Knowledge and meaning: The AIDS education campaign in rural Northeast Thailand

Sot. Sci. Med. Vol. 38. No. 1. pp. 135146, 1994 Printed in Great Britain. All rights reserved

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0277-9536!94 $6.00 + 0.00 Q 1993 Pergamon Press Ltd

KNOWLEDGE AND MEANING: THE AIDS EDUCATION CAMPAIGN IN RURAL NORTHEAST THAILAND CHRIS

Department of Anthropology,

LYTI’LETON

Sydney University, Broadway, Sydney, NSW 2006, Australia

Abstract-Nearly 80% of Thailand’s population live in the rural sector. To date, these villages have been subject to top-down dissemination of HIV/AIDS education information via the mass media and bureaucratic networks. This report details an ethnographic enquiry into the impact education campaigns are having in one village in Northeast Thailand. It is found that AIDS information is primarily integrated with local conceptions of sexual behaviour and commercial sex. By the early 199Os,heterosexual behaviour is a major mode of HIV transmission in Thailand. Local and international media discourse focuses on the commercial sex industry in describing the spread of the virus. However, the lack of detailed research of sexual practices in Thailand makes accurate projections of HIV transmission difficult and allows unsubstantiated claims to be made concerning typical Thai sexual behaviour. This paper explores the local context in which these practices are found and discusses the meanings villages attached to HIV/AIDS information. Knowledge levels and behaviour change are assessed and it is argued that community based imperatives are essential for effective future campaigning. Key words-AIDS/HIV,

rural NE Thailand, sexual behaviour, commercial sex, social context

INTRODUCITON Roughly 80% of Thailand’s population lives in rural areas in more than 60,000 villages [l]. HIV/AIDS education campaigning has involved nationwide dissemination of warning messages with television playing a key role. In increasing numbers nongovernment organisations (NGOs) are beginning to work with specific target groups but most of Thailand’s rural villagers have learned about this disease from national top-down campaigns. These campaigns have primarily targeted two practices: needle sharing and promiscuous sex. While the practice is widespread, intravenous drug use (IVDU) is more predominant in Thailand’s cities than in villages [2]. In terms of local relevance, most rural people associate AIDS and the threat of HIV infection with sexual behaviour and commercial sex. Detailed information on the culturally specific context of so-called risk behaviours is lacking in all countries [3]. AIDS has, of necessity, brought sexual practices into the limelight for research. Until recently, the only studies of sexual behaviour in Thailand were quantitative surveys (see [4] for summary). To understand the spread of HIV, both real and potential, the local meaning attached to these acts is essential knowledge. Commercial sex is at the forefront of descriptions of AIDS in Thailand but the blurred boundaries of its existence in a variety of venues in Thai society make accurate projections of HIV transmission enormously difficult. Lack of detailed research into sexual behaviour in Thailand, in particular in rural areas, has provided a vacuum in which uncorroborated assumptions about Thai sexual practices have flour-

ished. The research I report here attempts to partially redress this situation by providing ethnographic details from a rural community in Northeast Thailand. I discuss local sexual behaviour and commercial sex and assess the impact of the HIV/AIDS education campaigns. BACKGROUND

AIDS/HIV

in Thailand

There is a broad consensus that Thailand has all the prerequisites for rapid escalation of HIV transmission: a large number of heroin addicts [2], a large and heavily patron&d commercial sex industry, an active gay population [S], many seasonally migrating workers [6] and added to this, some 200,000 truck drivers many of whom ply the length and breadth of the country, stopping at the many truck-stop brothels 17-91. Indeed, HIV infection has spread dramatically since the late 1980s [lo]. The first reported case of AIDS was documented in 1984. By 1992, it is estimated there have been between 200,000 and 400,000 people infected with HIV [l 11. However, figures from the Ministry of Public Health of Thailand (MOPH) show that as of 31 December 1991, there were only 332 cases of full-blown AIDS (and 507 ARC) [12]. For most people in Thailand, AIDS remains a distant threat defined and described by the media. The Thai MOPH monitors the spread of HIV every 6 months by testing a random sample in eight designated target groups. In the December 199 I, National Sentinel Survey, the national median rate showed 22% of brothel commercial sex workers (CSWs), 5.6% of men attending sexually transmitted disease 135

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CHRIS LYITLETOW

(STD) clinics and 0.7% of women visiting antenatal clinics were HIV positive [13]. Provincial seroprevalence rates show large variations and national averages are higher than these figures [ 141. Seroprevalence in brothel CSWs in some Northern Thailand provinces is more than 50% 1151. Although Northern Thailand has consistently shown higher rates of HIV infection than in other regions, levels are increasing steadily in most provinces. For example, in the Northeast province of Khon Kaen between June 1991 and June 1992, seroprevalence rose in brothel CSWs from 15.3 to 25.9% and in men going to STD clinics from 2.5 to 5% [16]. Epidemiologists believe that during the mid to late 1980s successive waves of HIV infection moved sequentially through the male homosexual population, the drug injecting population and CSWs, reaching people outside these groups with such rapidity that they suggest Thailand is representative of a particularly Asian model of the virus spread. (For an overview of the epidemiology and socio-cultural context of HIV/AIDS in Thailand see [17, 181.) Clearly. by the 1990s a major mode of transmission of HIV in Thailand is heterosexual sex.

