Mechai Viravaidya is an iconoclast in the battle against HIV/AIDS in Thailand. An economist, Mechai saw as far back as 1987 that Thailand was headed towards a national disaster if it did not do something about the spreading infection. With his experience in family planning, Mechai launched a major national campaign to spread awareness about HIV. His unconventional methods included condom-blowing contests, condom key rings that said "in case of emergency break glass", and a restaurant called Cabbages and Condoms in Bangkok to raise money for awareness. The idea was to break taboos surrounding sex, and spread awareness by demystifying the condom. Today, a condom in Thailand is called a "mechai" after this visionary activist, son of a Thai father and Scottish mother.
Says Mechai: "We had to get people to be relaxed. We had to wipe out any embarrassment." Condom use in Bangkok's sex industry went up from 30 percent to 90 percent in seven years.
In 1992, Mechai was asked to join the government, and took his anti-AIDS message on a war footing-defying the all-important tourism industry, which said he was giving the country a bad image that would hurt business. Mechai ultimately proved that awareness about HIV actually saved the tourism industry. He lobbied to get the prime minister to head the National AIDS Committee made up of all ministeries. "We took it to the High Command, just the Ministry of Health was not going to be able to do it." He overturned a government ban on AIDS messages being broadcast over radio and television.
If Thailand hadn't woken up to its HIV/AIDS crisis when it did (and largely because of the work of this one man) it would have had four million people with HIV today at a cost amounting to 20 percent of the country's GDP. Instead, Mechai's awareness campaign turned the epidemic around, and the number of new infections has declined sharply. Today, Thailand has about one million infected people. His advice to Nepal is simple: "You are in the same stage of the epidemic as we were in 1992. Please Nepal, don't make Thailand's early mistake. Act now."
Asked about countries where people are squeamish about discussing sex and condoms, Mechai says with his characteristic bluntness: "Would you rather be sensitive, or dead?" Thailand's condom man was in Kathmandu this week to address a high-level South Asian meeting on children. In front of delegates at the Crowne Plaza, Mechai distributed condoms, blew one into a balloon, and showed the multipurpose uses a rubber can be put to: "A tourniquet for snake bites, to keep dust out of soldiers' gun barrels, the ring can be used to gather ponytails, the lubrication can be after shave lotion. There are different colours: red for Sundays, black for mourning."
Nepali Times talked to Mechai this week about the lessons for Nepal from Thailand's experience, the importance of political will and public awareness. Excerpts:
Nepal is at the same stage as Thailand was in 1987. What is your impression of how we are dealing with the HIV/AIDS epidemic?
It appears that there is awareness and willingness in Nepal to understand the epidemic. If you look at the consequences for Nepal I can't think of any sensible politician not taking it on head on. The cost of inaction is huge, it is not just the loss of life. It is going to be a tremendous strain on government health services and a loss to the economy. You will be losing a minimum of 25 years of a person's working life and you multiply that by the number of infections in the next ten years and you have a staggering figure. Add to that the medical costs to take care of people who are sick, the indirect cost for the family.
Three basic sectors of the economy will be hurt: Nepali workers abroad may face problems if there is an epidemic at home, foreign investment will be hit as workers fall sick, tourism will be affected as visitors avoid Nepal. So, it's not just the health of individuals that will be affected, the nation's economic health is at risk. I can't imagine any politician or businessman saying this is not a problem.
How did you fight the initial denial in Thailand in the early 1990s? That there are other more serious medical problems.
That is a typical reaction. But what we did in Thailand is just keep on talking, raising the issues in public warning people about the consequences of doing nothing. Media is important, civil society, businessmen, students-all have to be involved. The argument about other diseases is also very common: if not enough money is not being put into addressing those diseases it doesn't mean we don't have to do something about AIDS. We have to do both. But AIDS you cannot deny. The cause of the other diseases and AIDS is different. Human nature has made us interested in sex whether we like it or not, and through that you are going to get infections. Everyone who has sex, even if you are monogamous and your partner isn't, is at risk. There is no such thing as a high-risk group, only a high-risk nationality. Thailand is a high-risk nationality, Nepal could be too.
There seem to be worrying signs that the gains you made in Thailand in the past ten years are slipping a bit?
There is always a threat in every country of being somewhat nonchalant, saying AIDS is not around anymore so we can relax a bit. It is happening in the US, Australia where infections among gay people is up 30 percent. In Thailand, the government started spending less on condoms, and they went quiet on public information. But the new government has corrected that. So I think the slight rise is now going to go down.
How much of a factor does migration play in the spread of AIDS across boundaries in Thailand and its neighbours?
It has neutralised itself now. There were Cambodian women coming across in the sex industry, they didn't understand AIDS. But the Cambodians are taking action now, so it's not so much an issue. In the case of Nepal, you have a lot of men and women going out. Sometimes you go out infected and you come back infected, and after that you can't blame the other country anymore. What Nepal must do is educate men and women in the villages, saying wherever you go take condoms along if you are going to have sex.
Do you think Thailand had an easier time because of higher literacy levels and the higher status of women in the family and community?
