After almost 30 years of war and the reign of the “Red Khmer” the south-east Asian state of Cambodia (bordering Vietnam, Thailand and Laos) is now one of the poorest countries in the world. One of the most impressive of the few remains from the reign of the Khmer are the majestic ruins of Angkor, today a UNESCO World Heritage Site. The people of Cambodia have suffered many losses and seen a decrease in their quality of life: The average annual income of the 13 million Cambodians (Khmer) lies at $300 US. Infant mortality is the highest in south-east Asia (115 in 1000). Clean water is only available to 26% of the population; malaria, dengue, typhoid and hepatitis are widespread. When the UN Peace Corps (UNTAC) came into the country in 1989, a new disease was introduced: AIDS. UNAIDS estimates that more than 80,000 Khmer have died of AIDS so far and over 160,000 are HIV positive. The World Health Organisation (WHO) predicted in 2002 that 1 million Khmer will be infected by the year 2010…

Experts are discussing how AIDS was actually brought into the country and if it came with the UN soldiers, as the Swiss paediatrician Dr. Beat Richner at the children’s hospital “Kantha Bopha” claimed in an interview with the German TV station WDR. It is more likely that the disease was introduced from Thailand, which had a high number of infected people at that time. It is clear, though, that prostitution went up dramatically when UN soldiers came to the country, as prostitution was illegal under the Red Khmer (1975 to 1979) and during the occupation by Vietnam (1979 to 1989). The UN soldiers earned up to $180 US a day and spend part of it in Cambodia to the country’s profit. Rents in the capital Phnom Penh were one of the highest of the world in 1991, but sex was (and still is) cheap. The “National AIDS Programme” was founded in 1991 after an HIV-positive student became Cambodia’s first official case of this disease. The first serological investigation in 1992 showed that about 9.2% of prostitutes and 4.2% of those patients having sexually transmitted diseases were HIV-positive. The Cambodian Health Ministry estimated in 1997 – three years after UNTAC had left the country – that 42% of the prostitutes in Phnom Penh and 58% of those in Battambang close to the border with Thailand were already infected.

Prostitution in Cambodia is in reality probably as old as Angkor. Chinese scripts from the beginning of the Second Millennium show accounts of ladies who were offering sex in exchange for expensive silk materials. Under the French colonial reign Phnom Penh was famous for its three “B’s”: Boulevards, Bars and Brothels. The shores of the Mekong River saw a rich mixture of Asian traditions and European life style until the beginning of the Vietnam War. After that the Red Khmer under Pol Pot wanted to transform Cambodia into an agricultural state and killed over two million people to that end – half of them died of malnutrition. Their radical reforms were partly adapted from Mao Tse Tung’s ideology, thus destroying social structures. Showing emotions did not go unpunished. Love was forbidden.

Many Khmer men today go to a brothel up to five times a week. Other clients are sex-tourists, mainly from Japan and China; child prostitution and prostitution by force are common. Homosexuality is hardly of any importance. Tun Samphy of the “Urban Sector Group” estimates that there are about 200 gay “sex-workers” in Phnom Penh; on the other hand, though, there are about 20,000 prostitutes, the so-called “Taxi Girls” who earn about one to two dollars per client. A proverb aiming at the insatiable sexual desires of men says: “ten rivers are not enough for one ocean.” Prostitution is accepted by society and also by wives since it does not endanger the family structure like a mistress would. Marriage is part of a socioeconomic contract which does not include sex. Extramarital adventures are seen as a sport and pastime – but only for men. Women have to be virgins at the time of their marriage (which is sometimes still arranged by parents). This is one of the reasons why young men have their first sexual experiences in brothels. Mou Sochua, founding member of the Cambodian women’s movement and ex-minister, says: “If you want to fight AIDS, you have to change the role of women in society. One in four women is a victim of domestic violence. Almost no woman has the confidence to ask her husband to wear a condom.”

Another proverb says: “men are like gold, women are like a white cloth”, which means that once white cloth has fallen into dirt, you can never wash it clean. Prostitutes are banned by society as “bad girls”. The same name is used for the indirect sex workers like karaoke hostesses, masseuses or animation girls – the so-called “beer girls” who work in many bars serving beer (also hired by German breweries like “Beck’s” and “Holsten”) and who provide company for the men. Many of these girls are divorced and single parents, which makes them uninteresting to Khmer men and forces them to become self-supporting. They do not have the sufficient education or training for a proper job, therefore night work – and thus often (hidden) prostitution – is the only way to survive.

