DANGER FROM THE FAR EAST

By Christian Fiala

1998

The horror stories from Africa with their supposed six million AIDS deaths also could not escape the fate of all headlines – they were becoming dated, had worn themselves out, and no longer interested the readers. They had, so to speak, written off the "dark continent". People knew that civil war was raging there, that chaos ruled, that AIDS was snatching people away, and they had adapted their own behaviour to it. The woman civil servant I once unwillingly listened to as she told her friend how she "spent the whole week with this enormous Black without leaving the room" has probably changed her holiday habits. Having sex in Africa was universally regarded as being risky, and so it was – not least of course because of the number of sexually transmitted diseases raging there.

To the extent that "sex tourism" to Africa disappeared from consciousness, the fear that AIDS could leap from Africa to Europe generally died down. The African "AIDS catastrophe" had become a catastrophe that no longer concerned us.

The AIDS scare thus needed a new peg, and the newspapers quickly found one: Asia, preferably Thailand.

Once again Der Spiegel proved its market leadership: on the front cover under the headline "AIDS in Asia – killer epidemic in sex paradise", an Asian woman peeks over a lace fan patterned with death’s heads. The inside headline is certainly familiar: "AIDS – a continent on the edge of the abyss". A huge abyss. After Africa has fallen in, now it’s Asia’s turn.

The lead-in is also remarkably reminiscent of the magazine’s reporting on Africa: "On the world’s most populous continent AIDS, the immuno-deficiency disease, is spreading like wildfire". And then the necessary escalation from the African to the Asian apocalypse. "Asia will soon have more cases than Africa. Experts are expecting millions of deaths and more victims than anywhere else if something isn’t done soon".

To increase the horror of the domestic reader, whose attention has already been grabbed by the "sex paradise" headline, the first photograph shows an obviously German tourist with a group of Asian prostitutes. A doomed man, so to say.

And just as it had done in its first AIDS cover story, Der Spiegel gets poetic in its first paragraph. "The world is living in the age of the bloodthirsty goddess. But the devastating work of the mistress of all epidemics will soon be threatening to visit an apocalyptic plague on the whole continent of Asia, where her myth was born... it came, said the Thai epidemiologist Mitchai Wirawaidja, like an incredible flood overnight."

I am not a Thai epidemiologist, but this is one opinion that I can argue with on the basis of my own experience. AIDS did not come in 1993 "overnight" as described in the Spiegel article. It was already there when I visited Thailand in 1987/88.

Like all of my colleagues, after finishing university I had been looking for a post in a hospital in order to complete my training. I took the opportunity of an exchange programme to move to a clinic in Chulalongkorn University in Bangkok.

After a few months colleagues pointed out some rooms on the second floor of an annex that were not freely accessible because they housed special patients – AIDS patients.

Officially AIDS did not exist in Thailand at the time. True, isolated cases had been described in particular examinations, but the understanding was that it was always a matter of foreigners or Thais who had been infected while abroad. Foreigners were deported immediately on diagnosis.

HIV tests were not carried out in any systematic way. Even blood donors only had to be checked after a law introduced in 1989.

The background to this approach was a political decision by the Thai government. People were afraid that reports of AIDS would endanger tourisme, the country’s most important source of income.

Only over the course of time did the pressure become so great that the government was forced to abandon this strategy and from the middle of 1989 started investigating the HIV virus intensively. Logically, the next year the number of HIV-positive tests shot up, because all the long-existent cases were made public all at once. The statistics from Thailand thus provided what the statistics from Europe no longer showed – an "explosive spread of HIV"– and so the medical journals competed with the tabloid press in coming up with gloomy prophesies. Talk was of "the fastest epidemiological spread of HIV by sexual transmission ever recorded", and no chance was missed to point out that "heterosexual transmission is absolutely dominant". In a study of soldiers, almost all those who were HIV positive admitted that they had been infected by prostitutes, and thus provided the "scientific" basis for the attendant headlines in Germany and Austria. "There are two million prostitutes in Thailand. The country is in danger of sinking into an AIDS hell. More than a third of the street girls are already HIV positive" Heidi Riepl reported live from Thailand for the Oberösterreichische Nachrichten, and put the emotional connection to the homeland in bold letters: "Europeans think that the whole of Thailand is a brothel".

They would have to, too, if they took Riepl’s "two million prostitutes" at face value. In all, Thailand – about the same size as France – has a population of some 50 million. "Two million prostitutes" would mean that almost one in twelve Thai women, from babies to old women, was a prostitute. Prostitution in Thailand has in fact long been widespread. Even the Government admits to a hundred thousand prostitutes. Estimates range from two hundred thousand to five hundred thousand. This prostitution is the logical flip side of a social system that is extremely strict on sexual matters.

