AIDS and HIV in Viet Nam
Mark A. Bonacci
In 1991, I was producing a documentary film on public health in Vietnam. One of the most enlightening interviews filmed was with the administrators of the Bach Mai Hospital in Hanoi.
They told me that Vietnam's Ministry of Health had tested 20,000 individuals and had found only one to be HIV-positive. They said (and this was later confirmed by other officials in the Ministry of Health) that this one individual was a young woman in Ho Chi Minh City (Saigon), who was believed to have had "intimate relations" with a man from Frankfurt. However, they said, this woman was placed on the "Orderly Departure Program" (ODP) and was presently residing in Australia. "You see, the problem of AIDS in Vietnam is no more. We have fixed the problem," I was told.
Assuming that the 20,000 people tested were indeed a representative sample, then extrapolating to Vietnam's population of 70 million people, there are in all probability a remaining 3,500 persons who are HIV-positive, that presumably have not emigrated under the Orderly Departure Program.
When I traveled to Vietnam in January of 1992, to consult to several Asia Resource Center Health Care projects there, World Vision was instituting a training program in AIDS education and several HIV testing centers in Vietnam
Mr. Wattonapong Santatiwat, vice president of World Vision in Asia, was quoted in the Bangkok post on January 1, 1992 as saying that 31 people had now tested HIV-positive in Vietnam. Throughout Vietnam, as I met health officials including those at the Cabinet level I was told either that "those tests were not properly done," of the 31, "30 were Thai fishermen fishing off the Vietnamese coast," or "the newspapers are making too much out of nothing." In short, the Vietnamese officials appeared to be emulating the Thai stance of several years prior: sheer denial.
Some were more realistic, however. Nguyen Dinh An, vice president of the People's Committee of Quang Nam Da Nang Province, stated, "I would say there are about 200,000 prostitutes in Vietnam. This is caused firstly by the unemployment problem... With our open door policy especially for tourism, the homecoming of 150,000 Vietnamese boat people under repatriation programs and other factors, the chance for AIDS to develop in Vietnam is very likely." Similarly, Dr. Nguyen Thi Ngoc Phuong, Deputy Speaker of the National Assembly and Vietnam's leading medical authority, told me, "We know that AIDS does not need a special visa to enter Vietnam." Further, Dr. Xung, the Director of the Ho Chi Minh City Drug Rehabilitation Center, told me in a filmed interview, "The government says that there is only a handful of HIV positive but we have seen at our center many unexplained deaths amongst young drug addicts. We assume they died of AIDS, though they were never tested."
That Vietnam is not, in any way, prepared for an AIDS epidemic, is self-evident. Because Vietnam is the second poorest country on earth (only Laos has a lower per capita income) few resources will be available for HIV testing kits or for long-term hospital care. Vietnam's socialized medical system is already over-taxed by thousands of people who were disabled during the Vietnam-American war.
Vietnam's health officials are also hobbled by some rudimentary misconceptions. I have been told by these officials time and time again that "because there is no homosexuality here, AIDS is not a Vietnamese problem." Both tenets in this statement are equally absurd. While homosexual behavior may be culturally proscribed, a taboo of sorts, it would be ludicrous to suggest that it does not occur. Further, even in the presumed absence of homosexuality, high risk behaviors engaged in by heterosexual couples are as high risk as these behaviors engaged in by homosexual couples. That vaginal intercourse is not considered as high risk for the receptive partner as is anal intercourse is a moot point--the virus can still be transmitted in this way.
The concept that it is behaviors, not sexual preference that places someone at risk of infection does not seem to be grasped by these health officials. Further, the high risk behavior of IV drug use is very prevalent in Ho Chi Minh City and increasingly in other parts of the country.
Because Vietnam today, and to an even greater extent Cambodia and Laos, are countries in which deaths in the countryside from malaria, cholera and schistosomiasis are still commonplace, little attention has been focused on this microorganism, the HIV virus. Many of the poor in the countryside, faced with these more elemental and swift killers, may not hope to survive the five to ten years past infection that the HIV virus will take to claim them.
