Rice Paddies and Water Buffaloes

So I’ve finally seen Thailand. Not the five story malls of downtown Bangkok that rival anything in the US, including Rodeo Drive. Not the Starbucks, McDonalds’ and KFC that now compete with the night markets for young Thai’s business. Traveling about six hours south to the small city of Chumphon , I saw my first rice paddies, water buffalo and rubber plantations – the Thailand of the picture books of my youth. The landscape is dramatically more jungle-like, filled with big palms, banana trees, and houses set up on stilts. In the south, the spirit houses seem to come in pairs – one bigger and set taller, another smaller and set lower to the ground – almost like mother/daughter bungalows – often painted in matching colors, and with elaborate offerings. They are, I am told, supposed to appease two different groups of ghosts – those of the heavens, and those of the earth.

Chumphon is by the sea. We were there to facilitate a leadership training for members of the local PLWHA group. Our first night, group members took us to visit the central shrine of the city – a shrine honoring naval heroes who protected the city over its history. From the shrine, one looks out on the sea and to the islands off the coast. These are the islands where locals climb the cliffs in the dark to collect swiftlets’ bird’s nests – a great delicacy in Asia. Not yet developed as a tourist area, the Chumphon beaches are sleepy and quiet. We had dinner outdoors by the beach. While people ate and sang Thai movement songs to Ott’s guitar playing, we watched the squid fishermen’s boats line the shores off the surrounding islands. Dogs slept in the street. Stray cats visited, looking for leftovers from dinner. Under the stars, with voices raised in song and the wind coming off the beach, we seemed a long way from Bangkok. Yet the idyllic nature of the setting masked the common struggles that group members in Chumphon share with thousands around the country. While they are infinitely better off than many PLWHA around the world, many had talked that day of facing stigma and discrimination, and of being less able than their peers in the city to get access to second tier ARV drugs if first tier regimens don’t work for them. This, too, is the Thailand of picture postcards – and even here – KFC, like HIV, is coming to every corner.

No One Walks in Bangkok

A New Yorker at my core, I’m used to walking all the time. It is the way to live in a city, the way to see and experience it. Bangkok challenges this basic premise of city life. On its face, Bangkok should be a great place to walk – it’s got terrific and interesting neighborhoods, wonderful back lanes to explore, and a 24/7 lifestyle. But no one walks in Bangkok (at least not any serious distances). It’s too hot. It’s too polluted. There are too many cars and motorcycles everywhere. Even many of the back lanes have narrow, if any, sidewalks. And if this weren’t enough of a deterrent, the slip on sandals one is inclined to wear in an environment where you’re regularly taking your shoes on and off to enter homes and offices aren’t the greatest for striking out on a stroll.

I’ve been determined to walk anyway. Early in my stay here, not able to find an available taxi near my office during the evening rush hour, I decided to walk instead. I’d traveled the route enough times to know that it was definitely a reasonable walking distance. Despite the crowds around the evening markets and movie theaters, it took me about forty minutes. True, it wasn’t totally a pleasant experience. But it felt good to be out on the streets, even if the exhaust and street smells weren’t the nicest. And I’ve discovered – now that I’ve walked the route at least a half a dozen times – that each time, I see a little more. Stopping along the way, I’ve begun to be able to make out which vendors sell what types of food (each has its own specialties, which can be discerned by the array of raw ingredients in the carts.) I’ve got a good idea which are the most popular by the consistent lines waiting to place orders. I’ve learned to tell the uniforms from the different schools apart by the pins and logos on the shirts and blouses that students wear. I’ve gotten immense pleasure anticipating the kinds of offerings I might see at the spirit houses in front of the IMAX theater, where young moviegoers often leave Slurpees purchased at the nearby 7-11 or cans of orange soda to appease the ghosts. And, if truth be told, I’ve enjoyed the incredulous reactions of the TTAG staff, who now regularly ask, “Did you walk home again last night?” when I answer, matter of factly, “Of course I did.”