Prohibition is surely not the way to counteract the spread of AIDS: for example, in 2001 many karaoke bars were closed, leaving the “indirect sex workers” – often girls from the country – jobless. Many of them returned to their villages and infected their partners; others turned to street prostitution without access to free health facilities or condoms. These services were common in brothels, where the “100% Condom Use Policy” (CUP) was introduced in 1998. This model was introduced from Thailand but is only effective in theory: the economical situation of the girls is often so desperate that they have sex without condoms for an additional charge. The clients’ argument goes as follows: “why use a condom if I pay for my pleasure?” Another reason is that about 50% of all prostitutes take drugs when they are working which, according to Heng Buthak from the “Khmer Women’s Cooperation for Development”, “lowers the level of inhibition and the consciousness for ones personal safety. The prostitutes also sometimes motivate their clients to take drugs since they are more likely to pay better when they are drugged…”

Since protection by condoms does not seem to be an effective measure in Cambodia, the medicine “Tenofovir” from the US drug manufacturing giant Gilead was going to be introduced in 2004 and tested on almost 1000 HIV-negative prostitutes as an AIDS prophylaxis. Feminist organisations as well as the “Asian-Pacific Sex-Worker Net” protested against the introduction of this drug. After an extensive debate in the media, the study, which would have also been financed by the “Bill and Melinda Gates Foundation”, was prohibited by the Prime Minister Hun Sen. Even the opposition gives credit to him for this measure. The head of state as well as the governing parties seem to be disinterested. After the attempted coup in 1997 the main emphasis lies on domestic affairs. AIDS has become part of the agenda only since the new millennium: every year two million US dollars are made available to the “Special Priority Action Program”. The aim is to halt the spread of AIDS until 2015. Various state institutions have created a strategic framework which works together with international aid agencies and the UN.

Two institutions (in addition to the Ministry of Health) are the cornerstones of the governmental anti-AIDS campaign: The “National Centre for HIV/AIDS, Dermatology and Sexually Transmitted Diseases” (NCHADS, founded in 1998) and the “National AIDS Authority” (NAA, founded in 1999). These manage and coordinate all governmental activities. The strategy of the NAA follows two different principles: first, the individual’s behaviour has to be changed from “risky” to “safe”; second, socioeconomic aspects have to be changed in order to make it possible for all to protect themselves more effectively against AIDS or to live better with AIDS. A charter published by the NAA defines the rights of AIDS infected people – some examples are free AIDS tests and fair treatment by the media and those living alongside infected people.

Stigmatisation of the ill and their relatives is still one of the biggest problems and thus distorts the statistics. Through fear of becoming outcasts, many families hide those infected with AIDS. This is especially a problem in rural areas, where HIV-positive sons and daughters die of malnutrition because their parents do not take care of them. If it becomes known that one member of a family is infected, the whole village avoids them. The “Khmer HIV/AIDS NGO Alliance” (KHANA) writes in the “Human Development Report 2001”: “It is enough if one parent is infected for the whole family to become stigmatised. Their children are no longer allowed to go to school; they are mocked by others and are not allowed to play with those coming from an infected family. If the parents die, many of the (up to now) 40,000 orphans have to provide for their living themselves. Some leave their home…they lose their land or other belongings and have to work in order to pay off loans taken out by their parents.”

These loans are often used to pay local healers – so-called “Krouk Khmer”. They ask for up to $5000 for the promise to heal AIDS. Ignorance and superstition make many Khmer susceptible to charlatans. Buddhism became the state religion again in 1989. Many believers see AIDS as punishment for sins committed during the last life. Only the monks of high reputation (numbering over 40,000) could change this belief in a public statement, and thus help the AIDS infected and orphans, as they do in Thailand. Influential “High Monks” of the Buddhist Sangha (community) have refused to do so for a long time. Only two out of over 3000 pagodas train monks: in “Wat Norea” (Center of Salvation/Battambang) and in “Wat Opod”.

Here the monastic counsel of the Takeo province bought a piece of land in 1999 which they donated. They appointed monk Duch Tel (above, second from left) as the “AIDS-representative” – in the picture during a visit from/to the Director of the National AIDS Authority, Dr. Tia Phalla (middle). As part of the project “Partners in Compassion” he provides basic services from home care to companionship to the dying??Sterbebegleitung together with American priest and Vietnam veteran Wayne Mathysse (left) and 12 other members. The annual budget lies at $44,000; the only medicines available are vitamins and paracetamol; the crematorium is decorated with printouts of children each showing the date of death. Duch Tel: “The people of Cambodia are not afraid of dying. But they have to learn how to show compassion (Khmer “meta”) – the common root of the Christian and Buddhist religion.”

