的情况。"一名在缅甸从事旅游业的34岁的受访者说道:"但某种程度来说,在我国同性恋依然被看不起。"Tin Soe解释说在缅甸人们总是把同性恋和佛教的因果报应联系在一起。"人们认为同性恋是因为上辈子做了坏事,例如通奸或强奸妇女而遭到了报应。但我并不这么认为。


    对同性关系罪行化是殖民时期缅甸统治者制定的刑罚,如今却仍被缅甸当局用来歧视和打压同性恋者。缅甸人权教育中心主任Aung Myo Min解释道:"他们以此做为借口来敲诈和骚扰同性恋者,并不会真正去法院解决这些案子。" Aung Myo Min是一名流亡海外的缅甸同性恋活动家,他所服务的机构驻扎在泰国。他说在缅甸的公共场所,对男同性恋进行性暴力和侮辱的例子数不胜数。"然而由于恐惧和羞耻心,许多受害人并不愿意上报自己所遭受的侵害。"


    互联网为男同志提供了相遇的场所,这比在现实生活中公开寻找伴侣要安全得多。比如Tin Soe就通过Facebook认识了他现在的男朋友。但他解释说很多人并不敢把自己的照片登在同志网站上。

    这种谨慎的态度使得唤起公共卫生意识的工作不易进行。根据联合国艾滋病毒/艾滋病项目报告显示,在缅甸的大城市,例如仰光和曼德勒,29%的男男性行为者感染了艾滋病毒。Tin Soe表示"我们国家有很多积极分子和活动家,但他们却无法公开地进行倡导工作。我们将在酒店里举办工作坊和会议,但却无法张贴海报,也不能使用话筒。所有工作都必须保持低调。"

    同时,缅甸的女同性恋也非常隐蔽。Aung Myo Min表示,缅甸社会对男性文化的接受度更高,很多人无法区分同性恋者和跨性别者。他说:"如果一个女人想变成男人是可以被原谅的。"


Asia Report 翻译

组织: 缅甸人权教育中心

原文链接: http://www.rnw.nl/english/bulletin/myanmar-gays-seek-thai-style-acceptance

When Men Talk About Sex

| 评论(0)

Sutthida Mallikaew

CHIANG MAI, Thailand, Mar 14 (IPS Asia-Pacific) - Tun Yo may not have known much about the ways of the world when he first came to work in one of the orange groves here seven years ago. After all, he was just a young boy of 14 at the time and one of the thousands of Burmese migrants who pour into Thailand every year.

Indeed, even when he finally got married, chances are he knew little or nothing about family planning or reproductive health. In fact, Tun Yo probably could have cared less.

That, however, is no longer the case. As one of the participants in a project aimed at Burmese male migrants here in Chiang Mai, Tun Yo recently attended a reproductive-health training workshop that has inspired him to discuss birth control methods with his wife. In addition, he says, he has become conscious of sexual hygiene and has learned about how to avoid getting sexually transmitted diseases (STDs), including HIV and /AIDS.

"I think compared to women, men are not interested much in their health," comments Dr. Samphan Kahinthapong, Northern Region director of the Planned Parenthood Association of Thailand (PPAT), which runs the project that received support from the International Planned Parenthood Federation (IPPF). "In fact, if men are responsible for their reproductive health, (that) will help both their health and their partner's."

It was this thinking that had PPAT creating and then implementing the project that began in June last year and ends in March 2011this month. Aside from offering training workshops that employ some of the migrants themselves as traineors, the project includes mobile clinics that provide contraceptives and treatment, as well as conduct tests for STDs.

In coming up with the project, PPAT had noted that most of the estimated two million Burmese migrants currently in Thailand have limited or no access to health services and education. Perhaps as a consequence, it said, the Burmese migrant community suffered from "early or unwanted pregnancies, early marriage, sexually transmitted diseases (STDs including HIV/AIDS), unsafe abortions, and violence against women".

