A Country with a Low Immune System

By Avner Ofer May 2000

l

The United States announced this week that the Aids epidemic is a threat to National Security and that all efforts must be taken to fight this disease. Although most people are aware that HIV/Aids constitute a major global threat, this declaration by the US government emphasizes the high degree of impact that this disease has had on people’s lives. The current world situation, regarding countries affected by the HIV epidemic, is troubling. However, some countries in particular are dealing with extreme levels of infection among their population, and in this paper I will address such a country, Cambodia.

The title of this paper reflects the susceptibility of Cambodia to the HIV/Aids pandemic. As an entity, Cambodia is showing a wide range of characteristics that make it prone to the expansion and explosion of this deadly agent within its borders. Historical, political, social, economical, and even cultural attributes have played a part in putting Cambodia at the top of the list of countries infected with the HIV/Aids epidemic in Southeast Asia.

In a torn country such as Cambodia there seems little hope for change or improvement in the current situation. Even though many NGO’s are playing an important role in educational programs, data collection and preventive medical assistance, the predictions for the future draw a gloomy reality for the Cambodian people.

Let me start with numeric information as a basis for the discussion. The information is based on 1997 data collected by the UNAIDS/WHO organizations. The critical age group for evaluating the severity of the HIV/Aids epidemic is what the UNAIDS/WHO refer to as adults — 15 to 49 years old. In 1997 this age group constituted almost half the population of Cambodia with 4.9 million people. According to this report, 120,000 adults (2.4%) were infected with HIV/Aids in 1997. The U.S. Census Bureau estimated in 1998 that this number increased to 5% of the population infected with the HIV virus. The following demographic pyramid shows distinctly the gap among the specified age group.

This alarming increase is what makes Cambodia a major problem in dealing with the spread of HIV. The numbers (as seen in the following tables) are an indication to the impact of this disease in Cambodia, but the extremely rapid diffusion of the epidemic within Cambodia is the true cause for concern. As Beyrer states, "…it is the startling speed with which this population density has been reached that is more troubling." His supporting evidence includes the increase of HIV positive blood donors in Phnom Penh from 0.076% in 1991 (less than one in a thousand) to 3.62% in 1994 (one in thirty). "This is about as fast as a virus with HIV’s infectiousness can spread, and suggests an epidemic out of control. These numbers… point to disaster" (Beyrer 1998).

Some examples of this rapid increase include data gathered regarding sex workers and pregnant woman in Phnom Penh. In 1992 10% of the sex workers tested, proved positive for the HIV virus, while only four years later, in 1996, that number rose to 42%. The following table, depicting cases of HIV among pregnant woman, is yet another clear indication to the rapid increase in HIV cases within Cambodia. As can be seen in Graph 2 the number of cases in Phnom Penh increased exponentially within a short period of four years (U.S. Census Bureau).

To exemplify the problem I am including data gathered at various locations in Cambodia, dealing with infection among the woman and prostitution populations. The data is from the U.S Bureau of the Census - HIV/AIDS Surveillance Data Base Installation, from 1998. In Phnom Penh out of 400 woman checked, 3.8% were infected with the HIV virus. Among the prostitute population of the city, 61.3% of the 150 examined proved positive. In comparison, the rural woman population proved positive in 2.5% of the cases among the 1200 examined, and the prostitutes in the rural province of Kampong Cham proved positive in 28% of the 150 cases. These alarming numbers point to a serious problem within the capital of Cambodia, where the numbers are staggering by world standards. However the overall concern should take into account the fact that although the rural numbers are lower they too constitute high levels of infection in comparison to neighboring countries.

These figures when put in perspective to the amount of time that the HIV epidemic exists in Cambodia, are disturbing. The epidemic probably started to find its way into Cambodia between 1988 and 1990. The fact that the numbers of cases throughout the country have exploded is a case in point to the susceptibility of Cambodia to the disease (Beyrer 1998).