AIDS/HIV

in rural

Thailand

In sub-Saharan Africa, an area cited as the predictive model for HIV transmission and its demographic consequences in Southeast Asia [ 191, seroprevalence is regarded by some researchers as a crisis of a greater magnitude in urban areas [20]. It seems unlikely Thailand will mirror this pattern exactly because most people live outside the cities and there is considerable circular seasonal migration. The migratory lifestyles of much of the labour force including many CSWs ensure that HIV is, at least, a potential threat to every rural community [21]. Nationally, the rural sector employs more than 60% of the labour force earning 16% of the GNP [22]. The past two decades of headlong economic growth have resulted in income disparities (on average, urban dwellers earn nine times the income of rural people) that annually send hundreds of thousands seeking to supplement family incomes away from the land-based rural economy. In the Northeast, in particular, agricultural dependence on haphazard seasonal monsoons has prompted a constant reciprocal movement of villagers to and from the primate centre of Bangkok or to other regions where labour is required all year [23]. Many single young men and women spend several years in Bangkok before returning to their village to raise families [24,25]. In keeping with Thailand’s demographics and income opportunities, most CSWs come from rural areas, primarily the North and the Northeast, and many return to their villages after several years of this work [26-281. During their time as CSWs (categorised in most discussions as either direct, brothel prostitutes, or indirect, those working anywhere other than

brothels), mobility is common. and not merely from city to city. There are many locales in rural areas where sex might be bought: bars. brothels, restaurants with rooms attached. sometimes simply a straw mat in a rice field. A survey I conducted in 17 of the 20 districts in Khon Kaen province located 98 such places in villages and towns outside the provincial capital. This did not include many ‘secret houses’ of which propriety disallowed casual disclosure nor the more transient establishments that teams of mobile CSWs frequent, such as weekly cattle auctions or queues of trucks waiting to unload sugar cane at processing factories. Apart from the recognised risk of infection from male to female or vice versa, these latter, informal venues pose an additional risk of direct male to male transfer of HIV due to the rapid succession of clients and the lack of facilities for CSWs to wash [29]. National

programs

Most of Thailand’s villages receive information about HIV/AIDS via the mass media, in particular television and radio. Provincial health authorities send information, posters and pamphlets. via the Public Health network to the roughly 7800 rural Health Clinics throughout Thailand. The Population and Community Development Association (PDA), a large NC0 working in AIDS education/prevention programs, has also organised national campaigns to distribute information via tapes and posters to most villages, utilising the Ministry of the Interior (MOI) as the transfer network. Despite pockets of resistance in certain sectors, the government is proceeding with the National AIDS Program, begun in 1989, which encompasses surveillance, research, education and provision of health care. Seminars are conducted for many sectors of the population. Educational messages, news items and documentaries appear regularly on television and the radio throughout the country. A radio soap opera of 364 episodes broadcast across the country told the tale of people and their contact with the disease. Condoms are available free at every health clinic and district hospital and are distributed free to CSWs when they visit government STD clinics. AIDS clinics and counsellors are planned for every district hospital and a national network of clinics for anonymous testing is being established. There have been specific surveillance and education programs targeting groups at risk of infection. Posters and pamphlets are supposedly distributed to every health clinic in the country. Videos and tape cassettes have been issued to district hospitals. Hotlines have been established in Bangkok and regional centres in the North and Northeast. Billboards with warning messages stand outside government buildings and close to main thoroughfares throughout the country. The Ministry of Education has included health education about AIDS in the curricula of all public

AIDS education campaign in Thailand

schools, primary and secondary [30]. If what occurs in the region studied during this research is typical

nationwide, primary school students are taught about AIDS during health education classes in their final 2 years, although the presentation is generally cursory. At secondary school level, videos and slides are shown occasionally and the students receive more detailed information about HIV/AIDS and the transmission of the virus. In 1991, the Royal Thai Government established a committee comprising both public and private sector officials to oversee the National AIDS Program. The presence of the interim Prime Minister, Mr Anand Panyarachun, as chairman of this committee enhanced the program’s influence. The same year roughly one hundred million dollars was spent on AIDS prevention efforts [8]. The budget submitted by the AIDS Division, MOPH to the Thai Government for AIDS programs in 1992 solicited funding for 14 different government ministries to establish individual enterprises [31]. Such a spread of programming activity does not, however, necessarily ensure efficiency or cooperation. It has often been noted that there are frequent breakdowns in communication and coordination in Thailand’s sprawling bureaucracy [32,33]. NC&s, both national and international, have also begun education and intervention programs. The most prominent of these is PDA whose head, Mechai Viravaidya, is well known internationally for his success in organising family planning initiatives and he has also acted as government spokesman on AIDS. Perhaps the most ambitious of PDA’s several national programs, to date, was a series of seminars in 1990 and 1991 for Provincial Governors and District Officers. These seminars initiated a flow of information intended to proceed via cassette tapes to the headman in each village and from there to every villager in Thailand. PDA has made ‘spots’ and documentaries for television and distributes messages to 473 radio stations. There is a coalition of NGOs working on AIDS projects, mainly in Bangkok. There are also many NGOs in the Northern provinces, particularly Chiang Mai, which are developing educational and support services. Counseiling centres in Bangkok and Chiang Mai have been opened and advice services to regional NGOs wishing to tackle education programs have been established. More innovative attempts, to date, have been the use of traditional theatre as an educational medium in several rural provinces. As funding arrives from overseas donors, the number of NGOs working in HIV/AIDS education and prevention programs is rapidly growing. In 1991, the MOPH began coordinating provincial level AIDS education campaigns reaching the total population. Although this has involved concerted targeting of CSWs and attempts to instigate 100% condom use in brothels, for the rural population it has largely meant the continued distribution of inforSSM 38,1--J