The project aimed at providing information on sexual and reproductive health to 4,000 people and related services to 1,000 people. Male Burmese migrant workers at orange plantations, construction sites and elsewhere here in northern Thailand were the target beneficiaries.

It may have helped that most of these workers are Thai Yai, a Burmese ethnic minority in which relations between genders are more equal compared to those in other ethic groupstribes. Yet even then, some men admit to attitudinal changes after taking part in the project.

For instance, they say that they now don't think of household chores as being solely the burden of women, especially since both men and women these days work outside of the home.

One 37-year-old female worker also says, "It seemed to be embarrassing to talk about sex with my husband, but with the knowledge he now has, I tell him when I don't want to have sex because I have my period or when I'm so tired."

"He doesn't refuse when I ask him to buy my (sanitary pads)," she adds. "If we were in our home community in Mong Pan (in Shan state, Burma), I don't think he would buy them. The men there feel so embarrassed even to wash look at women's clothes."

Other male and female Burmese workers say that after undergoing training as part of the project, men seemed to respect and understand the women more. Participants showed more concern about having "quality" family life, they say.

Project officer Benjawan Srivichai also says increased understanding between the sexes is among the changes they have seen so far among the participants. "Males used to monopolise decision-making, but now they listen to each other more," she says. "We have heard more about men and women being equal. In addition, male and women workers have more access to reproductive-health services, condoms, and contraceptive pills."

PPAT is now thinking of extending the project's life span to ensure that such changes last. Dr. Samphan says as well that doing so would enable PPAT to expand the target beneficiaries to include boys. Moreover, he says, a long-term project would more suitable in addressing the seeming trend of early pregnancies.

Gender expert Niwat Suwanpattana meanwhile says that the PPAT project is a good initiative. But he thinks its focus is too limited to hygiene and contraception. Niwat, who is an advisor to the Thai Network Coalition on AIDS, says that he would like to see it move on to other directions, such as toward encouraging women to see sex beyond being a mere "duty" to their partners..

This is not the first time, though, that PPAT has had a project aimed at Burmese migrants in Chiang Mai. In recent years, it has provided reproductive-health services, but these were mainly for women migrants and consisted of gynaecological exams and pap smears, among others. P Yet while PPAT tends to have projects in the same areas for years, it has no problems with changing its programmes in accordance to the community's needs.

Migrant workers like Tun Yo couldn't be happier with its most recent initiative. Says Tun Yo: "I have never used condoms before, and now I know how to use it and that it is used not only for birth control but also for preventing HIV and other STDs."

"(My wife and I) are also discussing more about when we should have a baby," he says. According to Tun Yo, the project has made them realise there were many family birth control planning options they could choose from.



Orgnization: the Planned Parenthood Association of Thailand (PPAT)

撰文:Sutthida Mallikaew




7年前当Tun Yo第一次来到泰国北部的桔园打工时也许并不太了解这个世界。那时他仅仅14岁,只是每年成千上万来到泰国打工的缅甸民工之一。事实上当他结婚后对计划生育和生殖健康也知之甚少,而且Tun Yo自身也不太关注这些问题。


然而,现在情况却出现了转变。Tun Yo最近参加了一个关于生殖健康的培训工作坊,这激发了他与妻子共同探讨避孕措施的兴趣。另外他还补充道现在他很注意性卫生,并且学习如何避免感染包括艾滋在内的性传播疾病。


泰国北部地区计划生育协会(PPAT)负责人Samphan Kahinthapong 博士表示:"我认为同女性相比,男性并不是那么关注他们的健康。"该协会接受来自国际计划生育联盟(IPPF)的支持,在泰北执行相关项目。"事实上如果男性对生殖健康负责,那么将有益于自身和伴侣的健康。"她说。