Although more proof is repetitive, it shows the extensive affect of the disease in recent times. Cumulative deaths from Aids since the beginning of the epidemic, around 1988-1990, amount to 15,000. During 1997 over a third of these cases occurred--6,300 deaths. Another indicator to the problem is the number of orphaned children (under the age of 15) that their parents died of Aids. Total number of orphans since the start of the epidemic amount to 7,300. The number of orphans in 1997 (the last year the data was collected) is remarkably high at 6,900 children (UNAID/WHO). All these statistics paint a scary picture of Cambodia’s HIV situation. It is clear that the disease has found fertile ground in Cambodia and is spreading rapidly. The obvious question is why?

Although most of the aspects that have created the current situation in Cambodia are interrelated, I will focus on the few most prevalent and their contribution to the explosion of the epidemic.

Prostitution may be the leading cause for the wide spread HIV outbreak. However, there are many aspects to consider when examining such a sensitive and often complex issue. Beyrer hypothesizes that the HIV virus found its way into Cambodia from brothels located in the far west of the country, bordering Thailand and servicing the soldiers of the area, or from seaman who often visit brothels on the islands in the gulf of Thailand. Moreover, the spread of the virus within Cambodia is most likely associated with sexual transmission, and involves contracting the disease from prostitutes.

As in other Southeast Asian countries, prostitution is prevalent for a number of reasons that are interrelated to each other. As in any other business, the demand for sex is the driving force behind the booming numbers of prostitutes within Cambodia. Again, the reasons vary. From local indigenous population demands, such as the acceptability of young men to visit prostitutes prior to their marriage, since the virginity of their wives is important (Wienrawee 1999); Soldiers, police and officials who frequently are away from their homes are regular consumers of the sex industry (Beyrer 1998); And the "economic liberation in Cambodia has revived an entrepreneurial capitalism in which commercial sex is flourishing, along with sexually transmitted diseases, after being suppressed for decades under communism." (Weniger 1996).

To meet the growing demand, especially within Phnom Penh, from businessmen, tourist and locals, the sex trade industry has flourished. Trafficking of young girls from within Cambodia, as well as from other countries into Cambodia has become a lucrative business. Lim explains that "the illicit recruitment and sale of women and children across national borders is organized not only by individual agents but also by international underground syndicates operating effective networks with official connections." These people buy, kidnap, and coerce young girls and boys into prostitution. Again there is an array of compelling circumstances leading individuals into prostitution. The rural population of Cambodia is extremely poor. In the aftermath of the wars, the killings, and the tortures, a rural farmer has an almost impossible job of rebuilding a normal life. The foreign aid that pored into Cambodia was either spent on developing the capital, or went into corrupt hands. Thus, the farmer’s main concern is making a living, and if that deems the necessity of selling a daughter into prostitution for survival, more likely than not that will be the case (Beyrer 1998).

The main concern of this paper, though, is the HIV problem that is rampage in Cambodia, and not the social aspects that lead individuals into prostitution, although those do play an important role in explaining the large prostitute population in Cambodia. Sufficient to mention that Cambodia is competing with Thailand for the title of most prostitutes in Southeast Asia. Consequently, the trafficking of prostitutes from high-risk areas, such as the "Golden Triangle" area of Burma, Thailand, and Yunnan, has increased the number of HIV positive sex workers in Cambodia. The flourishing sex industry is responsible for much of the excessive spread of the disease. Clients, mostly local rural men, have no money or education to protect themselves from sexually transmitted diseases. So, the transfer through the population is facilitated by unsafe practices with a community that is susceptible to the disease, namely prostitution, and then the domino effect of passing the disease to wives, their babies, and mistresses (Beyrer 1998).

