Total population 10,516,000
Number of people with HIV
Official gov't NA
Number of people with AIDS
Official gov't 978
Number of openly positive 4
5% Blood products
When peacekeepers moved in in the early '90s, the sex industry exploded, along with AIDS. It now has the continent's highest HIV infection rate: 40% of sex workers, 30% of the military and 15% of pregnant women have the virus. One of Asia's poorest nations, only half the people have access to medical care. Gov't and NGOs are in a valiant race against time.
Just got back to Svay Pak from my holiday in Vietnam. It's the 25th anniversary of the liberation of Vietnam, and according to the U.S. embassy, my American life was supposed to have been at risk. The same old paranoias. I went to my favorite place in Vietnam, Da Lat, a beautiful old town in the hills, with old French alpine houses, winding roads and the most gorgeous winter vegetables on God's red soil earth. I meditated in a Zen Buddhist monastery and converted to Buddhism on my birthday. My dharma name is Tu Chon, True Compassion. Something to work toward. I wish the same could be said of Vietnam's terror-tactic HIV prevention billboards, which show a hooded grim-reaper figure and a very large needle dripping infected blood in the top corner. Does the Ministry of Social Evils (stranger than fiction, but true) really think it can scare a generation of Vietnamese into HIV prevention? And still, Vietnam has seduced me. It is my melancholic mistress. I am content with her only when I am in her embrace.
Back to Phnom Penh. Dusty, hot. A city of 1.1 million. And back to work, coordinating my Médecins Sans Frontières (MSF) [Doctors Without Borders] team's many outreach activities in Svay Pak, 11 kilometers away from the center of town. I like Svay Pak. I like walking around the three little streets and eating pho (noodles in spicy broth), hanging out with old Mai with the toothless, glowing grin, and practicing my few words of Vietnamese with the sex workers in their, well, storefronts.
After nearly seven years in Africa, I wanted to come to Asia. It's where I need to be now.
Every day at around 11 a.m., the metal gates are pulled back, and the ladies are in business. They sit nonchalantly in their plastic chairs, applying whiteface makeup, smoking, gossiping, waiting for that car to pull up. A chorus line of loveliness.
The government of Cambodia, under advisory of Thailand, has instituted a "100 Percent Condom Use" policy for sex workers and their clients, launching the initiative in Kompong Som (formerly Sihanoukville, named after the survivalist king). According to government statistics, they have had nearly a 100 percent success rate. However, a British STD consultant I met said that he offered a sex worker in Sihanoukville 20 U.S. dollars to have sex without a condom and she agreed.
The Khmer, or Cambodian, clients come mainly at night, but during the day, the clients are primarily European, North American, Japanese, Chinese and Korean. Svay Pak is on the Asian sex tour. They travel from Thailand to Svay Pak -- but only during the day because they are too afraid to come at night. It's interesting at night -- the streets, lined with open brothels during the day, become a row of closed iron-grated jaws that open quickly and swallow the motorbikes that drive up. Spooky.
I got into an argument today with a colleague (who shall remain nameless) who claimed the necessity of constantly updated HIV statistics. The HIV prevalence rate at the last survey, funded by USAID and carried out in 1996, was just over 18 percent among the sex workers in Svay Pak, while the rate among the rest of Phnom Penh's sex workers was over 40 percent (and still is). This lower rate makes sense, as Svay Pak, a fishing village, is an entry point for the Vietnamese sex workers, most of whom come as virgins.
But apparently the survey counted an abysmally small number of women because most refused to be tested. They didn't want the brothel owners to know their status and turn them out. The women also didn't want other sex workers to know for fear they would use the information to scare away clients. But sometimes I wonder if knowing even matters. If the sex workers tested positive, would they stop working? Would they pay attention to HIV prevention messages with their clients? What would be the priority in the women's minds: money -- for family, self, debt repayment -- or long life? Here, an HIV-positive sex worker has few options. Either continue working or return to Vietnam -- and lose face with the family for losing desperately needed income. Or go through a program that teaches them something like doing pedicures, which would earn them a fraction of what they earn through sex work.
