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STRATEGIES OF CIVIL SOCIETY TO ADDRESS AIDS IN ASIA: EMPHASIS ON THE SEX SECTOR Sharifah H Shahabudin Professor and Director, Center for Academic Advancement Universiti Kebangsaan Malaysia http://www.un.org/womenwatch/daw/csw/hivaids/Shahabudin.html
Introduction Asia has about 3.3 billion people representing 60% of the world’s population, with a large population of children and the poor. It also has the world’s two most populous nations and systems of government that range from constitutional monarchies to republics and dictatorship. It is a continent of diverse people speaking hundreds of languages and subscribing to different cultures, beliefs and religions, living in a plethora of political, economic and social situations. The diversity in the continent is also mirrored within the countries. The tremendous diversity in Asia makes generalisation about HIV/AIDS meaningless because it prevents the appreciation of the specificity of the spread of HIV in the local social context, and the cultural sensitivity that make strategies effective in one setting but useless in another. Against the background of such diversity, this paper tries to highlight the key issues and strategies related to the sex sector that were brought up at the International Conference on HIV/AIDS in Asia Pacific held in Kuala Lumpur from 20-27 October 1999. Asia is said to have the gift of time to learn from and to act early to prevent the kind of generalised epidemic that has engulfed the African continent. About 20% (7-8 million) of the world’s estimated number of people infected with the virus reside in Asia Pacific (MAP network, October 1999) but no country in Asia has a prevalence rate of more than 5%. However, the public health significance is large because of the size of the population and the rapid spread of the virus. Epidemiological surveillance shows injecting drug use and heterosexual transmission to be the major routes of infection. Prevalence is rising among women - young girls, spouses, pregnant women, migrant workers and sex workers. Countries are at different stages of response depending on the political commitment, organisational capacities of the government machinery, mobilisation of NGOs/civil society and community resources, private sector participation and socio-economic status of the population. Civil society refers to citizens and citizen groups whose essential responsibility is to keep open such freedoms as assembly and association to allow and encourage citizen participation and influence in every aspect of society (O’Connell and Gardner, 1999). Civil-society institutions are often better than government at meeting human needs, especially of the most vulnerable (Glenn, 2000). The experience of Vietnam shows that in resource-scarce countries, community mobilisation appears to be the mainstay of HIV/AIDS prevention and care. The community is the centerpiece of HIV/AIDS education. Hundreds of thousands of voluntary and nonprofit organizations of every conceivable size and nature, form a third space--between the super organizations of government and business and the intimate sphere of family and kin. In that space, individuals find both personal meaning and a chance to join with others to reshape their worlds (Van Til, 2000). The 5th ICAAP highlighted many innovative community programmes and community based care and support, particularly those involving specific groups such as sex workers, truck drivers, male tourist workers, MSM, transgender kotis, and fishermen. The role of civil society is to negotiate among themselves and with governments and the private sector, to improve the prospects of an enduring democracy for a more equitable future. Networking and orchestrating the capacities of others to achieve a desired goal will become the most effective mode of operation. Educated, skilled and networked (physical and virtual) local citizens acting as global citizens may bring democratic politics for global public good. However in many countries of Asia there appears to be a need to further strengthen trisectoral partnership and networks among governments, NGOs and the private sector at local, national and international levels so that best and worst practices can be shared to improve accountability and capacity building. Despite the diversity of Asia, one thing remains clear and common – the deleterious impact of prostitution on women. Regardless of whether prostitution is viewed as self determination and a form of work or as sexual slavery and violence against women, it is inarguable that the most deleterious effect is the increased risk of venereal diseases, HIV/AIDS in particular. Most of these women have difficulty protecting themselves because of economic dependency and the threat of physical force. Lesions and injuries in sexual intercourse, especially when they start young, also make them more prone to infections. The risk of infection is also increased when the women continue to prostitute through their menstrual cycle to avoid the fines levied by bars for taking time off for their periods. Besides those risks, the women often become hearing impaired because of the incessant loud music in the