For several reasons, Vietnam will follow Thailand into this epidemic, albeit at a slower pace. First, Vietnam has tried, since the mid-1980's, to emulate Thailand's success in the tourism trade. Because of the U.S.-imposed trade embargo on Vietnam and the fact that Vietnam's currency, the Dong, is not recognized on the international monetary market, Vietnam desperately needs foreign currency. If the Ministry of Health of Vietnam wants to purchase pharmaceuticals from Italy, Holland, Germany, or Sweden (four countries that have in the past decade sent a great deal of medical aid to Vietnam) it must do so with the currency of these nations or with American dollars. Thus, the impetus to attract European and North American tourists to Vietnam has been very strong. If we assume that Vietnam presently has a rate of HIV infection of less that 1/10,000, we must realize that this rate will increase exponentially with the influx of European and American tourists. Several social and economic factors also indicate that prostitution will become more endemic in Vietnam, to the degree that the economy hinges on the tourism trade. First, the increase in the numbers of prostitutes catering to the foreign tourists is already evident. Though officials of Vietnam Tourism have stated repeatedly to delegations I was on in 1987, 1989 and 1991, that there is no prostitution outside of Ho Chi Minh City ("and we are presently cleaning that up"), several male members of these delegations, including myself, received propositions in hotel lobbies, bars and from women knocking on our hotel room doors in Hanoi and Hue.
The extreme poverty facing these women dictates that they will ply their trades in even greater numbers as more and more tourists come to Vietnam. The prices we were quoted by these women ranged from $10 to $50--this in a country where a secondary school teacher earns approximately $10 per month.
Historically (as in Thailand) prostitution in Vietnam has been viewed almost as an acceptable means of helping the extended family economy. There are legions of folk stories of young Vietnamese women going to work in the bars and brothels to prevent their families' loss of their ancestral farms. Indeed, the Tale of Kieu, Vietnam's most famous and legendary 19th Century folk tale by Nguyen Du, is about a beautiful young woman who is sold into prostitution to save her family's farm and to prevent the starvation of her parents and siblings. Characteristically, she is philosophical and asks, "What does it matter if the flower falls, if the tree stays green?"
In this very romanticized view of prostitution, Kieu ultimately comes home a heroine, surrounded by an adoring and grateful family. The Vietnamese view of prostitution seems similar to that held by most Thais; pragmatic and almost non-judgmental. In this milieu, the combination of extreme poverty and acceptance of prostitution, dictates that the profession will continue to flourish.
The extent of the rise of the tourism industry in Vietnam should not be underestimated. According to the Saigon Times of January 8, 1922: "in 1991, there were 180,000 foreign visitors to Vietnam... The number of overseas Vietnamese coming to Vietnam this year is 56,000. These figures represent a three-fold increase from last year's figures."
Further, there has been a tremendous influx of foreign investment, which will no doubt be accompanied by non-Vietnamese administrators and personnel from many foreign countries. Since the Law on Foreign Investment was liberalized in 1988 foreign capital investment in Vietnam has risen from 359 million dollars U.S. (in 1988) to 1.2 billion dollars U.S. (in 1991) (Saigon Times, January 8, 1992, p. 8). A release of January 2, 1992 from Reuters stated that approximately 20,000 Japanese, British, French and Singaporean investors will have traveled to Vietnam in 1991.
With the Vietnamese government's announcement in early January of 1992 that "vast deposits" of uranium had just been discovered outside of Da Nang and that marketing this and its offshore oil deposits would be a "major emphasis" in 1992, one can guess that the influx of foreign visitors will continue to rise rapidly.