I also fear that the women will be punished if they are found to have an STD. The government assures us that only the brothel owner will be punished. But every expense lands on the womens' backs. Literally. They repay bribes to get out of jail, for transport costs and registration fees for the "100 Percent Condom Use" policy. Everything.
Strange weather. It's supposed to be the hot, dry season, but it was cloudy when I woke this morning. Sometimes the rain manages to break through, washing Phnom Penh until the trees, grass and flowers shine a waxy sheen.
However, the "100 Percent Condom Use" meeting didn't exactly shine. Reps from Cambodia's National Center for HIV, AIDS, Dermatology and STDs were very nice, said they wanted to work together with NGOs, but in the end, nothing was specifically recommended about our becoming the appointed STD control clinic for the condom policy. So we wait and see.
Other problems. The Municipal Health Department wants us to move our clinic to its own health center -- five kilometers from Svay Pak -- for reasons of the program's sustainability. They expect we'll leave, and someday we will. But issues of sustainability are fairly moot at this point as the government has little money to keep programs going. Besides, if Phuong (our guard and so much more, including chief condom seller) has to bring the women to the clinic on his moto, guess who will pay for the transportation? Obviously, we lose the STD consultations. And will the sex workers stop hanging out at the clinic? Will we lose the opportunity to offer them English classes so they can negotiate safer sex with their foreign clients, who all speak a little English? Will we lose the opportunity to learn from the sex workers what kind of HIV prevention material they want to work with? It could be a bleak future for HIV intervention in Svay Pak, indeed.
I discussed the introduction of the female condom tonight with some Family Health International (FHI) folks. It failed completely in the United States. We already know the acceptance rates: 15 to 25 percent. But at $.62 per condom, we get to order nearly 100,000. MSF and FHI want to introduce it so the women have a choice. In many cases, requests that clients wear condoms fall on deaf ears. But what if he's too drunk to get hard enough to put on a male condom? What if he is rough with the woman? If she can excuse herself to insert the female condom, or insert it ahead of time, she has a chance to protect herself against STDs, HIV and a steady stream of spooge (a Judy Blume Forever word?). We all agreed that the female condom should be implemented only with the approval and feedback of the sex workers. If they don't want it, we may have to find another use for them. Piñata, anyone?
Today was hard. It's always hard for the staff when we have an obvious AIDS patient. The bantering in the reception room ceases; the edges of tone and gestures are softened, rounded. I passed by our medical assistant Sok Serey's consultation room. On the bed was a man, his features sunken, as if the force of his weight shedding inward had pulled his skin with it. His eyes were large and seemed focused on a single thought -- maybe on breathing through the pain -- but aware.
Serey said he was transferring him to the Infectious Disease Ward of Sihanouk Hospital in Phnom Penh. He then told the man to stick out his tongue. A rote action; a thick, white film. I touched the man's leg and smiled. His eyes didn't change. I gently touched his wife's back as I left. It is so hard to know what gesture to make, or if it makes a difference. In Cambodia there is nothing for him. No double or triple therapies. No fluconazole for his thrush, or at least none that he can afford. Here, those who contract HIV die, and fast, due to poor hygienic conditions and poor diet. AIDS is a poor person's problem.
I watched the man's wife help him into the car, his balance poor and his legs spindly as he tried to lift himself up into the MSF Landcruiser. He settled against his wife's still-soft body. I desperately hope that she remains that way -- soft, rounded and healthy.
I hate Mondays. But today was pretty good by all accounts. Had a successful brothel-owners meeting -- absurd, isn't it? I feel perfectly normal discussing their fears of sex workers escaping, or not being able to work enough if they have to travel for health care. One good thing: The owners (of the building? the women?) agreed to include a condom in the price of sex. Now, free with the purchase of a blowjob, intercourse or just plain cuddling, you receive -- a condom! Pay an extra $10 if you don't have to wear it? OK!
I went on a Home Care Team visit today. The two teams we supervise are part of a network of eight in Phnom Penh which receive drugs from Cambodia's National Center for HIV, AIDS, Dermatology and STDs, paid for by Khana, a local organization subsidized by the HIV Alliance in England. After a couple of years, the capacity is building, although it's time to integrate PWAs into our work. I can't think or say it enough!