As mentioned earlier, the military plays an important role as a supplier of clients for the sex industry. Historically, Cambodia has been, and still is, a country at war. The transfusion of the epidemic is tremendously increased through repeated encounters with prostitutes from various areas. Soldiers carry the disease from one region to the next and bring it home to their families as well. However, a more concerning phenomenon is the foreign military personnel’s influence on the HIV situation. As Heyzer states, "Military camps and naval bases are fertile areas for the emergence of a specialized system of prostitution. Countries of the region (Southeast Asia) that have at some time in their history hosted foreign military bases are particular targets of sex tourism." Cambodia has been subjected to foreigners for decades (the French, Vietnamese, and UN forces to name a few), bringing with them bloodshed, devastation, sometimes salvation, but also death in the form of the HIV virus. A specific case in point is the presence of UNTAC (United Nations Transitional Authority in Cambodia) between 1991-1995. This UN mission "included 20,000 people from numerous countries, including the US, Western Europe, Bulgaria, Uruguay, India, Pakistan, Bangladesh, Thailand, Korea, and several African states" (Beyrer 1998). The presence of so many "rich" foreigners brought a wave of prostitutes into Cambodia; through increased trafficking of girls, in migration of workers from neighboring countries, and local girls turning to prostitution to make more money. Prostitutes reported having an increase from 5 to 10 clients a night during this period.

Byerer raises two main concerns regarding the presence of so many foreign soldiers. The first is the introduction of HIV into Cambodia. The levels of HIV infected blood donors, during the UNTAC period, showed dramatic increase (from 0.076% in 1991 to 3.62% in 1994). The explosive increase among the local population is an important indication to the disease as a whole. Since the blood donor population is not part of a high-risk group, their infection numbers are critical in evaluating the country’s HIV situation. Thus, this increase has been associated with the presence of UNTAC soldiers and their use of prostitutes, who in turn passed the disease to the local population.

The second issue is a reverse transferal of the disease upon return of the soldiers to their homeland. Many of the soldiers present in Cambodia came from strict countries that govern issues concerning sex education with complete censorship (such as Pakistan, Bangladesh and India). In turn, many of the soldiers were not educated on safe sex practices, which exacerbated the spread of the virus. Fifteen percent of Indian soldiers returning from Cambodia were tested HIV positive. Although their goal and mission were peaceful, the UNTAC undeliberately brought long term suffering to the people of already torn Cambodia.

Land mines are a cruel reminder that war has long lasting affects and dangers that the population of Cambodia has to deal with on a daily basis. As a society torn by violence, Cambodia has little resources at her disposal to confront the land-mine issue. Apart from the obvious threat to human life from these inhumane war devices, the HIV infection is another consequent of the mines. Apart from Phnom Penh where most of the blood is screened for the virus, the rest of the country survives on what is available. In most cases throughout the rural areas and the war zones, land mines maim and mutilate their victims but the contaminated blood transfusion seals the wounded individual’s fate. This is yet another added aspect that makes Cambodia so vulnerable to this deadly pandemic (Beyrer 1998).

With statistics such as 100 people infected each day and 20 people die as a result of HIV/Aids, the work cut out for the many organizations is tremendous (Gluck 1999). Cambodia is a land drowning with NGO’s both international and local, all fighting up-hill battles. There are hundreds of foreign organizations combating every issue from deforestation, human rights, development, and health. The health industry is in the hands of NGO’s, relief agencies, foreign donors, and the UN, since almost all the medical workers in Cambodia have been killed during Pol Pot’s rule (Beyrer 1998). The two main indigenous groups working on the HIV/Aids problem within Cambodia, are the Cambodian National AIDS Prevention Committee, and the Woman’s Development Association, which began as woman’s rights body and is working on HIV/Aids prevention and care of the infected. The National Aids Authority has implemented programs as well to control the disease. A national project supported by all the groups is the mandatory use of condoms in brothels and providing sex workers with monthly tests for HIV (Gluck 1999). This is a promising project but one that requires much foreign financial support.

The issue of condom use is also complex. Education is a major concern for achieving any substantial results with the mandatory condom program. Out of the 20,000 men that visit a prostitute each day (Anonymous 1999), most are poor uneducated people that have no concept of the disease. As one doctor in Cambodia explained, "we have long time with the war, people very poor, they don’t understand very well about health, HIV/Aids, they are thinking about eating… they are thinking about the problem of the stomachs, because they are poor" (Gluck 1999). Moreover, educating the woman who work in the sex trade is a difficult task. Many of these young girls are so traumatized they have no power over their situation and find it impossible to negotiate with a drunk man entering their body to use a condom. Furthermore, they are young (many start as young as13 years old. 80% of the sex workers are youth (Wienrawee 1999)) and have never been introduced or discussed sexual intimacies (part of the cultural taboo of discussing such issues), so touching a condom and even thinking about where to put it, is a painful process (Beyrer 1998).

