AIDS Outreach in Pakistan and Bangladesh

Meghan Houser, Staff Writer

At an international forum this September, UNAIDS director Michel Sidibé spoke out against the criminalization of homosexuality for hindering global efforts against AIDS: “We have to remove these laws as they reflect deep-seated stigma and prejudice…Gay people are the ones who brought attention to HIV and AIDS but as we moved on to generalizing services for people with the virus, we forgot them.”[1]

80 countries worldwide consider homosexuality illegal. There are movements across the globe to overcome these sanctions, often led as much by public health and AIDS relief groups as human rights advocates. These advocates have gained major recent victories, such as a decriminalization ruling in India in July, a decision Sidibé dubbed a huge victory because “removing laws that criminalize and discriminate herald a new framework and new commitment and a new movement to universal access to health and human rights.”[2]

Some activists hoped that India’s “new commitment” to discrimination-free access to AIDS services would spread beyond its borders. But in some of these nations, antihomosexuality laws seem hopelessly entrenched through complexes of government denial and cultural phobia.

Islam is the state religion of Bangladesh and Pakistan—two nations that share British India’s old penal system—and while these countries do not necessarily invoke Sha’aria (under which the penalty for sodomy is death), their cultural climate grievously complicates any effort to decriminalize homosexuality.

Until the legal tide turns, how can HIV treatment for homosexuals be promoted in these countries? National approaches range from near total denial of the issue in Pakistan to promising cooperation with NGOs in Bangladesh. This has produced varying results in the treatment and containment of the epidemic.

In Pakistan, where an official in the National AIDS program stated in 2005 that “our better social and Islamic values” keep AIDs prevalence lower in the country,[3] the epidemic is undeniably growing: the first case was reported in 1987, which had grown to 1913 cases by 2002, and ballooned to 96,000 by 2007.[4] In 2006, a full seven percent of HIV positive individuals in Pakistan were gay men, a figure most likely underestimated due to difficulties in data collection.[5]

The paradox of Pakistan’s handling of the AIDS crisis is that at-risk groups such as homosexuals are the ones most often bereft of outreach driven underground by Pakistan’s strict Islamic moral and behavioral codes. “If my family found out they would kill me, I mean really kill me,” says Shelley, 23, a sometime male sex worker from Rawalpindi. “There is simply no room for what we are in Islam, which is very difficult for me as a Muslim and a gay man to live with.”[6] This taboo makes even finding volunteers for treatment difficult. Abid Atiq, program director of a sexual health NGO called Interact Pakistan, notes, ““We have to find them [homosexuals at risk] because they cannot find us…there’s a lot of distrust … They want to know who we are. Are we the police? Will we arrest them?”[7]

Pakistani officials also refuse, in large part, to endorse preventative sexual health education—a sentiment reflected in cultural perceptions as much as law. “When I go home at night I simply can’t talk about the work I do with my wife, my parents, my brothers or sisters,” says Atiq. “99% of families in Pakistan can’t even begin to discuss the issue. Not won’t but can’t.”[8] While there have been advertisements to promote AIDS awareness since 1993, words such as “sex” and “condom” are often ommitted. Even possessing a condom is discouraged: A male sex worker interviewed in 2005 cited fear of law enforcement as his main reason to go without.[9]

Unsurprisingly, a UNAIDS sur vey in 2007 found that around 90% of male sex workers had unprotected anal sex on a regular basis. It has been estimated that only about 20% of sexually active gay men were being reached by any sort of AIDS prevention program.[10]

Though Bangladesh shares Pakistan’s religion and British India’s Penal Code, the outlook for HIV management among homosexuals seems brighter. The Bandhu Social Welfare Society, an NGO that has provided more than 76,000 gay men with sexual health education, is expanding with government support.[11]