137

mation via the MOPH and MO1 networks. In a recent review of the government’s progress in countering the threat AIDS poses to Thai society, the MOPH candidly admits much of the education material is unfocused and untested [34]. The operating principle of all national programs, both government and NGO alike, has been very much a shotgun approach with the hope that fine-tuning will come later. The villages in Thailand have thus, to date, been recipients of blanket top-down information dissemination about AIDS. National portrayal

of risk

In the mid to late 1980s. as the epidemic was slowly recognised in Thailand, the media presented AIDS as solely a problem of homosexuals or drug users [35]. Since then, the media has turned its attention to heterosexual transmission. The national campaigns have chosen two slogans to broadcast: do not share needles and do not be promiscuous (or if you doprotect yourself). Generally speaking, in rural communities it is indigenous notions of heterosexual behaviour that constitute the conceptual framework into which the education campaigns introduce AIDS knowledge. Although intravenous drug use and homosexual practices remain contributing vectors to the epidemiology of AIDS in Thailand, they tend to be viewed at both the local and national level as less pertinent to village life. IVDU is considered more prevalent in cities, particularly Bangkok, than in rural areas [2] and of the four regions of Thailand, the Northeast has the least recorded number of heroin users [36]. Homosexual practices are an ill-defined (and underresearched) aspect of Thai social life and although homosexuality, male and female, is present in village communities it is not common [37]. In this research, I have chosen to focus on heterosexual behaviour and the mention of CSWs will subsequently refer only to female prostitutes. The rapid spread of the virus among brothel workers has focused attention on the commercial sex industry as the main reason Thailand has shown such a high rate of transmission and furthermore the reason the virus is now spreading in the general population. This concern is no doubt justified given the premise that the size of an infectious pool and the degree of polypartnerism affect the speed of the virus’s spread [ 181. However, the notion that prostitution is responsible for the scale of the epidemic also sets the stage for stereotyping and sensationalism. Local and international media discourse on HIV in Thailand, at present focuses almost exclusively on the commercial sex industry. Quoted estimates of CSWs sometimes reach higher than two million [cf.381 and articles in international news periodicals about HIV in Thailand routinely include eyecatching pictures of brothel prostitutes (see for example: Newsweek [39], Far Eastern

Economic

Review

[40], New

York

Times

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CHRIS

LYTTLETON

Magazine [41]). AIDS in Thailand has been given a face-a young female CSW. Because commentators on Thai society describe Thai men’s pursuit of sex outside of marriage so regularly it is commonly regarded as a male prerogative [42-45]. The stereotypes which link such behaviour and the spread of HIV in Thailand parallel the Western constructions of an exotic African sexual ‘otherness’ [cf.46]. This Oriental ‘otherness’ is predicated on images of unrestrained male libidinousness and because premarital and extramarital sex in Thailand customarily take place in a commercial context these constructions often carry with them the undertone of moral judgement. Blanket generahsations appearing in discussions of HIV in Thailand apply not only to the Thai men whose sexual profligacy is regarded as a national character trait but also fuel constructions of Thai women’s sexuality. Highly visible prostitution, coupled with common Western notions of Oriental female submissiveness, creates an image of constant female availability. Given the tenor of many of these claims, both the number of CSWs and the extent to which men visit these women are issues requiring clarification. The number of CSWs is enormously difficult to calculate given their typical mobility and the variety of venues for commercial sex. Based on statistics recorded by STD centres, the official government count is 86,400 female CSWs [47]. An influential study, however, put the number, in 1980, at around 500,000 (271. A more recent investigation that used a team of researchers in a sample of provinces reported a figure between 150,000 and 200,000 and argued that claims of higher numbers were statistically “impossible”: e.g. if there were one million CSWs, one in every six Thai women between the age of 15 and 24 would be a prostitute [48]. It is not possible to ascertain the actual number of women involved in commercial sex; I estimate it to be somewhere around a half-million and lower than many estimates portray. Published reports of the number of men who have engaged in commercial sex show ranges from 43 to 97% depending on the sample group (summarised in [17]). Rural men are underrepresented in these surveys and city mores are, in popular presentation, extended to cover all the Thai population. Newsweek, quoting a “reputable study”, reports 400,000 Thai men see CSWs each night [39], New York Times says 450,000 [41]. A cover story in Far Eastern Economic Review similarly quotes “studies” stating 95% of all Thai men over the age of 21 have slept with a CSW [401.

Attitudes to commercial sex and frequency of patronage vary both individually and regionally. As the commercial sex nexus is critical to the spread of HIV in Thailand, an understanding of local responses to prostitution is required to appreciate the effects of AIDS education campaigns and how these campaigns might best be modified to suit local conditions.