I saw the three brothers: Pich Paearom, 9; Pich Paearak, 6; and Pich Paearith, 3. Their mom died in January 1999. Their dad comes to visit once a month. They live with their grandmother, who is overwhelmed. She lost her daughter, her only child, and will lose her grandsons one by one. She cries when the older one is in pain, yet she jokes with us. Sometimes she plays the disciplinarian with them, meting out the odd slap for naughtiness.
Paearom, the oldest, is a real charmer. He told me he wanted to marry a pretty girl, but poor, because he's poor. He also wants to be a motor-scooter taxi driver like his dad. He did a little dance for me -- like a jackhammer, bouncing up and down in a frenzy -- but he also demonstrated his graceful Khmer hand swirls, dives and arches. He has a terrible scarring around his collarbone that hurts when touched. Chronic open sores scarred shut. I wonder how he feels watching sores and lesions map his body. He has not been told he will die.
Paearom asks for money so he can buy pants and a shirt to wear for the upcoming Khmer New Year. If he has these, he will take a walk to celebrate. He said it so poignantly that the simplicity of taking a walk became imbued with a kind of profundity. Out the window flew my public health perspective of "the group comes before the individual." I went straight to the market and bought all three boys outfits for their walk on New Year's. When I was leaving, the charmer slyly slid in, "Next time, don't forget the shoes!"
Asked Lyly to work with the clinic. She's funny, sweet. She doesn't talk much, but she has that defensive strength that a lot of the sex workers have. She looked OK -- a bit thin, with lesions on her arms, and she seemed resigned, even despondent.
She is HIV-positive and wants to leave sex work but cannot because of her debt. Lyly managed to leave once before -- but then her mother borrowed $1,000 from a brothel owner for family problems, and back Lyly went to the brothel life. I want to hire her, but she can earn up to $500 a month doing sex work, while I can only offer $50 a month for three hours a day. I don't even have a job for her. But I feel so strongly that prevention work should be linked to actual PWA faces. Seems so obvious in the West. Here, we schlep around our wooden dildo and demonstrate how to roll a condom down it. Lyly said that she'd like to come and help with outreach, to just be in the clinic to talk with people who are scared, confused or curious.
I'm making ACT UP buttons for the staff in Vietnamese and Khmer. I want to start a chapter here in Phnom Penh. Baby steps.
One of those Svay Pak days! A young woman came into the clinic this morning after a night with two Japanese clients. She was very upset. Apparently one of the men had pulled her ponytail, wrenching her head back while cupping her neck in his palm. They stole her watch and her bag. I was ready to kick some ass. I went into the brothel, and the commune leader was there, mad. And the women standing around were mad. And Yiem, the counselor, was mad. Everyone was mad except for the two men who sat smugly on the couch. One started in with "She promised $15 for all night -- she only had sex once." Yiem made the universal sex gesture -- the old finger in and out of the fist -- saying, "Very rough. Very rough." The one man had rough sex with her and refused to wear a condom. This got my panties in a twist. I turned to him and said, "Are you stupid?" Luckily, his English was very poor, and my loss of professional face went by unheeded. Then the police came, and the two men were taken off to the station to fend for themselves -- which means bribing their way out. And why were the police so cooperative? Khmer New Year's is coming, and certain civil servants, who are paid some $20 a month, need more money to properly celebrate. I just wish they would target the brutal clients for extortion, and leave the women alone.
Jamie Uhrig -- formerly of UNAIDS Vietnam, now a consultant -- turned me on to a nun in Saigon (Ho Chi Minh City) who takes in Vietnamese sex workers and teaches them a trade so they can leave the business in Cambodia. And she doesn't work with the government, so the women aren't reported to the Ministry of Social Evil! Will try to see her next time I am in Ho'ville. At least the ladies have a place to crash if they want to cross the border.
We're still waiting for the governor of Phnom Penh to make good on his promise to kick all Vietnamese out of the city. Or was it the country? Either way, I'd be out of a job. If I had to leave before my year was up, if I couldn't follow through on the activities that we are trying to start, I'd feel extremely irresponsible and ashamed. AIDS isn't over until it's over for everyone.This is a long-term process, and we've just started. I want to stay and fight.