Interestingly, Bangladesh often centers AIDS awareness drives around mosques. Since 1998, some 20,000 Bangladeshi imams have been coached to spread the word about high-risk practices and resources for treatment. ‘’They can easily overcome the social taboo against discussing HIV/AIDS,’’ says Syed Ashraf Ali, director general of the Islamic Foundation Bangladesh. ‘’An imam addresses a familiar cohort, one that he meets every week.’’[12]

These and other widespread, state-advocated AIDS initiatives have led to a more hopeful statistical picture for Bangladeshi homosexuals: a UNAIDS study in 2005 found that almost 80% of homosexual men were reached by prevention programs, and more than 45% of sexually active gay men reported using a condom at their last intercourse.[13]

Some admissions must be made in comparing these two profiles. Bangladesh still has a long way to go in addressing the AIDS epidemic among its homosexuals, and maintaining the illegality of same-sex relations can only hamper further efforts by keeping the homosexual community silent. It is equally true that Pakistan’s government is not wholly in denial about the need to address AIDS among homosexuals: the government recently developed an “Enhanced HIV & AIDS Control Program” targeting high-risk groups.[14]

Whether one focuses on the clouds or their silver linings in Pakistan and Bangladesh, one can only hope that Mr. Sidibé’s “new movement” towards universal human rights and healthcare is truly afoot, leaving prejudice by the wayside.

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1 IGLHRC, “India: Government Defers Decision on 377 to Supreme Court,” International Gay and Lesbian Human Rights Commission, September 18, 2009, http://www.iglhrc.org/cgi-bin/iowa/article/takeaction/resourcecenter/974.html#

2 Ibid.
3 Laura M. Kelley and Nicholas Eberstadt, “Behind the veil of a public health crisis: HIV / AIDS in the Muslim World,” National Bureau of Asian Research, June 2005 (NBR Special Report), 4.
4 2007 AIDS Epidemic Regional Update Summary: Asia. UNAIDS, 2007. <http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/default. asp> (Accessed 17 Oct 2009)

5 “Pakistan: Progress towards Universal Access and The Declaration of Commitment on HIV/AIDS.” UNAIDS country factsheet, 2007. <http://cfs.unaids.org/country_factsheet.aspx?ISO=PAK> (Accessed 17 Oct 2009)
6 Nicholas Harvey. “An Inconsistent Truth.” Fyne Times, 2008, 2-6, <http://www.nickandmaggie.com/article/An_Inconsistent_Truth,_Fyne_Times.pdf> (Accessed 17 Oct 2009)
7 Ibid. 3.
8 Ibid. 1.
9 Alefiyah Rajabali et al., “HIV and Homosexuality in Pakistan,” The Lancet Infectious Diseases (vol.8, issue 8), August 2008, 511 – 515.
10 “Pakistan: Progress towards Universal Access and The Declaration of Commitment on HIV/AIDS.” UNAIDS country factsheet, 2007.

11 2007 AIDS Epidemic Regional Update Summary: Asia. UNAIDS, 2007.
12 Qurratul Ain Tahmina, “Bangladesh: Anti AIDS /HIV Efforts Follow Men To the Mosques,” Inter Press Service, November 15, 2002. <http://ipsnews.net/interna.asp?idnews=13898> (Accessed 17 Oct 2009)
13 “Bangladesh: Progress towards Universal Access and The Declaration of Commitment on HIV/AIDS.” UNAIDS country factsheet, 2007. <http://cfs.indicatorregistry.org/country_factsheet.aspx?ISO=BAN> (Accessed 17 Oct 2009)
14 “Pakistan: Progress towards Universal Access and The Declaration of Commitment on HIV/AIDS.” UNAIDS country factsheet, 2007.

Alexa Stern, Interviewer

Frank Donaghue has served as Chief Executive Officer of Physicians for Human Rights since 2007. With more than three decades of experience in the nonprofit sector, Donaghue has a distinguished track record in humanitarian service, fundraising and management. Under Donaghue’s leadership, PHR has continued to increase its impact on issues of torture, asylum, conflict, global health, and forensics, and its student program continues to thrive.

