POSTING 66: ASIAN CRISIS -- HIV TESTING ISSUES 


about Epidemiology & the department

Epidemiology academic information

Epidemiology faculty

Epidemilogy resources

sites of interest to Epidemiology professionals



Frerichs, R.R. Asian Crisis -- HIV Testing Issues

SEA-AIDS Network, January 18, 1999.

Posted in response to:

SEA-AIDS, January 15, 1999

From Ivan Wolffers, CARAM Asia

The economic crisis and HIV-infection

The dissemination of HIV-infection cannot be seen apart from economic developments. Like those with a bio-medical background talk about STDs as a 'co-factor' for the HIV-epidemic, people with a background in social sciences know that the modernisation process in developing countries is a 'co-factor' for HIV. Because of the modernisation of Asia which is closely connected to the economic developments, literally millions of people have been replaced, new communities have been developed, social networks disrupted, traditions have been forgotten and new identities created. It has had a deep impact on human behaviour and on relationships between people (including sexual relationships). It is obvious that the economic crisis has also had an impact on the HIV-epidemic.

Economic development is rarely equally distributed and this leads to people moving to places with opportunities. The migration from rural areas to the cities in Asia has been impressive. In China alone there are 100 million internal migrants (one in five people interviewed in Shanghai is a migrant) and the figure for the Southeast Asian countries will not be very different. Economic development has had a huge impact on the relationship between Bangkok and rural areas. In the dry season we see Thai farmers in the Northeast move to the South to work on fishing boats. We have also witnessed the migration of many young women to the cities to work in the sex industry. In some villages one can see the houses with a car in front and with a parallax antenna and one understands what the daughter in this family is doing in town. The sex business is seen as one of the important mechanisms to redistribute wealth back to rural communities. The recent ILO-publication 'The Sex Sector' (about Thailand, Malaysia, Indonesia and the Philippines) has reaffrimed the importance of the sex sector in Southeast Asia and this is narrowly related to migration and the difference in economic opportunities. In Vietnam, Cambodia and China we are also witnessing a booming and rapidly growing sex sector. Young men without partners move to cities to work and find ways to fulfill their natural needs. Young women also try to find employment in cities but because of the lack of opportunities for women they often end up in the sex sector.

International migration is a part of this process. Burmese women move to Thailand. Cambodians also go to Thailand. One third of the sex workers in Cambodia are Vietnamese. About one million Indonesians are living and working in Malaysia. Philippine housemaids and entertainers can be found in many countries. Four million Bangladeshis are working abroad. International migration has become a common strategy for many rural populations to deal with their poverty. It is estimated that there are 20 million international migrants in Southeast Asia, many of them undocumented.

The economic crisis has had many consequences for the vulnerability to be infected with HIV of internal and international migrants, though some of these may only be understood later. It was expected by the authorities that the crisis would partly be solved by rural migrants moving back to their rural communities. There they would find the support system that would help them get through the crisis. This, however, was a combination of wishful thinking and lack of understanding the realities of migrants. On the contrary, migrants have not been moving back to rural areas, while poverty in rural areas has been a pushing factor for many to go to places where they expect better opportunities. It has made many migrants more exploitable and pushed them into kinds of work that they would never have done before the crisis. In the research done by CARAM Asia (Coordination of Action Research on Aids and Migration) we have seen that especially young women feel a strong responsibility for supporting their families at home. If the garment factory where they were employed closes they will find other work. There is no hard evidence of this, but many have observed that there is an increase of 'indirect prostitution'. In our own research in Indonesia we see that direct sex work is becoming less popular (it is too expensive because of the money that goes to pimps and bribed policemen). However, in shopping malls and at night at the streets there is more sex work activity.

Indirect sex work makes sex workers much more vulnerable to be infected. In addition, it is also a nightmare for all of us who are involved in intervention programmes. Indirect sex workers are much harder to reach. In addition, as many see it as a temporary emergency activity, they do not see themselves as sex workers, and this makes it even harder to develop effective intervention strategies.

Apart from increased vulnerability of internal migrants, in the situation of international migrants we see extra problems due to the economic crisis. To create employment for the local population authorities are embarrassed with having a vast migrant population from abroad (people they have been attracting before to make their economies bloom). In many countries authorities have turned to forced testing and repatriation as a means to solve their problem with international migrants. A small sample of news items from international media in 1998 may be convincing:


From the newsroom of the BBC World Service: UAE deports foreigners infected with HIV (the figure of 6000 is mentioned).

New York Times (12/01/98): Saudi Arabia 349 with HIV deported.

Associated Press (September 04 1998): Singapore to test ALL foreign workers for AIDS.

The Sun (18-8-98) Fomena: 87 Foreign workers HIV carriers Kuala Lumpur.

"All who were found unfit were deported as we don't want them to be around and spread the disease to our people.."