For many people, especially the young generation (60% of the inhabitants are under 20 years old), TV has taken the place of “god”. Two million people saw “Punishment of Love” in 2003 – a soap opera about a beautiful girl from the country who becomes infected in Phnom Penh and dies. Thanks to “road shows” the soap opera could be seen in many isolated provinces where TV sets are still rare. The producer is “Population Services International Cambodia” which is a local branch of the world’s biggest American “social marketing” group PSI. It employs 200 mainly local people in Cambodia. They use campaigns like this in order to promote their cheap health items like “Number One” condoms. In 2003 they sold 20 million of these for about three cents each.

The initiatives of PSI and “Partners in Compassion” are entirely different but they have many things in common: they cater to the needs of the people at different levels; they work in an interdisciplinary, intercultural and efficient way. On the other hand there are a number of other projects which shine mainly due to expensive cross-country cars, hi-tech offices and extensive reports. The KHANA brochure of 2001 lists 80 anti-AIDS NGOs, but in reality there are many more. To provide help in Cambodia is a tough business: cooperation rarely exists. There is a vivid fight for the big budgets from USAID or the EU to name just a few. Foreign managers earn up to $8000 a month. Cambodia has the highest number of aid organisations in the world after Somalia. The French NGO manager Pierre Legros (AFESIP) says: “We foreigners have put the land on a drip.”

Four governmental hospitals for AIDS patients exist in Phnom Penh. Hospital employees are paid between eight and fifteen dollars per month, depending on their status and the size of their family. The underpaid employees charge for everything they do. Many do not turn up for work in order to earn extra money in private hospitals or to cultivate vegetables (Khmer: chamkar). Ill people are only attended properly in foreign NGO stations – e.g. at the Sihanouk Hospital, where “Médicins sans Frontières” have been offering a free anti-retro-viral-therapy (ARV) since 2001. Patients have to be checked at regular intervals since doctors have experienced that their patients do not know how to measure the medicine correctly into doses or because they forget to take it at all and live unhealthily.

So far about 3000 Khmer have been treated with ARVs free of charge from foreign aid. Thai or Indian generic drugs are used. The “Global Fund for AIDS, Tuberculosis and Malaria” for Cambodia has provided 34.9 million dollars, money with which local doctors are now being trained in programmes running for 11 weeks. An additional 58.9 million dollars from the Health Ministry is going to be used to help 20,000 AIDS patients to receive governmental ARV treatment until 2009. The falling prevalence rate (from 4% to 2.6% in the last two years) is seen as a first success. Nevertheless Cambodia is at the top of the south-east Asian WHO statistic. Critics claim furthermore that the rate does not represent the actual decrease in new infections, but that it could be caused by an increasing number of deaths due to AIDS.

In 2003 40,000 Khmer were tested for AIDS. About 20% of these were HIV-positive. UNIFEM regional director Lucita Lazo said at a press conference in June 2004: “The characteristics of the epidemic are changing. It is becoming female. 46% of the newly infected are Cambodian wives; every day about seven of them are infected by their husbands. Therefore there is also an increase in infections from mother to child.” (Neravapin has only been given to pregnant women at the “Calmette Hospital” and at the “Japanese Hospital” in Phnom Penh so far, in order to stop the infection from mother to child.)

The character of Cambodia is also changing: the road network is being improved, the deep sea harbour is being built up to an international standard and the first shopping mall with escalators has opened. Life in the conurbation areas is getting easier (also due to tourism), but the level of rural life deteriorates further. Presently 75% of the Khmer are still peasants. Less and less families can live from agriculture. The young in particular move away to the cities and border regions in search of work. Here the slum areas are growing. The migration of the young means loss of roots: they leave the security of the village society and enter an insecure future. Over 100,000 women are currently employed at the textile factories in Phnom Penh which make high profits by paying very low salaries. If Cambodia signs the World Trade Agreement, these women might become unemployed and might (as many fear) look for alternative employment in the sex industry…

These developments cannot be stopped anymore. International donors, aid organisations and the state itself have to create the basic conditions for a social network and “community development” as soon as possible and in cooperation – even though this appears to be an illusory venture with the current government. At the same time the people of Cambodia have to take an active part in this development. The UNICEF warned already in 1996 that: “without a significant change of behaviour it will be impossible to pay for the personal, economic and social crisis of the epidemic.” Dr. Nong Kanara (AIDS Care Unit) believes that already 90% of the people of Cambodia are aware of the dangers of AIDS. But does it make them change their behaviour? “You know, many people only change in their next life…” he says.

(Abstract by Nico Mesterharm for „German AIDS Days 2004", Munich)