HCGHR: Over the past decades, numerous global health organizations have developed. What is your vision of the collaboration and cooperation between Physicians for Human Rights and these other organizations?

Donaghue: First of all, I think there’s great collaboration. For example, we did a report on human torture with Human Rights Watch, and so we’re part of a broad group of human rights organizations that meet regularly. Whenever there’s a human rights issues we… talk about what position all of us would take in a kind of one voice way. For example, when Obama came into the administration, we sent together a document outlining basically what we think his priorities should be for human rights. So we really do work closely together. Sometimes, however, organizations will take a position that another human rights organization doesn’t. We were the first organization to come out and call what is happening in Darfur “genocide,” and other organizations weren’t ready and still haven’t basically said that. So there’s times we agree, and times we disagree, but I think there’s a lot of collaboration. I meet with my colleagues at Amnesty [International], Human Rights First and Human Rights Watch (the mainstream human rights organizations) a lot. For example, in the campaign against torture, I think Human Rights Watch and Human Rights First each brought their own unique skills, particularly [for] the legal issues of torture. We brought the health issues to the table and together they’re the kinds of things that raise the bar and the visibility. So without the legal ramifications and the health documentation, you don’t move the bar as far as you can together.

HCGHR: There has been a lot of talk about the “brain drain,” in which physicians and nurses from developing countries leave for jobs in more prosperous nations. This issue has come up in U.S. national news, as Congress considers a bill that would bring in more foreign health practitioners to augment the domestic healthcare workforce. What is your opinion on this legislation, and how do you think the problem of the “brain drain” can be solved?

Donaghue: We’ve written a couple of reports on brain drain, particularly in Africa, and we were particularly instrumental in the new PEPFAR reauthorization (the President’s AIDS funding) to get included in that reauthorization the money for 45,000 new health care workers in Africa. The brain drain issue is obviously complicated, but let me take it from the developing countries’ perspective, rather than the United States’ perspective. The vicious cycle that happens is: the United States sends money for PEPFAR to, let’s say, Uganda, and the money is going primarily to folks in the capital. And so, the doctors and nurses from the inner lands are coming into the capital to get much greater salaries than they were getting working out in a clinic. They come into the capital in Uganda, and then Americans and other Europeans come in and “poach” them from the capital because they are now the most skilled, have the most training and greatest ability. So it’s almost like this vicious circle: we fund them to help their people, we pull them into the city, then we steal them from them and do it again and again and again. So I think brain drain is a really complicated issue, both if you’re in Nebraska and if you’re also in Impala, and just taking doctors and nurses from developing countries to meet the growing need here is not helping the developing countries that we claim to be helping. I think we need to come up with some other solution. We’ve been working a lot with developing countries in how they build a workforce. We just published a document that is a sort of “how-to” for developing countries on how to build a health workforce system–how to retain health care workers. But I think it is wrong for the U.S. to fund getting doctors to move from the clinics to the capital and then stealing them for [ourselves]. We see that in Britain and we see that in the U.S. all the time.

HCGHR: What do you believe to be one of PHR’s most successful campaigns/projects and why do you think that it has worked out so well?