If one disregards the major exception of Bangkok, with its estimated nine million inhabitants, most of the population lives in the countryside or in small towns. The country is blessed with a landscape that is not only particularly beautiful but also unbelievably productive, which is why Thailand has become one of the world’s major rice exporters. Living standards, the infrastructure and medical standards are generally comparable with southern Europe and have little in common with those of developing countries. As far as levels of hygiene are concerned, Thailand need not fear comparison with Europe. On top of this, the kingdom is one of the few countries to have escaped colonialism, because France to the east and Britain to the west wanted a neutral buffer-state between the territories they occupied. It is thanks to this accident of history that Thailand has been able to retain its language, culture and tradition right up to the present day.

Part of this tradition is the very rigid division of roles between men and women, which subjects women to an extremely strict code of behaviour. Premarital sex is strictly forbidden. A kiss or holding hands in public is absolutely unthinkable. When visits do take place it is under strict supervision. A woman is expected to enter marriage as a virgin. Just as naturally, men are expected to have pre-marital sexual experience. The result is well-developed prostitution – which is illegal, just as it is in particular European countries. As in the rest of the world, the law is not observed, and in particular areas – some corners of Bangkok or Phuket and whole districts of Pattaya – it is publicly flouted. But, as in all puritanical regions, the sex bars don’t indicate sexual permissiveness but, quite the reverse, sexual restriction – and naturally discussion of sex is taboo.

Since there is no registered prostitution, HIV tests cannot be carried out among prostitutes systematically: the girls who work in massage parlours or who work in the sex bars whose owner hasn’t given the police a big enough bribe are rounded up. On such occasions, in 1992 one in four women was HIV positive, and in the north even one in two. How far this kind of result can be applied to all Thai prostitutes is unclear: the samples are by no means representative. On top of this, the most important accompanying questions are not asked. How often did these prostitutes practice anal intercourse? How many of them are drug addicts? (In northern Thailand – as I will discuss below – drug addiction is extremely widespread.) How often do women prostitutes live with the men who are selling their own services?

This is a second sexual characteristic of Thailand: homosexuality is unusually widespread. True, it is taboo, but is presumably encouraged by the strict separation of the sexes. Thus in various studies 25 per cent of men admitted to sexual experience with the same sex and up to 15 per cent had practised anal intercourse. The small ads in the two English-language Thai dailies that I read regularly during my stay in Bangkok carried almost as many references to gay bars as they did to other sex bars.

Apart from this, similar rules seem to operate as in heterosexual sex-life in Thailand. There is widespread homosexual prostitution, also used by foreigners, which is numerically almost as extensive as heterosexual prostitution. Thus scientists who carried out a study on syphilis and HIV infections in Chiang Mai (a northern city of about 150.000 inhabitants, the same size as Würzburg or Innsbruck) were able to get as many as 1,172 male prostitutes to participate.

Twenty per cent of them were HIV positive.

Another figure is noticeable: 57 per cent of those questioned characterised themselves as heterosexual, 14 per cent were even married. For them, same-sex prostitution was just a kind of side job, the risks of which they were not remotely capable of assessing. Almost half of them never or only occasionally used a condom actively or passively, although anal intercourse is quite common.

"Outside work" more than half of the Chiang Mai male prostitutes said they preferred sex with a woman. It is safe to assume that many of them had a girlfriend who was also a prostitute.

On the basis that in long-term cohabitation there is a seven to ten per cent chance of HIV being transmitted from a man to a woman, and that this probability rises to 46 per cent if there is anal intercourse, this is undoubtedly the most important source of infection.

As in Europe, drug use is another source of infection. The border region between Thailand, Burma and Laos, the so-called Golden Triangle, is the world’s largest opium-poppy growing area. It is well known that raw opium and subsequently Heroin is produced, and naturally nothing can stop part of the production being sold and consumed in the producing country.

Thailand thus has a considerable drug problem, and is just as incapable of solving it as the countries of the West. Officially, anything that could damage Thailand’s image is treated with extreme caution, but nevertheless about a hundred thousand drug addicts, 0.2 per cent of the population, are admitted to (Germany has 0.15 per cent). About 40 per cent of these drug addicts are HIV positive, and presumable a not inconsiderable proportion of these men and women get the money for Heroin through prostitution.

Just as they are here, though somewhat more arbitrarily, the addicts are put in jail and there prevented somewhat less than they are here from continuing to shoot up their Heroin. Since it is not always possible to get new needles in prison, needles are shared – an ideal way of transmitting HIV.

This explains the results of an investigation into Thai drug addicts, which showed that practically all those who were HIV positive had done time in prison, thus also explaining why northern Thailand is the region hit hardest by HIV and thus by AIDS.