It is a shame that there has been so little outcry over this gross violation of human rights of people with HIV/AIDS. It might be that even the advocates of the HIV cause are less interested in human rights violations of foreigners than of their 'own people'.

For instance, the crisis has resulted in policies of the Malaysian government to demand medical checks from documented migrant workers if they want continuing of their contracts and any health problem can be used against them. In a scheduled checking round for 100,000 migrants in Johor Baru only 2,000 migrants showed up out of fear that something might be found and they would be repatriated. Migrants even feel unhappy to visit a clinic when they have symptoms of STD. The authorities have demanded from all doctors to report diseases to a central point. Health care is used against the individual and migrants will prefer to ignore STD symptoms and treat themselves with inappropriate medication (nowadays it is a hassle to know which antibiotics are still good to use because of the increased resistance). It has amazed me that there was some discussion on SEA AIDS on boycotting ICAAP99 because of the case against Anwar, while this situation is far more outrageous (it neither is worth a boycott if we are able in October to challenge Malaysian authorities to a discussion on these points).

Apart from the devaluation of currencies which has resulted in higher cost for treatment and prevention programmes (which I will not cover in this reaction) and the fact that many organisations (including NGOs) have shifted their priorities towards solving the direct consequences of the crisis and show decreased interest in HIV/AIDS, the above mentioned consequences of the economic crisis in SE Asia have tremendous impact on the dissemination of HIV. We have to understand that and we should not be short sighted and also discuss and study the vulnerability of people for HIV-infection after the crisis is over. Because probably the most important co-factor to make people vulnerable for HIV-infection is their social, economic, and gender position. As such it is interesting to quote CARAM chair-person Irene Fernandez (during the World AIDS Conference in Geneva in 1998) "Worldbank and IMF policies are mong the important co-factors for HIV-infection".

On behalf of CARAM Asia

Ivan Wolffers

R.R. Frerichs Posting

 

I would like to commend Ivan Wolffers and his colleagues at CARAM Asia on their insightful posting that appeared today on SEA-AIDS. They describe well the shifting nature of the population, the economic pressures that affect the region and the health consequences that arise. With that said, however, I would like to further address one section in their posting that deals with HIV testing to see what policies might be encouraged or developed to address their concerns.

Specifically, their text in question is


Apart from increased vulnerability of internal migrants, in the situation of international migrants we see extra problems due to the economic crisis. To create employment for the local population authorities are embarrassed with having a vast migrant population from abroad (people they have been attracting before to make their economies bloom). In many countries authorities have turned to forced testing and repatriation as a means to solve their problem with international migrants . A small sample of news items from international media in 1998 may be convincing

From the newsroom of the BBC World Service: UAE deports foreigners infected with HIV (the figure of 6000 is mentioned).

New York Times (12/01/98): Saudi Arabia: 349 with HIV deported. 

Associated Press (September 04 1998): Singapore to test ALL foreign workers for AIDS.

The Sun (18-8-98): Fomena: 87 Foreign workers HIV carriers Kuala Lumpur. "All who were found unfit were deported as we don't want them to be around and spread the disease to our people.."


No developing countries other than Cuba have widespread HIV testing programs that make HIV easy to identify. Instead, in much of the world the overwhelming majority of those carrying the virus are unaware of their own status and thus inadvertently transmit the virus to their sexual or blood partners. This process continues at a high level, with millions of new infections occurring each year. At the same time, HIV infected persons in the developing world who are aware of their status have rightfully called out for therapy, hearing of the medical benefits that come with treatment adherence in wealthier societies. Thus there is economic pressure on government health ministries to address their cries for help, as is done for other diseases. 

Of course, if there is little testing there is less awareness, and less pressure to respond with expensive medicines. The medical care burden of HIV infection comes not from the asymptomatic HIV infected state, but rather from the symptomatic AIDS state when it is obvious to most that the person is sick. By avoiding testing, the care problem can be put off for another day. Yet public health professionals know that such avoidance carries a high cost, to be borne a decade later when AIDS cases appear.

At present there is much political pressure to avoid widespread testing, with some viewing such disclosure as an infringement on human rights. Thus there is a political cost of domestic testing that many health officials may not be willing to absorb. Such officials likely reason, however, that this political cost should not have to be absorbed for foreign workers, and thus support both testing and exclusion of those found to be infected.

Given the thoughtful nature of much of what Wolffers and colleagues wrote, I would like to encourage them to draft an effective testing policy for countries in Asia to consider, specifically focusing on foreign workers. In considering the policy, however, they should keep in mind the epidemiological reality of the disease, including transmission pathways. 

Broad principles such as human rights are important to consider, and certainly elevate our social horizons. If not biologically practical, however, our adherence to a poorly conceived human rights mandate can cause great harm.

Return to INTERNATIONAL CONTROVERSIES