Donaghue: I’ve only been here for two years, so it’s hard for me to say. Obviously, being a co-recipient of the Nobel Peace Prize for our campaign to ban landmines is huge. There aren’t many organizations who have won a Nobel Peace Prize. I think it’s indicative of exactly what PHR does. We’re really good at creating a campaign, creating public pressure around an issue and mobilizing people to become activists. Since I’ve been here, certainly our Health Action AIDS program [has been successful], which is all about AIDS in Africa and getting PEPFAR reauthorized, getting language around health care workers, and the whole feminization of AIDS coming to light. During the Bush administration, PEPFAR was just dropping pills all over Africa, but you can’t stop AIDS that way. You can only stop AIDS when you take a more comprehensive approach. For example, teaching people about reproductive health, allowing women to say “no.” The Bush administration said “reproductive health” was code for “abortion,” so you couldn’t get any money being used for reproductive health. Also [successful has been] lifting the travel ban on people who are HIV positive. Those have been the big issues most recently. We did get the reproductive health in the reauthorization, we did get health care and health workforce in the reauthorization, and so I think those are all really positive accomplishments. Personally, I think Zimbabwe was amazing for us. I got a call in November from a medical student. I said, “How are you doing, Norman?” and he said, “I’m doing as well as everyone else.” I said, “No, how are you doing?” He said, “I’m just sitting here like everyone else waiting to die.” That was the day we decided to go, and we were on the ground in 30 days, and the report was released worldwide in another 30 days. I think it was a real indication that PHR and the way we operate is somewhat different. We can be much faster in the way we bring data to the field. For me, that personally has been the most rewarding. But I think everything we do, for example the work for the campaign against torture, is mind-boggling and astounding. We have a full-time person that just investigates… every single aspect of the administration (the previous administration) and what they did to perpetrate torture on human beings. His work and the way we release it: we don’t always come out with what we know with the name PHR on it. We deal with a lot of media, reporters, providing them with information they can use to further our work because justice doesn’t need our name on it…

HCGHR: In a Physicians for Human Rights article on health professionals’ involvement in monitoring and aiding torture, PHR calls for those who violated ethical standards to be held accountable through criminal prosecution. What about professionals who were truly just there to monitor the interrogations and did not contribute to the torture techniques?

Donaghue: We believe that psychologists and physicians should not be present during any torture. That is a violation of the very core of why they’re healers. However, the psychologists that were involved primarily with the CIA developed a reverse interrogation technique… This was a training that we used to provide American soldiers when they were being tortured [on] how to avoid torture. That’s how it all started. It was invented by some psychologists in California, and they sold it (literally) for lots of money–how to teach that and how to break people. So we used it for our people on how to protect them, and we used it for our people on how to torture others. So a guy comes in to Guantanamo, a psychologist meets with him, and determines that the issues that will really crack this guy are, say, sexual humiliation or isolation, because these are the things that they are psychologically most vulnerable to. Then they feed that information to the torturers so that the U.S. CIA can use those very specific techniques to break these people. It’s more than just being present. We wrote a report called “Broken Laws, Broken Lives,” which is our last report on torture. We sent doctors, psychologists to interview a dozen men who had been in Guantanamo Bay or Abu Ghraib. The stories in the books are so disgusting that the doctors that reviewed the document, our board of advisors, said it was almost something you couldn’t read–guys being face down in urine for weeks, soldiers sticking guns in them every day for weeks, untold sexual humiliation, isolation for months, never seeing another human being. There is one story where they would play [recordings of] screaming women in the next room and tell these guys it was their wife or their 12-year-old daughter that they were raping. Psychologists were present. You can’t tell me under any code of ethics that that is acceptable. It’s totally a lie that these psychologists were present to protect the victim of torture. They were there to empower the CIA on how to break these people more thoroughly. In the past six years, we’ve been really instrumental in getting the American Medical Association to adopt a policy that physicians could not be present during torture. It’s very clear that the American Psychological Association has, if you will, “gotten in bed with the Devil,” and they’ve made a lot of money on selling their “souls” to the CIA. We brought much of that to light. It continues to come to light that the leadership of the American Psychological Association should be held accountable for the torture and destruction of the lives of thousands of people.

HCGHR: Can you tell us more about a PHR project on which you are currently working?