METHODS

Research methods The research was carried out in one village, Nong Waeng, from March to November 1991, as part of ongoing fieldwork. I gathered data primarily by means of ethnographic enquiry. Talking long and often about certain issues has provided me with a composite picture of the villagers’ behavioural and psychological responses to information about AIDS in this village. It must be noted that the researcher is a male; however, all pertinent conversations involved the participation of a female Thai research assistant whose native language is the local dialect. Conversations and in-depth interviews with both villagers and female CSWs who work near the village or in the provincial capital took place over the 7 months that my assistant and I lived in Nong Waeng. Over this period, it became possible to broach issues of a sensitive nature with many people in the village. After 3 months, I distributed self-reported questionnaires to assess knowledge levels about HIV/AIDS. The questionnaires, compiled using the WHO/GPA KAPB questionnaire and a pretested questionnaire developed by the Faculty of Nursing, Khon Kaen University, were given to all villagers between the ages of 14 and 60, n = 435. Except for the question, “What causes AIDS?‘, the respondents had to choose an answer, primarily in a yes/no format. Campaigners have accepted the sometimes technically incorrect use of the AIDS acronym as a bow to pragmatism for HIV is seldom mentioned in national public campaigns. Very few villagers have heard of HIV. They have heard of AIDS. In discussion with the villagers, I used the term AIDS to denote both HIV infection and symptomatic conditions of AIDS. Observing behaviour and conversing with informants provided the opportunity to test whether certain of the questionnaire answers accurately reported peoples views. For instance, it became clear that women did not feel comfortable answering a question concerning their premarital sexual experience and questionnaire answers underrepresented its occurrence. The men, we found, were not inhibited in revealing details of their sexual behaviour within the questionnaire format. In societies such as rural Northeast Thailand, where written information remains for many an unfamiliar medium, survey technique methodologies have limited value in disclosing details of sexual practices and when used as a sole source of data will not be able to accurately quantify behaviour change. Questionnaires can show knowledge at the community level and have value as such, but they are only one step in the investigation of what the villagers do with this knowledge. To obtain a fine-grained picture of the social contexts relevant to the spread of this disease, survey research must be combined with ethnographic data collection [49,50].

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AIDS education campaign in Thailand Research setting: a oilrage in Isarn Nong Waeng is one of 1861 villages in the province of Khon Kaen, Northeast Thailand. It lies 43 km from the provincial capital and is average in most objective characteristics. Its official population is 865 but actual numbers vary seasonally. The only times the number of residents approaches this official figure is during the several annual festivals that draw family members, who work elsewhere, back to the village. By local standards, it is a middle to large sized village and neither comparatively wealthy nor very poor. Seventy percent of the families own farmland with an average holding of 13 rai (roughly five acres). Khon Kaen province lies in the middle of Isam. The most populous of the four regions and one-third of the land mass of Thailand, Isam is home to more than one-third of Thailand’s 56 million people. With the lowest per capita income and the highest seasonal migration [23] it is well known as the poorest region primarily because of the harshness of the climate and the limited ability of available resources to support the growing population [51]. The local Isam dialect is closer to Laotian than to central Thai and for historical reasons the people think of themselves as more culturally akin to Laotian people. There exists, however, a strong pragmatic nationalist identification that is fostered by a sense of elitism associated with the Central Thai language and mores [24]. All AIDS health messages broadcast via radio and television are in Central Thai. Central Thai is the language used in all the schools. Most of the villagers can understand the general gist of spoken Central Thai but not everyone can speak it fluently or read and write proficiently. As is typical of many areas in the Northeast, the villagers work elsewhere during the dry season when rice harvesting is finished (January-May). From Nong Waeng, many go to plantations in Kanchanburi Province in the Central region to cut sugarcane. Because of soil degradation and the reliance on rainfed agriculture, there is virtually no local employment during this period. Subsistence living has become almost nonexistent and due to increasing reliance on cash economy, some family members of most households must leave to work in the Central region. Most people prefer sugarcane cutting despite the physical rigour of the work because they can borrow money, interest free, some months beforehand from the companies owning the sugar plantations. They then work to repay this debt and accrue whatever extra they can. They can also, should they choose, go together as family units. Young unmarried villagers prefer to go to Bangkok to work, to experience all that is ‘modern’, but this often depends on parental permission. In characteristic fashion, villagers tend to follow the direction of informal networks of work contacts [20] and it is common to find that seasonal labour locales vary from village to village.

Migration is an issue that impacts strongly on public health [52] and, because of its divisive effect on families and the opportunities this provides for multipartner sexual activity, an issue that both influences the reception of AIDS information on the personal level and contributes to the epidemic’s formation at the macro-level. In Nong Waeng, 76% of the men and women answering the questionnaire have worked cutting sugarcane in other provinces, 20% have worked in Bangkok and 6% have worked abroad. Ninety-nine percent of the villagers between the ages of 18 and 50 have left the village to work elsewhere at least once. Families are regularly separated, sometimes for long periods of time.

FINDINGS I.

Local Risk Behaviours

1.1. Needle use

Although illicit narcotic drug injection is not present in the village per se, a local ‘injection doctor’ commonly performs both intravenous and intramuscular injections of medical drugs and vitamins for villagers requiring this service. This ‘doctor’ is usually a villager (or sometimes retired government worker) who has acquired the skill by practice rather than any formal medical training. He (or she) makes a living offering the service to villagers who in many cases find it more convenient than having to go to a medical clinic. In village society injections are a highly valued means of taking pharmaceutical drugs because of their supposed efficacy in curing illness [53]. Although these ‘doctors’ operate illegally they are commonly accepted as an alternative to government medical officials. The link that the villagers make between needle use and risk of HIV/AIDS infection does not generally extend to these practitioners and thus seldom influences the choice of this service. The manner in which these needles are treated after use is relevant. In Nong Waeng and two of its neighbouring villages there are three practising ‘injection doctors’. Two of these asserted that having heard of the dangers of AIDS on television they no longer inject with reusable syringes-villagers, however, maintain they do. The third doctor showed me how he cleaned the needles that he uses. He placed the used needle in a small flat-lidded oblong tin can filled with water, then positioned it on a little pedestal above a piece of cottonwool dipped in alcohol. The cottonwool was lit and burned for some thirty or forty seconds before being extinguished by the weight of the can. The water got hot but did not boil. The ‘doctor’ was sure he had sterilised his needle and it was ready to be used again. Some villagers say these practitioners do not always clean the needles between clients.