For myself, as I knew all these circumstances, it was already clear to me in 1987 that AIDS would have to be more widespread in Thailand than elsewhere. It was also clear to me that this had nothing to do with Thai AIDS viruses having behaved differently to those in Europe and being transmitted through the vagina.

What is the basis of this conviction? This emerges in exemplary fashion from an investigation carried out among recruits in northern Thailand which triggered off a spate of horror stories. In contrast to my experience with young Austrian soldiers, among whom cases of HIV are found only rarely, here 7 per cent had already been infected. The findings in the Golden Triangle were even more shocking, where it was established that 15.3 per cent were HIV positive.

The authors of the study drew a simple conclusion: "All HIV-positive men in our study had been infected by sex with female prostitutes."

This was justified on the basis of statements by the men concerned, only very few of whom declared themselves as homosexual while three-quarters admitted having slept with a prostitute at least once. Since very many prostitutes in this part of Thailand are HIV positive, everything fits together, so to speak.

Only it also fits together that northern Thailand has the most drug addicts and a particularly high number of homosexual rent boys, and that soldiers are particularly averse to admitting to their homosexuality, let alone homosexual prostitution.

The authors of the north Thailand study were theoretically well aware of the problem. They expressly stated that it was not possible to verify the truth of the statements concerning contacts with prostitutes. Nevertheless, they did not for one moment call into question their result, which contradicted all the results from Europe and the USA, but only noted laconically in a subclause: "The reasons for the frequent transmission of HIV from women to men in Thailand are unknown."

One of the few supervised Thai partner studies, within which the degree to which people who were HIV positive infected their partners was to be investigated, came to the same result as corresponding investigations in Europe: the danger of infection from women to men is as good as nil.

Nevertheless, the American Harvard virologist Max Essex travels the world presenting from lecture to lecture the thesis that, because HIV sub-type E is supposedly five-hundred times more infections than sub-type B which has so far been prevalent in Europe, the sub-type E common in Thailand is responsible for the rapid spread of the disease among heterosexuals– because the vaginal mucous membrane is supposedly particularly permeable to the E type.

As might be expected, a new wave of alarmed and alarming newspaper articles was triggered off. For Austria, the Kurier of 29 November 1995 saw the "second AIDS epidemic" looming, after "almost 50,000 Austrians visited Thailand last year", so that the Virologist Josef Eberle of the Pettenkofer Institute could be convinced that "individual cases of these extremely infectious sub-type already exist in Austria."

At the Austrian AIDS Congress in September 1996 – after a good hundred thousand more Austrians had visited Thailand – a researcher from the University of Graz reported with visible regret that in the investigation of HIV positive Austrians who had said they had infected themselves in Thailand, they had not come across the "aggressive" subtype, which the newspapers had given the title "supervirus".

In June 1997 the Institute for Virology at the University of Vienna struck gold: for the first time the sub-type E agent was identified in four Austrians. "All four are men and had been infected in Thailand," a researcher at the institute informed Die Presse.

He did not even raise the possibility that the four men might have been travelling as homosexual sex tourists, but explained that it was thought "that these viruses are responsible for the heterosexual spread of AIDS in the Far East". By the next paragraph Die Presse is already talking about the scientist who crops up most regularly in this context: Max Essex. "According to research by the US expert Max Essex, the sub-type E AIDS virus infects male and female sexual organs much more easily than other sub-types. Experts have thus warned of the possibly devastating consequences of this virus." At the Vienna University Institute of Virology, meanwhile, this point is regarded critically. Despite the spread of this virus that has already occurred in the USA, there has not been an explosive increase of HIV infections through sexual contact there.

In Germany, Josef Eberle first discovered a type E in 1995, and he has been able to establish this type in two out of the one hundred cases he investigated. According to a German ministry of health study, between 40,000 and 70,000 Germans per year have been visiting Thailand as sex tourists. Although homosexual tourism is hardly mentioned in the media, it can be assumed that some homosexual sex tourists must have visited Thailand. If the type E was actually five-hundred times more infections than usual HIV viruses, and if it was actually spread through heterosexual contact, then on the basis of these figures it should have spread through German like a whirlwind.

In March 1996, in a special meeting called on the type E virus, an expert commission at the Robert Koch Institute came to the conclusion that there was no serious difference between the "supervirus" and other HIV viruses in relation to the method and speed of transmission.

In conclusion we can say that the "second AIDS epidemic" is not happening either. *

Dr. Christian Fiala M.D. is living in Vienna, Austria and is the author of the book "Lieben wir gefaehrlich? - Ein Arzt auf der Suche nach den Fakten und Hintergruenden von AIDS" ("Do we live dangerously? - A doctor in search of the facts and background to AIDS") Deuticke Verlaag, Vienna, ISBN 3-216-30293-8. This article is a translation of Chapter 12.

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