Dr. Narong Rith, deputy chairman of the National AIDS Authority was quoted saying: "Generally parents, policy makers, and authorities are afraid and reluctant to implement activities that are in fact removing the threat to young people. They do not want to inform young people about sex because they believe this will lead to teenage promiscuity and immorality" (Anonymous 1999). Thus, these cultural perceptions create barriers for workers in the sex education and HIV/Aids prevention in doing their jobs. Education plays the most important role in combating the spread of the disease. Unfortunately the education system in Cambodia is hampered by many factors. Much of the HIV/Aids education usually begins only in the sixth grade, but in Cambodia only 40% of the children are left in school by this age, since many have to help support their families. Outside the school framework there have been a few success stories. MTV produced commercials dealing with HIV/Aids education, which were effective in delivering their message. However, only the wealthy teenagers who can afford this luxury, which is a limited population, viewed them. Another educational video was produced by one of the many NGO’s in Cambodia, which sponsored a boat tour along the Mekong to record a soldier infected with HIV on his return home. The video was well made and again a great tool for education for those able to view it (Weinrawee 1999).

Combined, these issues of cultural taboos, poverty, traumatized girls, and the problems with educating the population, has wrought havoc on the Cambodian society.

According to the US Census Bureau the main indicator for the impact of HIV/Aids in the developing countries is the crude death rate (see Graph 3). Cambodia is at 15 people per 1,000 without the virus (compared to neighboring Thailand at 6.1), and 16.5 people per 1,000 with Aids (compared to 7.1 of Thailand). These numbers are remarkable and are equivalent to the numbers is devastated African countries. The graph depicts projected numbers for the year 2010, which show an increase in the number of crude deaths. These numbers represent a major threat for the development of the country. As can be seen in Graph 4 and 5, both the life expectancy and growth rate in Cambodia are impacted by the disease. Life expectancy will drop by 3-4 years by the year 2010 and the growth rate would be reduced 8 percent by 2010. These are serious indicators to the extreme situation of the HIV/Aids pandemic in Cambodia

Graph 3 Graph 4 Graph 5

A country of land mines, wars, bloodshed and fear, Cambodia has proved a fertile ground for the HIV/Aids epidemic to grow roots in. The people of the Angkor kingdom face a new threat to their way of life. HIV/Aids dictates a gloomy future for this once proud nation, which today is struggling to survive. The disease has found a host in a country torn by internal and external forces, which is battling to regain its balance after years of conflict and destruction. Even though the NGO’s and the international community have been disposed in Cambodia for years and are contributing time, money, and effort to rebuild, educate, and help the Cambodian people, Cambodia remains a country with a low immune system.

Anonymous. 1999. "Cambodia targets youth on World AIDS Day." Reuters, (December)

Beyrer, Chris. 1998. War in the Blood: Sex, Politics and Aids in Southeast Asia. London:

Zed Books Ltd

Gluck, Caroline. 1999. "AIDS in Cambodia." BBC. (October)

Heyzer, Noeleen. 1986. Working Woman in South-East Asia: Development,

Lim, Lean Lin. 1998. The Sex Sector: The economic and social bases of prostitution in

Southeast Asia. International Labour Organization: Geneva

Opperman, Martin.1998. SexTourism and Prostitution: Aspects of Leisure, Recreation,

and Work. Cognizant Communication Corporation: New York

UNAIDS (U.S. Agency for International Development). 1999. HIV/AIDS in the

UNAIDS/WHO Working Group on Global HIV/AIDS and STD Surveillance

http://www.who.ch/emc/diseases/hiv and http://www.unaids.org

U.S. Bureau of the Census: HIV/AIDS Surveillance Data Base Installation

http://www.census.gov/ipc/www/hivaidsw.html

Wienrawee, Pawana and Livingstone, Carol. 1999. "Southeast Asia: Slowly getting