CHRIS LYTTLETON

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1.2. Multipartner

sex

In Nong Waeng some men have had sex with CSWs-some men still do. Forty-eight percent of the sexually active men indicated they had visited a CSW. This most commonly occurs when young men visit brothels in either the provincial capital or a large town the same distance from the village, or married men are separated from their families by seasonal work. Some men visit the restaurants in nearby large villages where the waitresses will have sex with customers. The nearest of these restaurants is 10 km away and has 13-16 women who charge US$8. While the 48% of men who have visited CSWs is not insignificant, it falls well short of the overwhelming majority often cited in descriptions of Thai male society. Forty-seven percent claimed never to have had sex outside marriage. In contrast to a recent survey of conscripted army recruits in the North which reported that 73% had had their first sexual experience with a CSW [54], in Nong Waeng only 28% of the men cited the same experience. Fifty percent said their wife was their first sexual partner. A further 22% described a friend as their first lover. Although it is not uncommon in urban settings, very few village men have either opportunity or sufficient funds to support a relationship with a second or minor wife (mia noy): I heard of only one case. The fact that many village men have never visited CSWs cannot be attributed solely to economics (in nearby towns CSWs charge $2-15 years ago this was less than 50 cents) nor lack of opportunity as brothels are readily located. It indicates a deliberate choice based on a moral aversion to such activity. 2. Commercial

Sex in the Context

of Village Life

2.1. Men seeing CSWs As might be expected, local sexual behaviour is complex and those men who visit CSWs cannot readily be categorised by single variables such as age, income, or marital status. Distaste for commercial sex prevents some men from visiting CSWs. This is demonstrated by single men who cannot bring themselves to accompany their friends to the brothels, men who find themselves unable to perform in such a situation and married men who indicate they never have and never would visit a CSW. Men, both young and old, described “a friend” as their first sexual partner and for some this is the option of choice. Young village men sometimes carry love charms which, if of suitable potency, render the unsuspecting victim helpless. While the act of having sex confirms a young man’s manhood, villagers rate the skills of those who can seduce a young woman who does not require payment more highly. But in Isarn, migration is one important factor which prevents social propriety effectively inhibiting liaisons with many partners. Not only do men leave the village, but sometimes women leave to work and husbands stay behind. Some Nong Waeng women

commented that men separated from their wives were likely to seek sexual liaison with a CSW: “it’s a man’s nature.” Villagers hold no overt contempt for the men who visit CSWs, and in some cases, visits are at least outwardly accepted by their wives. While most village women who knew their husbands had visited CSWs expressed pain at this occurrence. Thai women, generally speaking, feel powerless to change men’s behaviour in this regard. Social lore teaches the wife that to be accepting and uncomplaining is the best strategy to effect the return of an errant spouse. And some women. both urban and rural. say they prefer casual liaisons over the threat of their husband finding a second wife. There is, however, a view that extreme philandering does not speak well for the man’s character. A man who is ‘no good’ is one who drinks, smokes, gambles and often visits CSWs. Parents do their best to dissuade their daughters from marrying such a type. In one instance, while discussing a marriage dissolution between a village male and a CSW he had brought home to be his wife, local women blamed the male’s irresponsible character because after all: “what could one expect from a man who visits CSWs?”

2.2. CSWs from

Isarn

Researchers suggest that attitudes towards promiscuity and prostitution are stricter in the Northeast region than in the North [18,27]. While many CSWs come from Northeast villages, it has been well documented that historically an even larger number of CSWs have come from the North [17,27,55-571. Although acknowledged as everpresent. in Isarn prostitution is considered immoral by many [58] and women entering this trade lose, in varying degrees, the respect of the villagers. Nominally, prostitution is disapproved of throughout Thailand, but village sanctions against acknowledging that local women are CSWs appear stronger in the Northeast than in the North where acceptance of this occupation is widespread [42, 561. Nor do Isarn villagers seem as ready to condone the material benefits to be gained by prostitution as Northern Thai people. A brothel owner in Khon Kaen, who employs both Isarn and Northern women, described their differing attitudes towards their work: The Northern women are much more focused and patient, they accrue money steadily that they then take back to their village-the Isarn women seem far more casual in their approach, not as concerned with saving money for the future. They spend the money as they get it.

One man from Nong Waeng has previously worked as a broker in the North, giving money to the parents of teenage girls who became indentured brothel workers, usually in Bangkok or South Thailand. This means of procuring is common in the rural areas of the North and plays effectively on young women’s socialised sense of filial duty [42]. He com-

AIDS education campaign in Thailand

mented this method of procurement was rare in the Northeast. Many villages in the North boast attractive houses built from remittances sent home by young women working as CSWs [27,42], but in Nong Waeng, locals attribute an expensive-looking new house to a family member working as a labourer overseas. When discussing prostitution, villagers cite the North as a possible indicator of the Northeast’s future. The Isarn women I talked with in and around Khon Kaen, who were, or had been, CSWs, had nearly all been married and were separated from their husbands. In contrast many Northern CSWs were unmarried and while reticent on the subject they anticipated returning home to marry at some time in the future. In Nong Waeng, there are six women who work or have worked as CSWs and two have recently left for Japan for this purpose. While there is an obvious pragmatic understanding of the need to earn money one way or another, the women are often demeaned behind their backs, in terms defined by this pursuit: “she sold herself”. There is one exception. One woman, whose (now ex_? husband was an alcoholic went to Japan and made a lot of money. She supported the family, built a house in the village and another in Bangkok where her children now live. Although villagers have not forgotten how she came by her wealth, they regard this woman as successful and cosmopolitan, the more so since she married a Japanese man after learning her husband had taken a minor wife. The idea is growing that a lot of money excuses the means by which it was obtained 1591. A successful CSW is thus worthy of some respect for having done something most villagers are unable to do-achieve material well-being. An unsuccessful CSW is, however, a double failure for having jettisoned her self-respect without gaining extensive material rewards. As with most Isarn villagers who find work in the cities, women become CSWs via networks of friends, relatives or associates. It has been suggested that more women from Isarn than the North work in locales catering to Western men (such as Pattaya and Patpong) because of their social bravado and more strident demeanour [60] but the reasons for this must also lie in the historical development of informal networks; the growth of prostitution in the Northeast was associated with the presence of the U.S. military camps during the Vietnam War [27]. The dream of many Isarn women who become CSWs is to marry a Westerner. How often this occurs is impossible to say but it has become an almost mythic enticement to women to follow this trail. Popular village lore always includes a tale of a local woman-if not from the home village then a neighbouring one-who has married and moved abroad with her husband, regularly sending money home to her family.