I think we use education and literacy as a crutch. We tend to under-estimate the role of face-to-face communication. A lot of the message that you need to spread in Nepal must go out on radio and television. Women in most developing countries are at a disadvantage when it comes to sex. We may have higher status at work, but probably not much higher when it comes to being beholden to men on sex. Being able to say: "Hey, husband, wear the condom!" Often it is the lack of effort rather than the illiteracy or the status of women. Nepal is putting in terms of its own budget only $30,000 a year for AIDS control. That is equivalent to the economic cost of one and half person who dies of AIDS. So the civil servants and others say, if we don't put our own money into it, it can't be important.
This is a war. The more you do today, the less of a problem it will be in future. The less you do today, the bigger will be the problem in future. It's your choice. When you have a war, you don't just use the army, you use the air force, the navy. The Ministry of Health can't fight this alone because it is before coming to the doctor that people get infected. You have to work on prevention: changing attitudes and behaviour. The only way Nepal will probably win this fight is when the prime minister chairs the National AIDS Committee.
How much of Thailand's success is due to the fact that you joined government?
I started on the outside, and I don't know how much harder we'd have had to push if I had remained outside. But by accident I got in, and once in, I gave the politicians little choice. I told the cabinet meeting everyone in this room will have a relative, if not themselves, who will be HIV positive 'x' years from now. I told the military, very few of you will be generals because you will be dead by then. You have to push, politicians will not do it naturally. And foreigners can't do it, Nepalis will have to do it themselves.
Part of your strategy has been to break taboos on sex, make the condom a household word, and not something to be ashamed of. What about ultra-conservative countries where HIV is a problem, how can they go about it and avoid a backlash?
The choice is very simple, you either spread awareness or you allow your children to die. It's as simple as that. Would you prefer to stay conservative and then go to your children's funeral when they are 25 or 30, or do you provide scientific information and moral guidance so that they know that one of the ways HIV is spread is through sex, and you can't tell if people are sick with HIV from the way they look, and how using a condom is the only way.
If you were directing AIDS policy in a country like Nepal with very limited resources what would your priorities be?
Definitely education and information are the most important. Also, family planning, because you reduce the demand on limited resources. Look at the difference between Thailand and the Philippines. We were the same level in 1972, same population, growth rate 3.3 percent, 7 children per family. Today we are 62 million and they are 76 million-14 million more. They didn't do the job that could have been done. So, with the same resources they have to spread it to an ever-increasing demand.
You moved on after your family planning and AIDS work. What took you to rural industrial development?
We had factories around Bangkok and people were delighted because we had investment, but if you took a closer look you saw that people migrated to the city, it destroyed the traditions and social fabric of the villages, and the money they could send home was very little because of the high cost of living in the city. So I thought instead of bringing people to the factories, let's take the factories to the people. They stay at home, they stay with the family, nearly all the money goes to the family, agriculture flourishes. I call this "the privatisation of poverty alleviation".
We go to a company like Nike or Pierre Cardin to convince them, we build the factory by borrowing money and they rent it, we get electricity, we train the labour force. Our company arranges all this and charges a fee, and the profits are ploughed into charity work in Thailand. The idea is to ultimately be free of outside donor support and do things yourself. It's a very simple idea, and in Nepal you may say there are too many problems, it won't work. But someone has to try, and someone has to start.
What is the main message you are sharing with South Asian politicians, businessmen and activists in Kathmandu this week?
Every other Asian country has gone through the stage of denial about HIV/AIDS. And when are you guys going to come out of it? Stop the denial, the problem is going to be there sooner or later, some sooner, some later. You have to see it as a war. Everyone has to fight together, and the chief executive of the country has to lead it. The Ministry of Health alone cannot do it. It is not a medical problem, it is a societal problem. Public education and information is the most important, and if you believe the citizens of your country are perfect and moral then you don't need condoms. But if they are ordinary people like my people then you better have condoms around and lots of them. That is the only thing that will prevent the transmission of HIV when sex comes into it. So, you have got to get everybody involved, everyone who can change attitudes and behaviour. You must be very careful about keeping the ratio of AIDS money for prevention and care. A happy ratio would be 75 percent for prevention and 25 percent for care, and later when the epidemic comes under control reverse it. But no Asian country except perhaps Singapore will have enough money for treatment. Don't expect to solve this problem medically, that is a long way away. Business has to be involved because sick staff can't work and dead customers don't buy. If you think of your children and you don't want to see them dead, you better start now. You have to have political commitment backed up by a financial commitment. Don't just rely on foreign assistance. They might get tired of you and stop giving you money after a while.
Which countries in the region have you been most impressed with, the way they have tackled AIDS?
Malaysia's prime minister Mahathir Mohammad hosted a major AIDS conference. Vietnam and Cambodia are taking it seriously. Unfortunately India's response is like chicken soup where the chicken flies over the pot only. India may not be as bad in terms of proportion as Africa, but in numbers it is going to be far greater with already five million or so infected, the base is very large. People in India should go to Africa and take a look-countries like Zambia where life expectancy has dropped to 32 years. Unless India takes real action it will start showing the same horrifying results as Africa, with orphans and mortality. In Thailand, if we hadn't started in 1990, we would have had 4 million HIV infected people by now. We now have one million. If we could do it, anyone else can do it too. In Nepal it's just a question of getting started and getting someone to push. You need a new organisation dedicated to saving lives, helping the country.