Donaghue: We have a couple of exciting projects. One is our continuing campaign against torture… It is being funded primarily by Atlantic philanthropies to continue to demand accountability and holding those who did this accountable and prosecuting them. We work full time on gathering evidence–everything from those doctors and psychologists engaged in it to others in the military and the government who knowingly committed these crimes at the highest level of the administration, including the [former] vice president. Asylum is another project we’re working on. Our custody work is around torture because it’s about being held in custody and also asylum seekers in this country. A woman who was genitally mutilated in her previous country, under the Bush administration, could be sent back to her country because she couldn’t be mutilated again…The arcane rules that are put in place for asylum seekers in this country are pretty outrageous. People are being put in mandatory detention and there is a crazy guideline that if you don’t request asylum within 365 days, you are automatically refused it. Most people that come into this country to seek asylum don’t know that rule, first of all, and live in their own communities and they don’t get all their facts that they need. For a woman who was raped in her country, [who] is often afraid to tell her family what happened once she gets here, getting the opportunity and understanding the law in order to gain asylum is really difficult. Number two, border control people can meet an asylum seeker at the border in Mexico and decide that you’re lying and send you back. It’s totally up to the border control people, so there is no real filter to say if these people are telling the truth. It’s basically happening by some policeman at a border deciding if this woman is telling the truth about her life being destroyed. Third, the health system in detention centers is deplorable. Often these people that come here to seek freedom from untold oppression and torture are treated very poorly. The government contracts with the same companies they contract to monitor “terrorists” and prisoners, so many detention seekers are treated like prisoners. They’re kept in detention centers just like prisoners; they’re treated like prisoners. The health care system is deplorable. So far this year, 60 people have died seeking asylum in this country for lack of medical care. These are people that left their country where they were tortured or abused and come here for freedom and die in our care. That’s outrageous. So we’re working on asylum. Basically, we’re pushing for removing mandatory detention, pushing for an improved health care system for asylum seekers…The other project is a study [we just released] called “Nowhere to Turn.” We sent doctors, women doctors, of course, into Chad to survey women who had been raped in Darfur as a weapon of war. It’s about our third report on Darfur and our goal is to launch a major, international project next year on how local NGOs can document rape and the impact of that in order to get the perpetrators. Right now, there’s obviously doctors doing this. I met a doctor from Congo, and I asked him what was the youngest and oldest female he had seen who had been raped. The youngest was 5 and the oldest was 85! And they were repeatedly raped. Rape is an increasingly serious weapon of war. We know it is used in Uganda, Congo, and particularly throughout Southern Africa. So our project would be to work with local NGOs and teach them how to gather the forensic evidence and documentation to prosecute those who are guilty of rape. It really could be a significant change agent because the women and women doctors in these countries are just speaking to each other. They don’t have access, the Congolese people to the Ugandan people.

Justin Banerdt, Staff Writer

Ed Hunter represents the Centers for Disease Control and Prevention in Washington before the United States Department of Health and Human Services, other Administration officials, and non-governmental entities. He also directs and oversees CDC’s legislative strategy. Since 2003, Mr. Hunter has been Deputy Director of CDC’s Washington Office. This office is the Washington, D.C. arm of the CDC Office of the Director, serving as a bridge between CDC and the Washington policy community.

HCGHR: What is your agenda while at the CDC and what changes do you hope to bring to the organization?

Hunter: The CDC is engaged very directly in a number of really high profile things right now. Obviously, getting the effective response to the H1N1 epidemic is key right now. That in many ways is dominating our leadership and much of our science base and certainly my office here in Washington. I am the head of the CDC Washington office where we deal a lot with Congress and other federal agencies and our Washington partners have a big stake in the 2009 H1N1 as well… There’s a lot of federal engagement and also clearly congressional engagement in a response of this magnitude. So our office is very much engaged in that and that is sort of a dominant thing for the agency since this virus appeared in April and it will certainly continue through the fall and throughout the flu season… Another is health reform. [Health reform is] a Washington policy agenda and there is a lot at stake for prevention through health reform, not just in health insurance and financing and whether there’s a public option and a lot of the other more visible things that are covered very well in the press. But there’s a lot of concrete things about what we can do to advance health, what we can do to advance prevention through the health system in terms of benefits and coverage for preventive screening and interventions. Also, what we can do at the community level to promote and protect health, [such as] setting the policies and other things in place in communities that actually keep people from needing medical care down the road. So that’s something that we are actively engaged in. Those are the two biggest things that I devote a lot of attention to and that the leadership of the CDC is very focused on right now.