bars. They also suffer intestinal disorders because they are forced to throw up so as to keep ordering expensive drinks (Hitchens, 1986). Stripped of their dignity and forced to dance naked in front of strangers or sleep with them young shy Thai women make themselves "very empty" according to a former prostitute (Erlanger, 1991). This state of dissociation is a defence mechanism against feelings of shame. The physical and mental sufferings borne by these women are often unbearable without the aid of drugs. A shot of heroin enables them to handle five or six men in a single night and to keep themselves in working condition (Gay, 1985). A United Nations study of a thousand Thai prostitutes revealed that a quarter were regular users of speed, barbiturates, and heroin. All these serve to keep the women indebted to and dependent on yet more unhealthiness. Most do not have access to good health care. When they are too ill to work, they are sent home to linger and die. Root causes of prostitution in Asia Indisputable is the fact that prostitution becomes the highest paying job available to many women of Southeast Asia and Asia when governments and development agents disregard the development of women's opportunities for economic independence. As long as prostitution is seen as a valuable national resource and men, whether foreign or local are willing to use these women to satisfy their sexual needs at an incredible rate, often without regard to disease or any common moral restraints, women will continue to be oppressed. Whilst these countries have benefited from the tourist presence and the resulting foreign exchange, the women who actually put themselves out for their countries are to a large extent victims of the international political economy, poverty rooted in social class, illiteracy, ignorance, armed conflict and gender discrimination. 1. Prostitution boomed in Southeast Asia when the U.S. made its presence in Vietnam. The number of prostitutes in Thailand for example, skyrocketed twenty fold to 400,000 after the United States established seven bases in the country (Gay, 1985). Some $16 million was injected into the Thai economy annually during this period. When the Vietnam war ended the boom was replaced by tourism which introduced prostitution as a large-scale business to the region. Group sex tours is Thailand's largest single source of foreign exchange (Rhodes, 1991).Sixty percent of tourists to Thailand visit for sex (Harvard Business Review). Today it is a $4-billion-a-year business involving fraternal relationships among airlines, tours operators and the masters of the sex industry.
7. The uneven and unequal nature of globalisation and liberalisation processes in international finance, trade and investment have also generated greater inequalities that have resulted in the wide and widening differences in incomes, wealth and resources among countries and also within countries. The financial crisis that started in Thailand in 1997 and which spread to other parts of Asia as well as Russia and Latin America gave rise to insecurity and greater instability with millions of Asians becoming impoverished. 8. The women of Southeast Asia and Asia are subject to age-old, deeply ingrained stereotypes and pre-conceptions. The continuing success of the prostitution trade rests on the perceptions of the clients that see Asian women as both desirable in their exoticism and willing participants in the exchange. Sex tours primarily market Asian women, described as "exotic and docile" (Tice,1992), "beautiful, obedient, available"(Neumann and Lin,1984) and "slim, sun-burnt and sweet ... masters of the art of making love by nature" (Robinson, 1993). These are the qualities that appeal to the foreigners who perceive Western women as too assertive. Strategies of Civil Society In addressing HIV/AIDS in the sex sector, civil society faces many challenges. In many countries it is even impossible to find a common ground for civil society to flourish. Conflict, alienation, bureaucracy, unbridled marketeering capitalism, loss of individual control do not nurture the civic virtue and community life that nourishes true democracy. In some societies, there is no freedom of speech and association whilst in others civil society is seen as small communities by free-marketeers who associate them with unfettered commercial activity (Barber, 1998). Strategies of civil society to address AIDS as it relates to the sex sector must eliminate or reduce the factors that contribute to the root causes of prostitution, prevention of HIV infection and to address issues of care for individuals, families, communities and nations. In the information age the concept of civil society is also extended to virtual communities and this brings opportunities for exploring new methods of addressing the epidemic. The 5th ICAAP highlighted the main areas of work of civil society. There are three types of beneficiary targets: (a) the population in general, (b) specific groups which include sex workers, the poor and marginalised and (c) those living with HIV/AIDS, again including those in the sex sector. The strategies are framed in the form of recommendations:
Governments have the fundamental responsibility to prevent HIV/AIDS, to protect the poor and to eliminate poverty which is the major cause of prostitution. The recent economic crisis or resource scarcity should not divert the attention of governments from making decisions based on national priorities and capacities. HIV/AIDS is a development issue and there is a causal relationship between HIV/AIDS and socio-economic development. Civil society in many countries are collaborating with their government to provide citizens with winning conditions of transparency, good governance, trustworthy legal and judicial systems, sound financial and regulatory framework and people centred social programmes. During the 5th ICAAP the Prime Minister of Malaysia called for an Asian Leaders Summit on HIV/AIDS. The Malaysian AIDS Council has been instrumental in making this call a reality and HIV/AIDS is now on the agenda of the ASEAN Summit to be held in Brunei in 2001. Strong political commitment is solicited in many areas:
2. Human Rights Advocacy HIV/AIDS is only one of the concerns in the daily struggles of PLWHAs, regardless of whether they are sex workers or other marginalised groups. Human right violation in the form of discrimination of their children, denial of housing, limited movement, mandatory testing, and deportation is the other epidemic they face. Those in the sex sector also face condemnation and arrest whilst the pimps and clients may go free. Civil society serves the interest of public health by protecting human individual rights through the following actions:
3. Use of faith organisations Faith organisations play an important role because believers will not do anything they think their religion forbids. However these organisations are working in the dominant cultural context where sex and sexuality are taboo subjects. AIDS and prostitution are associated with sex and sexuality and therefore perceived as inappropriate to discuss. Many also encounter a disturbing trend of discordance between belief in religious values such as love and caring and the actual practices with regards to prostitution and AIDS. Efforts are made to intensify the involvement of religious leaders as ‘influentials’ to correct misconceptions. Activities include: (a) incorporating universal core values in AIDS Education, for example: right to life; right to dignity; harm reduction; salvation; equality; love and compassion; responsibility (b) designing AIDS Education Program based on religious practices such as fasting; marriage contract and partnership; purification; prayer; alms; meditation; pilgrimage (c) recruiting religious 'influentials' to:
4. Use of the Media In most countries media reports remain the major source of information on HIV/AIDS. Despite the contributions of medical research which have improved the understanding of HIV/AIDS, earlier homophobic portrayals and association of HIV/AIDS with sex workers seem to persist. There is a proliferation of cultural meanings that have been written and rewritten as a result of the biological manifestations of HIV (Treichler, 1999). Words or acronyms such as "AIDS," "HIV," and "epidemic" and the process of creating new concepts such as "safe-sex" to replace the moralistic, value-laden proscription against promiscuity are occurring within a cultural context of stigmatization that tolerates and promotes sexism, racism, third-worldism and homophobia. Sensationalism is another disturbing news media practice and negates the effectiveness of the media for education and advocacy. Civil societies are showing innovative ways in which the media can be used in the context of diverse cultures. These include: · training media practitioners to adopt emphatic journalism in their advocacy role · encouraging investigative journalism by creating special media awards and other forms of recognition · media practitioners forging relationships with NGOs to seek a balance in the representations of HIV/AIDS issues · reinforcing the interpersonal elements of media effectiveness in the HIV/AIDS messages particularly through street drama, opinion leaders and counseling, public service advertising and campaigns as well as entertainment media such as soaps, dramas and films 5. Working with migrant labour and mobile populations Many Asian countries are hosts to migrant workers (including sex workers) from their neighbours. Many have left their spouses behind and they seek sexual gratification with sex workers. Migrants make a contribution to society, doing jobs shunned by natives. Yet they face discrimination everywhere they land. The role of civil society becomes even more crucial because many are also alienated due to social and language barriers. Civil society working with these groups often have to address the following problems:
6. Involving Youths Today’s youths, both boys and girls, need to be empowered to lead rather than follow in the fight against AIDS because the new millenium belongs to them. In many societies youths are not getting enough correct information about sex and sexuality and messages that are consistent with their needs. Further, some youths such as street kids, poor rural youth, abused children and homeless children, have special needs because they are also at risk to drug abuse, crime and prostitution. A significant part of the work of civil society is the recognition that the participation of youth and harnessing their energy in the prevention of HIV/AIDS are important and critical. Peer education programs have been initiated in many countries with considerable success. In mobilising youths, the following activities are key components:
7. Working with IVDUs The population of IVDUs is rising, amongst whom are sex workers. Similarly, the HIV infection amongst them is also rising. Complicating factors are the high risk sexual activities commonly found in this group and the difficulty in changing behaviour. Another obstacle faced is the reluctance of many governments to accept harm reduction strategies although they have been shown to be effective. The energy of civil society is directed at the following:
8. Involving Women The low social status of women in families, communities and societies coupled to the unfortunate cultural perceptions of them as sex objects, increased internal and international mobility and displacement of people have heightened the biological, social and economic vulnerability of women to prostitution and HIV. Inequality between men and women make them powerlessness to protect themselves from unsafe sex. It is also the factor that limits their access to care. HIV/AIDS and women are addressed by civil society from various perspectives and are targeted for the general population, women in general, men, young women and special groups such as migrant, nightclub and brothel as well as non brothel sex workers. Activities include:
9. Focussing specifically on the needs of PLWHAs Sex workers form a substantial portion of the people who are living with HIV/AIDS. Access to treatment is a matter of life and death for PLWHAs. Medications are out of the budgets of most PLWHAs and many don't even have access to clean water to wash down the pill. Discrimination is still widespread and hence they don't get access to the best of care and makes it impossible for them to go public with their concerns. PLWHAs are the most knowledgeable about issues surrounding HIV/AIDS and their contributions are essential in creating policies that are effective and humane. The conference called for intensification of actions in several areas:
Recent reports have suggested that fully one third of adult Internet visits are directed to sexually oriented Web sites (Associated Press, 2000). Such sites include chat rooms, and news groups (e.g Alt.Sex.Prostitution, alt.sex.wizards, alt.sex.safe, sci.med.aids, http://worldsexguide.org,). These Internet users (mainly homosexual men) can observe sexual images, participate in online sexual discussions with individuals or groups to exchange information about all aspects of prostitution, including but not limited to the legal situation in different countries, prices, reviews of brothels, bars, clubs, massage parlors, escort services, call girls, street prostitutes, and requests for information. The Internet is also used to identify sex partners for actual sexual activity. Persons with the motivation and initiative for making new sexual connections anonymously in their virtual social lives are greater risk takers in their actual sexual lives than those who do not use the Internet to find sex partners (McFarlane et al, 2000). This places them at greater risk for STDs including HIV. Several sex workers also regularly read and sometimes post to this newsgroup. Thus for populations with levels of education and income sufficient to support computer use, the Internet has become an efficient educator of risk-takers and facilitator of behaviors and practices among certain groups of individuals. Public health must anticipate the shape that these practices will take because the current young generation of computer users are experts and have unprecedented computer access. Internet communication has become second nature to them. What will the impact of these virtual meeting grounds be as these young people reach sexual maturity? Public health systems need to be prepared to deal with the consequences of activities involving these new communication media. These virtual anonymous meeting sites can also be used for partner notification (provider referral or contact tracing). It can circumvent the old problem of partner notification because those who use the Internet chat rooms to identify new sex partners anonymously and remained so during actual sexual activity can now be reached through the same chat rooms. In a partner outreach strategy, the San Francisco Health Department uses virtual medium aliases to alert chat room participants of potential disease exposure and to raise awareness (Rosenberg and Potterat,1999). To expand such services to developing countries, the following may be necessary:
11. Collaborating with International agencies International agencies are clearly visible and critical in HIV/AIDS prevention in most countries of Asia and the Pacific. It is crucial to keep HIV/AIDS as a global concern because many problems that lead to HIV/AIDS require international collaboration and initiative. Global events such as globalisation and liberalisation are fast generating a growing gap between the world’s rich and poor with the poor becoming poorer (UNDP Human Development Report, 1996). These processes dismantle national economic barriers. Global institutions such as the World Bank, WTO and IMF are given the powers to discipline developing countries into adopting these policies through structural adjustment policies (SAPs) that not only cover macroeconomic policies but also social services such as health and education. The push for liberalisation, privatisation and deregulation are making States withdraw from socio-economic activities, thus whittling away the opportunities for education and health for the poor. The aftermath of the financial crisis that started in Asia in 1997 demonstrated the danger of unbridled liberalisation. The unprecedented drop in GDP of 7-20% led to insecurity, political instability and massive widespread poverty in most of the affected countries. Although the situation has stabilised in 1999, it is unclear whether they will be able to regain their previous high growth. Poverty has to be urgently addressed because it gives rise to the crime of traficking in women, children and drugs across national borders. This problem is intensified by political conflicts within and across national borders that put intense pressure on people who flee as refugees. Desperate people turn to prostitution to survive. Prostitution is a billion dollar industry being run like a multinational corporation, extracting enormous profits from grotesquely underpaid local labour the body of a 15-year-old from a rural village somewhere in Asia. The United Nations and its agencies must regain their authority and resources in economic and social policy-making and influence. The various legally binding conventions as well as the several world conferences (including the five conferences on women) which are democratic and transparent have the potential to influence the content of the globalisation process as well as the national policies. Public intervention (international and nationally) is necessary to enable basic needs and human rights to be fulfilled. The market alone cannot do the job and in many cases hinder the job from being done. The UN represents the principles of partnership, where the international community and the State must intervene on behalf of poorer nations and people. The strength of the international agencies should be directed at:
Conclusion The epidemic in Asia has not become the inferno that has raged Africa. However, Asia cannot remain complacent because its population is large and poor and the virus is spreading surely and rapidly within its communities mainly through heterosexual transmission. Prostitution further compounds the HIV/AIDS problem. Prostitution has increased in Asia because of the massive poverty made worse by inefficient national and international political economic policies as well as the recent economic crisis. Lack of education and economic opportunities drive young girls to large cities in the hope of earning sufficient income to repay their parents. More often they are lured by unscrupulous sex traders who sell their bodies in the large cities of Asia. Refugees from political conflicts, sex tourism, local cultural perceptions of manhood, corruption and gender inequality not only serve to accentuate the feminisation of poverty but also contribute to a thriving sex industry. Trapped and coerced, the girls remain powerless to escape from the tyranny of sexual slavery. When they outlast their usefulness or they fall ill, they are sent home to languish in a miserable death. Strategies of civil society must be comprehensive, given the all encompassing nature of the problems of HIV/AIDS in the sex sector. Where they fail to take root, international agencies should encourage civil societies to grow. The smart partnership strategy among the three important sectors – government, industry and NGOs at local, national and international levels must be forged. This will enable the growth of cohesive civil democracy, citizensip engagement and people-centred approach which will foster ownership of process and stimulate local capacity to eradicate poverty, reduce traficking and prostitution, prevent the spread of HIV, protect human rights, make treatment available and provide necessary community care services. Political will is an important ingredient for developing national policies and programmes that are multi-dimensional and more effective, where high priority is given to human development. In such an approach international and national resources would be focussed primarily on developing human capacities and in fulfilling human needs of food, health, education and livelihoods. The voices of civil society and people living with the virus and disease must be heard in policy formulation and implementation. Strategies should also focus on involving human rights advocates, youths, women, people living with HIV/AIDs, intravenous drug users, mobile and migrant populations, the media and religious influentials. The use of the newer ICTs must be explored for innovative ways of providing information and doing contact tracing for those at risk of infection.
Reference
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