Vietnam suffers from an additional dilemma, vis-a-vis condoms. Culturally, they have rarely been used in Vietnam, where up until recently the infant mortality rates (400/1,000 in 1954) were so high, and children a much-needed agrarian work force, that contraception was rarely an objective. Further, Vietnam presently has a large Catholic population and for this large minority group, religious prohibitions against use of contraceptives will have to be overcome. Vietnam does not manufacture high quality condoms, and importing these is impeded by both the U.S.-imposed trade embargo and by the lack of foreign currency.
According to most Vietnamese health officials that I interviewed and most Vietnamese people I met, the one condom factory, at ho Chi Minh City produces condoms of such "roughness and tendency to rupture" that using these particular condoms is very unpopular.
One silver lining to this predominantly dark cloud is that public health education in Vietnam has, in the past forty years, been conducted with a great deal of sophistication and success.
In 1954, after the first independence war, ending with the Vietnamese victory over the French at Dien Bien Phu, the Vietnamese Ministry of Health mounted an extensive public health educational campaign. At this time, millions of Vietnamese suffered from malaria and from trachoma (which sometimes causes blindness) and hundreds of thousands from tuberculosis, venereal disease and leprosy. There was only one physician for every 180,000 citizens.
The major emphasis of the public health campaign was on preventive measures, because machinery and medicines which prior to this had been obtained from France became unavailable or exorbitant at black market prices. President Ho Chi Minh recommended that medical personnel should "focus their attention on the countryside where the overwhelming majority of the population live, and combine as closely as possible, Western 'modern' medicine with traditional medicine, with a view to building up a national scientific and popular medicine."
The major focus of the preventive medical program was general hygiene; cleanliness of food and water, clothes and home. An educational campaign was launched, stressing the need to sink deep wells, drink only boiled water and for midwives to attempt to deliver babies under as aseptic conditions as possible.
Vietnam was very successful in bringing down infant mortality from its prior rate of 400/1000 births and life span was significantly extended for the average Vietnamese.
In more contemporary times, Vietnam has relied on public education for an anti-smoking campaign and an attempt to slow the burgeoning population growth rate. The Ministry of Health has attempted to use public education to slow the annual population growth to 1.5 percent. The "Three Lates," late marriage, late pregnancy, and late second child are heavily emphasized in government programs, policies and communications to the general public.
If some of the expertise and resources in public health education were directed toward an anti-AIDS campaign, many lives would be saved. The author has suggested to the Vietnamese health officials that the most effective way for public health education to proceed on this issue, would be to travel to Thailand and the Philippines and study public health there, particularly the Empower Program in Bangkok and the Gabriela Network based in Manila. While these public health education programs will have to be modified to be appropriate for use in Vietnam, some of the techniques have been very successful--working directly with the bar-women and prostitutes, the use of psychodrama and organizing the men and women to demand more humane working conditions.
Unfortunately, Vietnam is following the American pattern--too little, too late.
Mark A. Bonacci and his publishers have generously permitted us to reprint the section on Viet Nam from his book, Senseless Casualties: The AIDS Crisis in Asia. Perfect-bound 8 1/2 by 11, 121 pp, glossy cover with reproduction of "AIDS Series/ Geisha and Bath, 1988", by Masami Teraoka, watercolor on canvas, original 108" by 81", courtesy Pamela Auchincloss Gallery. This great graphic shows a geisha opening a condom in the bath with her teeth. Never ever open a condom with your teeth, by the way, unless you really want to transmit bodily fluids. Senseless Casualties is available for $12.50 from Don Luce, International Voluntary Services, 1424 16th St. NW, Suite 204, Washington, DC 20036, and from Don Luce, Asia Resource Center, P.O. Box 15275, Washington, DC, 20003. Both publishers offer a discount for more than ten copies. The book contains substantial references, as well as narrative and exposition. Bonacci's previous publications include The Legacy of Colonialism: Health Care in Southeast Asia. The state of knowledge about HIV in Viet Nam is evolving rapidly. The number I have heard thrown around at conferences this summer is "53 infected," out of an unspecified number of Viets tested. For a sophisticated, updated figure, contact Bonacci, who is Professor of Human Services at Niagara County Community College.