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2.3. Why village women become CSWs The number of CSWs in Thailand is usually explained in terms of rural economics and poverty [27,42,61,62] and to some degree by the role Buddhism assigns to women [63]. The high number of CSWs has also been described as a corollary of the social value placed on virginity [64]. It would appear, however, that no single reason can be all encompassing and that predisposing and motivating factors will comprise a range of social and economic elements. Nevertheless, a subjective association of money and sex established in village culture facilitates the presence of remuneration of sexual services. Except for specifically designated occasions such as the annual Songkhran festival (the traditional Thai New Year) where villagers douse each other with water, all physical contact, between unmarried men and women is strictly prohibited. Adolescents in the village learn that physical contact (or subsequent sexual misbehaviour) carries a financial sanction. If a young woman complains of physical confrontation (unwanted hand holding, for example), the offending male must pay her (or her parents) a sum stipulated by the headman of the village. Different parts of the woman’s body warrant, if touched, different sums of money. If an unmarried couple sleep together and the man chooses not to marry the woman, he must pay for what has transpired. There are two conflicting forces here: a young woman sometimes allows the male to have sex with her in the hope it will lead to marriage, and parents have been known to encourage this scenario; on the other hand, refusal of marriage by the male leaves the young woman in a notably compromised position. In one recent instance, a young woman slept with a village man in the hope he would ask for her hand, however, he had no intention of doing so and immediately offered her money before it got to the level of the headman’s jurisdiction. He knew the cost of his actions and in keeping with village lore the woman accepted the money. Another couple in the village, carrying on an adulterous relationship, were eventually confronted by the woman’s husband. The headman insisted the offending male pay the offended husband. They bargained awhile and eventually agreed upon a sum. This system of fines is a common means of addressing social indiscretions, not only for sexual impropriety but also for unproven allegations or innuendo concerning sexual behaviour. The point I want to highlight in these abbreviated examples is that male-initiated sexual transgressions are punished by fines. It seems a short jump from the internalisation of this village sanction to the conception that sex, outside marriage, connotes, in and of itself, a financial transaction. In other words, sexual behaviour becomes conceived of as something with a monetary value. In the realm of physical contact with males, female bodies have a value

CHRIS LYlTLEToN

142

men) this model is quite different from what actually occurs. It is acknowledged that many young villagers team up in Bangkok, living together before returning home to get married. if the parents learn of a couple sleeping together they insist on immediate marriage or, failing acceptance by the male, a fine. Premarital sex is less common in the village but the situation is changing in face of exposure to city mores and notions of the ‘Western’ lifestyle. Villagers report that extramarital affairs are not uncommon.

attached to them, a monetary value of which everyone is aware. Casual sex, if discovered, costs the male, and both man and woman accept this situation. Importantly for the HIV/AIDS campaign, it is an exchange in which, in present-day Thai society, increasing numbers of young women are willing to engage. 2.4. Trends in village sexual behaviour Sexual mores are changing in Thailand and these changes have repercussions both for the HIV/AIDS education campaigns and the commercial sex industry. Contemporary adolescent urban Thai society is becoming more permissive [ 18, 571. A recent study of the sexual behaviour of Khon Kaen University students was deemed such an embarrassment that the only copy at the university is under lock and key in the president’s office. The report paints a vivid picture of student promiscuity [65]. These social changes are having an impact on village society, for example, pornographic movies are nowadays shown in temple compounds and whereas several years ago it was unheard of for young men and women to be alone together, this now happens regularly. Another contemporary trend is for some young women, often technical college students, to sell sexual services at the city disco’s [61] or simply in their dormitories [66]. Young villagers are aware of the expanding commercial sex industry and the sometimes ambiguous context in which it appears. They consider students who sell sex in need of money to finance studies, not CSWs per se. Some young men pursue liaisons this way and several young village women indicated that while in the city they had considered obtaining money this way. Although a woman in Thailand should remain a virgin until marriage and be faithful to her husband after marriage (there is no equivalent stricture for Table

I.

3. Eflects of the Education Campaigns in Nong Waeng

3.1. Source of knowledge

Ninety-two percent of the respondents had heard of AIDS via television catchphrases. The medical profession was cited by 57%; this usually meant having seen a poster or brochure at a clinic or hospital. AIDS information is occasionally given to the village women when they get contraceptives from the local health clinic. Doctors also come once or twice a year to village meetings attended by at least some of the Village Health Volunteers who coordinate health related projects and distribute health information in the village. Thailand now has several thousand of these volunteers in roughly 90% of the villages [67] but only 16% of the villagers cited this network and these volunteers as a source of information. The headman in Thai villages can address the community via an amplifier and loudspeakers mounted on a centrally located tower. This routinely begins just after dawn, both for personal use by the headman and broadcasting of radio news and cassette tapes. Eleven percent of villagers cited this as a source of AIDS information.