项目官员Benjawan Srivichai也表示目前与会者对两性有了更进一步的理解,一些变化正在发生。"男性过去总是掌握了更多决定权。但是现在他们开始愿意倾听女性的意见。"她说,"我们总能听到人们谈论男女平等。另外,现在男、女工人都能获得更多生殖健康方面的服务、安全套和避孕药。"


同时,社会性别专家Niwat Suwanpattana也提出虽然PPAT项目是一个很好的开始,但他认为项目太过于集中对保健和避孕问题的讨论。作为泰国艾滋网络联盟的顾问,Niwat希望项目的主题也能够的得到扩展,例如鼓励妇女享受性行为带来的快乐,而不仅仅把性看做"分内之事"。



Tun Yo一样的缅甸移民工人对于近期的项目活动非常满意。"我以前从来没用过避孕套,现在我不仅知道怎么用,而且还明白安全套可以预防艾滋病和其它性病。"他说:"我和妻子现在对何时生子这个问题也讨论的更多了。"Tun Yo表示这个项目让他们意识到有很多可以选择的避孕措施。

Asia Report翻译



机构:the Planned Parenthood Association of Thailand (PPAT) 泰国计划生育协会



 It's hard to say for sure how Kyaw Lin's battle with HIV/AIDS would have gone had doctors here been able to give him the medicine he needed earlier. But it's difficult to imagine it could have been much worse.

 Mr. Kyaw Lin, a factory worker from small-town Myanmar, was diagnosed with HIV four months ago. His family, suddenly reviled and isolated in their hometown, hired a car for the four-hour drive to Rangoon, the only real metropolis in this impoverished country, where they'd heard there were people who knew how to treat the virus that levelled the 33-year-old in his prime.
More related to this story

 They found doctors from Médecins Sans Frontières in Rangoon who knew what Mr. Kyaw Lin needed: antiretroviral medicines which slow the progression of symptoms, now in use worldwide to treat AIDS sufferers. But in Myanmar (formerly known as Burma) there aren't enough antiretroviral medications to deal with an AIDS crisis that continues to grow, in large part because of the country's imposed isolation from the outside world.

 While Mr. Kyaw Lin was clearly ill and in need of drugs when he arrived in Rangoon last fall, his CD4 count - a test used to measure the strength of the immune system that HIV attacks - wasn't low enough to qualify for a course of the limited number of antiretroviral drugs available. Instead, he was told to go home and come back when the disease had progressed.

 Now he is far, far sicker. By the time Mr. Kyaw Lin began his antiretrovirals on Jan. 19, he was suffering from an undiagnosed brain illness that leaves him silent and staring for much of the day, except for the occasional burst of unsettling laughter. His skin is covered in sores that he scratches at with a blue comb while his mother and sister - who have moved with him into a bare-bones shelter for AIDS patients on the outskirts of Rangoon - look on with evident worry.

 "We didn't have adequate medications for everyone. Even though he needed ARVs, he needed to wait - we only have enough for those who need critical treatment," explained a social worker at the shelter where Mr. Kyaw Lin and his family are staying, sleeping on straw mats in a room filled with three other AIDS sufferers and their families.

 When it comes to HIV/AIDS, Myanmar is doubly cursed. At a time when worldwide infection rates are slowing, and in many cases falling, front-line workers here are still overwhelmed by new patients who come in every day, often collapsing as they reach the clinics at the end of long overland or river journeys from small villages in the country's poorly connected regions. Many had never heard of HIV until their doctor told them they were infected with it.

 While Myanmar's AIDS crisis is not yet of the scale that some countries in Africa are facing, the country lags far behind in its ability to deal with the spread of the epidemic. International aid organizations estimate there are some 242,000 people (or just under 1 per cent of the adult population) with HIV, of whom as many as 120,000 currently need antiretroviral treatment. But there's medicine for only 20,000.

 That access rate is believed to be the worst in the world, a crisis even when compared with sub-Saharan Africa, where after years of neglect even the region's poorest countries are now able to provide antiretrovirals to upward of 50 per cent of their AIDS sufferers.