HCGHR: How will the hype around H1N1 be affecting the CDC’s other activities this year? Will resources be shifted to deal with this problem and do you foresee that other projects may suffer from this?

Hunter: The CDC has a very well established preparedness and emergency response mechanism and we’re really using that mechanism to its fullest for this response… We have a whole network of staffing, roles, and capabilities that we’ve been sort of rehearsing and exercising over the past four or five years–not only for a pandemic but also for a response to naturally occurring disasters and other illnesses. A lot of this is built in anticipation of something like an anthrax attack that we suffered in 2001. So that mechanism and the roles and the exercises… are being brought into play… so we actually have a structure and a framework to use for this response. It obviously pulls in a tremendous amount of resources from across the agency. We have somewhere between 1,000 and 1,500 of our staff that’s actually actively engaged in the H1N1 response, from an epidemiology and investigation point of view, for vaccine distribution, vaccine safety monitoring—preparing those guidelines, the laboratory elements of this, and of course the communication and IT aspects of this are really normative. It is pulling from every part of the organization and obviously it is partly paid for by emergency supplemental funding from the Congress [and] partly paid for from resources the agency already had. So it certainly is extending us to the max for the capabilities that we have…. Many resources are from the state and local level and health departments that are already stressed from state budget cuts and just because of the economic situation. There have been some federal resources that have been brought to bare—to help them do vaccine planning and distribution [and] some of the other preparedness side. [However] that’s something where putting H1N1 on top of an already stressed state in local health department infrastructure is a real challenge.

HCGHR: What lessons is the CDC taking away from the H1N1 pandemic in preparation for one that could potentially be far worse, such as avian influenza?

Hunter: I think one thing is the premise of your question: that this one isn’t potentially bad is hopefully correct, but might be optimistic… We are not done with this one. Influenza is a very unpredictable virus, it’s very clever, it’s a worthy opponent to all the systems and technology that we have in place so one would like to think that this doesn’t change in severity. But I think we have a long history of doing after-actions and corrective actions in every public health event that we are in. On this type of emergency response we do a systematic after-action; we’ve done some of these on an interim basis from the spring. We are better at communicating with our counterparts in state and local governments and around the world. I think we are learning a lot about how we communicate well with the public and with our partner organizations… Tracking I think is tremendously improved from where we might have been a year ago… We have tried very hard to rebuild some of the capacity at the state and local levels and to understand what it takes to do things like that… I think we’ve learned a lot about all the different parts of the United States government that have something to contribute to making an effective guidance to the public or just, for example, to schools, where we are not the only experts on what happens… So working more closely with the Department of Education we know better how to communicate with schools about what they should do in a situation like this. We probably have been asked more questions, just by the nature of this as it unfolds and expands and consumes people’s attention. I think we’ve been coming to understand all the various dynamics of [how] something like this starts to affect all of society as opposed to a more limited medical or public health world… I think we have learned a lot about what’s involved in trying to coordinate/motivate across all parts of the government and to talk to the public directly and healthcare systems… [In the end] we hope that every response we do gives us information to improve the next one.

HCGHR: The topic of our upcoming publication is health, equity, and health access. How is CDC policy trying to currently address health inequity in developing countries and what are common obstacles in addressing this problem?

Hunter: CDC has a big role in global health, partly through the president’s PEPFAR program… But one of the unique aspects of CDC is to help strengthen the health systems of countries around the world, particularly developing countries. That’s one of the really key things: to try and not just tackle one problem at a time but to build the infrastructure in countries for laboratory capacity, epidemiological capacity, and the overall health systems through the health ministry and others so that this can be sustainable and some health problems can be addressed in a real systemic level. I think that’s one of CDC’s major involvements on the global side.