Political Leadership in the Early Years of the Epidemic by Berkley Crain

Several weeks ago, my global health course discussed some of the greatest successes in the field, specifically in fighting disease. One such case study was Thailand’s 100 percent condom program, implemented in 1991 to address the country’s skyrocketing prevalence of HIV/AIDS and sexually transmitted infections (STIs), particularly among sex workers. While prostitution in Thailand is illegal, it is widely practiced and tolerated, and has thus developed into a thriving sex industry. Following the outbreak of AIDS, health officials in Thailand advocated a pragmatic approach to prevention, one that emphasized safe sex practices over eliminating prostitution. In 1989, the Ratchaburi province of Thailand mandated that all brothels enforce condom use. Condoms were distributed free of charge to all sex workers, and brothels that failed to enforce the “no condom, no sex” rule were subject to being shut down by the police. After the incidence of STIs plummeted in following months, all provinces adopted the program.

At the forefront of Thailand’s prevention efforts was Mechai Viravaidya, a political activist best known for his work in family planning. Mechai came to be known as “Mr. Condom” through his humorous, yet highly effective, condom campaigns. His efforts led to widespread distribution of condoms, beyond simply the sex industry. Taxi drivers, toll booth workers, and restaurants were enlisted to hand out free condoms to anyone and everyone. Mechai also led condom-blowing contests in schools, a highly controversial, yet innovative, effort to raise widespread awareness of the risks of unsafe sex. I suggest watching a 2010 TED Talk that Mechai delivered on his work in family planning. Since the 100 percent condom program and Mechai’s initiatives, Thailand has observed drastic declines in HIV prevalence. Some studies indicate that rates of infection dropped fivefold throughout the early 1990s. Thailand and its HIV/AIDS prevention efforts have been truly exceptional as one of few countries to rapidly reverse the spread of the epidemic on such a large scale.

As I read the chapter “AIDS in the U.S.A.” from Peter Lewis Allen’s The Wages of Sin: Sex and Disease, Past and Present, I kept thinking back to Thailand’s success story. What was it that set Thailand apart from the U.S. during the early stages of the AIDS epidemic, as both countries were faced with a mounting health problem that required immediate attention? Political leadership was paramount to Thailand’s prevention efforts, and is what the U.S. severely lacked during the early stages of the epidemic. Allen’s historical account of AIDS in the U.S. describes a complete failure on the part of the government to even openly acknowledge the issue of HIV/AIDS, much less take action. I was appalled to read that AIDS was never publicly addressed by Reagan’s presidency during the first six years of the outbreak. Even within the scientific community, hostility towards people with AIDS abounded; HIV/AIDS was proclaimed as a disease that gay men had brought upon themselves through irresponsible, perverse, and even sinful lifestyle choices. The U.S. was in desperate need of a political leader similar to Mechai; a voice to not only speak openly about the factors underlying HIV transmission, but to also advocate change. The responsibility of activism fell instead on those most affected by HIV/AIDS in America, specifically middle-class, gay, white males. According to Allen, the fact that infection was concentrated within such a specific community was hugely advantageous in enacting an American response to AIDS. Many of those infected shared similar beliefs and lifestyles, and were thus motivated to collectively speak out against the government’s total negligence. Thus, the earliest prevention efforts in America arose from within the gay community, especially through the organizations Gay Men’s Health Crisis and ACT-UP.

The histories of HIV/AIDS response in Thailand and America underline the importance of prevention efforts. Allen states that prevention is the most powerful, yet perhaps most easily misunderstood and mishandled, tool in fighting the epidemic. Thailand proved highly successful in developing prevention strategies as a result of effective political leadership. The U.S., on the other hand, seems to have sabotaged itself in its early fight against HIV/AIDS by assuming silence during such a critical period.

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