Modes of transmission

You can set AIDS bv:

% Who answered

Table 2. Characteristics % Who answered AIDS can lx transmitted via oral sex Someone with AIDS can be treated Natural remedies can cure AIDS Someone who has the AIDS virus must have visible symptoms Someone who looks healthy but has AIDS can infect other people Women who only have sex with their husbands have no chance of acttinp AIDS

yes

96 91 96 19

Unprotected se-x with an infected person Sharing hypodermic needles with an infected person Receiving a transfusion of AIDS infected blood Eating with someone who has AIDS Playing with a child who has AIDS Having protected sex with someone who has AIDS From mosquito bites Visiting the same medical or dental clinic as an AIDS patient Kissinn someone with AIDS

ii 22 31 42 44

of HIV/AIDS Yes

No

Not sure

36 I8 9

31 50 68

33 32 23

38

I2

50

59

I3

27

55

I9

26

AIDS education campaign in Thailand 3.2. Knowledge levels

Tables 1 and 2 document the knowledge levels about HIV/AIDS in Nong Waeng. Eighty-nine percent agreed that condoms can protect one from AIDS during sexual intercourse; 86% agreed than an unborn child can possibly contract AIDS from an infected mother; 84% agreed that to check for AIDS one has a blood test and 82% agreed that someone with AIDS will die. Most villagers readily reproduced the main content of the education/prevention campaigns (which is itself reproduced from Western notions of HIV/AIDS etiology). The questionnaire answers mirror the relative concentration of messages in the mass media campaigns. Thus the primary modes of transmission and method of protection are well-known in the village, but there is uncertainty about perceived vectors of transmission, e.g. mosquito bites and sharing food. Specific characteristics of the disease such as whether symptoms are associated with infection, or whether someone must appear infected before they can infect others, are misunderstood by some. When asked how long symptoms take to appear 29% answered “impossible to tell” and 20% said “less than one year”; 5 1% were not sure how to answer. 3.3. Perception of risk When asked what causes AIDS, the most common answers were: sharing needles (50%), promiscuity (43%), and prostitutes (32%). Twenty-one percent said sex causes AIDS. Only 15 villagers said AIDS is caused by a virus. It was a deliberate choice not to burden the national campaigns with technical descriptions but in their absence associations are established that present people, rather than a transmittable virus, as the cause of AIDS. It has been proposed that changes in behaviour concerning AIDS prevention are related to perception of risk [26,68]. The campaigns actively associate risk with certain behaviours. One campaign sticker, for example, succinctly states that to visit a CSW is to attend your own funeral (Kheun khru khu gap kheun men). Such an association has clearly been established: 96% of the respondents answered that unprotected sex with a CSW was a risk for infection. In the public education messages promiscuity is not defined and little attention is given to the judgements inherent in this terminology. Because of the association of CSWs with promiscuity in the public campaigns, some villagers state that the context defines promiscuity; sleeping with several different village women is not promiscuous unlike a single visit to a csw. Notions of risk are, of course, socially mediated constructs and behaviour change arises from the individual’s presence in this domain of negotiated meaning. The extent to which instilling a sense of risk as the instigator of behaviour change can be con-

143

trolled is an important issue. If perception of risk is going to be used as the vehicle of desired changes, a clear understanding of the socially constructed meaning attached to sexual behaviour is required to ensure prudence rather than paranoia. When risk avoidance is encouraged through fear arousal the danger is that the attitude is attached to people rather than actions. Existing campaigns have fostered the conception that CSWs, in particular brothel prostitutes, are a cause of AIDS. This notion has readily taken hold in Thailand. Well before the arrival of HIV, colloquial Thai termed venereal disease ‘female disease’ (rok phu ying) and even though the meaning directly implies that men suffer the symptoms, the choice of words indicates its perceived source (the CSW) and also attributes, perhaps unconsciously, blame. While it is clear that some women are still becoming CSWs regardless of public prejudice, it is not apparent to me whether the association of CSWs and AIDS is a deterrent to others. But villagers make jokes about the local CSWs having AIDS, and the subject of exaggerated stories concerning people in the district who are said to have AIDS is always a woman who has worked as a CSW. 3.4 Changes in sexual behaviour Some village men no longer visit CSWs and the campaign has certainly influenced the small percentage of men who were susceptible to media persuasion or unenthusiastic about such activities to begin with. The ambivalence of certain men towards commercial sex has a further justification-fear of AIDS--and they now profess to have lost all inclination for this pursuit. Other men, especially the younger men, who have in the past visited CSWs, admit that while less frequently, visiting CSWs is still a regular activity. They say that they will take their chances with this disease--for some, HIV provides another opportunity to test their invulnerability; to display a badge of courage to their friends. There is a trend, among those who can afford it, to avoid the cheaper prostitutes as these are perceived as more likely carriers of HIV. Instead, some men patronise massage parlours, others visit available technical college students. These students-or in village parlance, ‘good girls’-who sell sex outside the institutional&d venues are perceived as a safe alternative to brothel CSWs and the men eschew condom use. They are, however, expensive (usually %I2 or more) and require. a certain sophistication from the village male. Increasing permissiveness in village society has also provided some opportunity for young men to have sex with village women rather than CSWs. 3.4. Use of condoms The men are unanimous that they do not like to wear condoms: “it is not natural,” “it has no