 In Rangoon (also known as Yangon), there are international aid organizations present and therefore some hope of receiving treatment, though it sometimes comes too late. In the farther-flung corners of the country - particularly the areas near Myanmar's borders with Thailand and China, where fighting regularly flares between the army and ethnic militias opposed to the junta - the only option is often a cash-strapped government hospital with no access to modern HIV/AIDS medicines. (AIDS-related illnesses are the country's second biggest killer, after malaria.)

 The shortages mean that only those with a CD4 count of less than 200 are eligible to receive antiretroviral medications from MSF and the other groups distributing them. By that point, it's often too late as the immune system has been ravaged to the point that the sufferer is easy prey for tuberculosis and other diseases. The World Health Organization recommends that anyone with a CD4 count of less than 350 should receive antiretrovirals.

 Those helping fight Myanmar's AIDS crisis split their anger between Myanmar's military government and what some call an informal international ban on aid to Myanmar that has left humanitarian workers short of cash and hamstrung by impractical restrictions that forbid them from having any contact with the same Ministry of Health they're trying to support.

 "The government's health budget is much too low, and the amount of foreign assistance is much too low," said Andrew Kirkwood, country director for Save the Children. "Should the international community punish the people who need ARVs just because their government is not spending enough on health? To me, that's a very perverse conclusion to make."

 It's not just antiretrovirals that are lacking. At an informal shelter run by the Phoenix Association, a small and independent charity run by volunteers, there's no money for even the most basic supplies for the two dozen people currently in their care.

 "We don't have enough mosquito nets, pillows or mattresses. We can't even provide our patients with food. They have to buy their own and cook for themselves," said Thiha Kyaing, founder of the Phoenix Association.

 To illustrate the toll the lack of funding takes, he pulls out the records book for the Phoenix shelter on the edge of Rangoon. The numbers for 2010 were grim: 202 patients received, 60 funerals. "People die every day because of the criteria [for receiving antiretroviral medication]," said Mr. Thiha Kyaing, his soft voice barely audible as an infected two-year-old boy in the same room wails from a high fever.

 Speeding the epidemic's spread is widespread ignorance in Myanmar about the virus, especially beyond Rangoon. Particularly vulnerable is the country's vast community of sex workers, who often work in anonymous massage parlours and "beauty salons" off the radar and beyond the reach of the few trying to spread the message about condoms and disposable needles.

 Those who contract HIV-AIDS find themselves isolated and alone. Among the patients at the Phoenix shelter are a husband and wife who are expecting a baby any week now. The 24-year-old husband was immediately dismissed from his post as a soldier in Myanmar's army when his commanding officer found out he had contracted HIV, likely from a hospital blood transfusion. "They were afraid he would infect the whole regiment," his 24-year-old wife said. The couple will now have to raise their child on his military pension of $9 a month.

 There is some hope on the horizon. After prolonged negotiations, the Global Fund to Fight Aids, Tuberculosis and Malaria entered Myanmar in early 2011 with a budget of $105-million (with tighter than usual monitoring because of corruption concerns). But even that injection of money - which will be spent on education and prevention as well as treatments - will be far from enough. Even if the Global Fund achieves its own goals for distributing antiretrovirals, the number of HIV/AIDS sufferers receiving the treatment will still be less than 50 per cent.

 For the Global Fund, it's the second try at tackling Myanmar's HIV/AIDS crisis. The fund withdrew from the country in 2005, citing government restrictions that impeded its ability to monitor how grant money was being used.

 "The international community, particularly the folks working on HIV/AIDS, are frustrated with the lost time [because of the 2005 pullout]," said Elmar Vinh-Thomas, regional team leader for Asia and the Pacific at the Global Fund. "The funding gap in Myanmar is growing because the disease burden is growing."


Orgnization: Médecins Sans Frontières Phoenix Association


加入邮件组: yzdc@asiacatalyst.org