144

CHRIS LYTTLETON

flavour.” At this stage of the campaigns there has been little attempt to eroticise the use of condoms, and in local perceptions they are unpleasant safety devices. Sometimes the men have no choice in their use. At the nearby restaurant, the CSWs are adamant the men must wear them, although biweekly checkups at the local STD clinic suggest this stricture is not rigorously enforced. Later, the CSWs at this restaurant admitted that they did not insist on condoms on every occasion. The reasons are many: the clients are very often local government officials who pull rank; young men claim to be virgins and want the first experience to be ‘natural’; women regarding the man as ‘respectable’ or a regular client. Some CSWs will ailow the man to remove the condom so he will reach climax more quickly; some men will deliberately rip the top of the condom so that during intercourse it moves to the base of the penis. A local village teacher said he never uses a condom at this restaurant: from his point of view he does not worry about the CSWs having AIDS because: “they are subject to such health controls these days they couldn’t possibly be infected.” STD rates in Isarn are showing marked declines in the past 2 years [69l_a sign of increased condom use and some brothels in Khon Kaen are now known as ‘condom-only brothels’ [70]. Some men, however, constantly attempt to avoid using condoms and brothel CSWs sometimes acquiesce for fear of lost income. The CSWs say that the married men are more inclined to use condoms without complaint. Such compliance does not transfer to domestic scene’s-only 39% of the village men indicated they would use a condom if requested by their mate.

4. The Need for Loca&

Targeted Campaigns

At the nearby district hospital, doctors say the ‘AIDS problem’ has not yet reached the rural sector. Despite intellectually accepting that AIDS poses a threat to everyone, the perception of this disease remains abstract. for villagers and local medics alike. There is virtually no physical evidence in the rural sector in Northeast Thailand that AIDS is a devastating pandemic. Any message in the Central Thai dialect arriving via a new technology, television, is registered by people in Isam as belonging to a different worldboth physically and socio-culturally. Increased exposure to these messages simply reinforces the perception that they are not locally pertinent. Most villagers state they are afraid of the disease because it has no cure; but all add that they have never seen it. Men who visit CSWs feel it is not a local problem but something belonging to city lifestyles. The abstract knowledge is present, but the concepts are not associated with personal behaviour in any immediate way. One villager told me that the AIDS dangers were passing them by: “were the disease as serious as they say, people everywhere would be dying.”

The difficulty in personalising HIV/AIDS information is compounded by the practice of drinking before visiting CSWs. In conditions of inebriation, messages learned from television are too abstract to modify behaviours largely concerned with visceral satisfaction. For knowledge of AIDS to be an effective motivation for safe behaviour, it must be common knowledge, socially shared to such a degree that the local community itself participates in bringing a sense of appropriate behaviour to its members. When knowledge becomes shared meanings, the information is contextualised in local-specific conceptual networks with direct links to daily practices. Knowledge does not remain abstract, but rather, is actively generated by regular interaction with the people who form part of one’s immediate social world. Individual’s subjective assessment of risk is effected by locally generated meaning, not by the induction of knowledge from afar. National mass media campaigns can disseminate information and raise knowledge levels, but only the active participation of target groups translates this to behaviour change [71,72]. Two factors favour this type of HIV/AIDS campaign in Thailand: first, there is an extensive official Public Health system that includes volunteers in virtually every village and second, the presence of local people who are respected in their communities. Linking these two could establish continuity between official and local networks which would assist the successful communication of health information. In Isarn, more than other parts of Thailand. the village social structure lends itself to such directed focus [73]. Village networks could be utilised to incorporate campaign information into local discourse, encouraging behaviour change (to assess risk and choose the side of caution) and fostering a social environment which will accept those who are HIV positive or who develop AIDS so that denial and stigma do not remain the most inveterate aspects of this disease. CONCLUSION

In rural Isarn, two major factors establish the context for AIDS information to be translated into local conceptions of risk: the manner in which the information arrives and the existing attitudes to sexual behaviour and commercial sex. With regard to the first, the knowledge of AIDS that the villagers have received is largely media description that unintentionally distances them from its reality. Thus, to take one illustration, they do not consider injections by village ‘doctors’ to be a risk. There are two important contradictory issues concerning attitudes to sexual behaviour: (a) a sense of propriety, shared by women villagers and some but not all men, that fosters an aversion to commercial sex and (b) the fact that this sense of moral probity

145

AIDS education campaign in Thailand is under attack by both a gradual growing tolerance

of prostitution as a source of income and an increasing sexual permissiveness. The education campaigns are abetted by the first attitude and hindered by the second. Nevertheless, only 33% of the villagers regarded extramarital sex as a normal facet of present day society. One village man described AIDS as the ‘love your wife’ disease (rok rak mia). Sensitive adaptation of campaigns could utilise social ambivalence to commercial sex to increase their effectiveness. They must, however, confront a society where young people are experiencing more sexual freedom and there are increasing opportunities to receive money for sex. These currents run directly counter to the caution advised by HIV/AIDS education campaigning. In Nong Waeng, the national campaigns have increased knowledge levels and effected some behaviour change. Some men say that these days they would always use condoms with a CSW. One man no longer uses discarded hypodermic needles to fish molluscs from their shells. More importantly, only 11% of the villagers feel it is someone’s karma to contract this disease-the resounding notion is that it can be avoided. What is now required is that local people nurture local conceptions to make knowledge of HIV/AIDS personally relevant. Acknowledgements-I am indebted to the villagers of Nong Waeng for making me welcome. I am grateful to members of the Department of Community Development, Kohn Kaen University for facilitating this research. I would also like to thank Wimon Wateenun for her assistance in leaming about village life and Peter Hinton, Paul Alexander and Sylvia DeAngehs for their advice in the preparation of this paper. Funding for the fieldwork was provided by the Carlyle Greenwell Research Fund, Sydney University and the Australian Postgraduate Award.

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