More Than Just a Project

It’s close to midnight, and I’m sitting on the floor of Ott and Karyn’s home with some of the leadership of the Thai Drug User’s Network. There are papers strewn everywhere, and two or three laptops open and running. We’re talking about a document I’ve been working on to help TDN think through a restructuring of the roles and responsibilities of their Board and staff. We’re drawing organizational charts, with circles and arrows, translating as we go, talking about ways to consolidate roles and improve communication. They’re preparing Power Point slides to share with fellow network members later in the week at their Board meeting. They are almost embarrassingly thankful for the time I’ve spent helping them. I, however, am profoundly moved by the scene of which I’m a part. Taking a step back, knowing the discrimination that IV drugs users face in Thailand (as well as so many other places), I find myself wishing I could take a picture of them stooped over their laptops in the middle of the night, poring over documents not even written in Thai and publish it somewhere – a striking portrait with the power to undercut deep stereotypes.

Working with the Network over the last week, I don’t want to paint a romantic picture of the members. They are people who have lived difficult lives. Some have been in prison. Some are in recovery. Others use. Many are HIV+. Watching their interactions, I’ve remarked that it sometimes feels like the culture of the therapeutic community (of which many have been a part during their lives) and Thai values of saving face clash in difficult and complicated ways as members work together. Yet, I’ve never worked with a more dedicated group of individuals with deep commitment to their cause. While they welcome the resources and visibility that have come from their recent Global Fund grant, their dedication clearly has nothing to do with the project. The importance of their work – and getting it right – is not theoretical to them. It is their lives – and the lives of their friends and family that are at stake.

Tee-Shirt Mavens

Ott’s got an original Act-Up tee-shirt, given to him by one of the founders. Goi wears GMHC tee-shirts when she washes the floors of the office. And on Friday, Seree was wearing a tee-shirt take-off on Addidas, which has the company’s logo with the word “Addicted” underneath. (Karyn told me she and Ott brought them back from New York the last time they were there.) Then there are the dozens of tee-shirts that were produced around the time of the Bangkok International HIV/AIDS Conference in 2004 – demanding an end to medical apartheid, and equal access to ARV therapy for developing countries. And the harm reduction tee-shirts, with messages about safe injecting, and not sharing needles. And the tee-shirts about prisoner’s rights, and safer sex. One of my favorites is TNP+’s (The Thai Network of People Living with HIV/AIDS) – it’s bright red, with a line drawing on the front that says (in English) Positive Friends, Positive Life. I asked Kamon, one of the members of TNP+ why the message was in English. Ott replied, matter of factly, “because people think English is cool….” Indeed, observing the dozens of tee-shirts worn by the folks I’ve been around confirms the preponderance of English slogans. While some of the tee-shirts are, in fact, from the States, many others are made here – and often have English messages on the front, and Thai messages on the back. But no matter what the language, the advocates here in Thailand are real tee-shirt mavens, with an international flair for getting the message out.

When Words Fail You

I’ve spent a lot of time in the last few weeks sitting in meetings conducted in Thai. In most circumstances, I’ve not asked people to translate for me, relying instead on an occasional sentence repeated in English, or a summary I’ve received during meeting breaks. I’ve taken this approach to avoid disrupting the flow of work, and having my presence become a burden. Of course, meetings in which I’m directly involved require more translation. But participating in meetings where you don’t speak the language provides an interesting position from which to understand organizational culture. I’ve become very attuned to body language, and to the flow and rhythm of conversation – who talks to whom, whether staff are engaged in parallel discussions with leadership, or whether they’re talking amongst each other. I’m also gaining a better understanding of the rhythm of language here, and of patterns of conversation. Meetings are much longer than in New York. And even without understanding exactly what’s being said, it’s easy to understand why. People speak much more slowly (I’ve observed that folks raised in the North speak even more slowly than those raised in Bangkok, a fact confirmed to me by some of the staff who aren’t native to Bangkok.) By comparison, New Yorkers speak a mile a minute. Even Karyn, who speaks as fast as most New Yorkers, slows down considerably when she speaks Thai – not because she’s searching for words – she is amazingly fluent – but because the language is more gracious, and seems to demand greater care when speaking.

People also seem to pause more between speakers. You could probably count to three from the moment one person stops speaking, and the next one begins. By New York standards, this sometimes seems an eternity. But I’ve also found it quite respectful – the space a recognition that people are listening and trying to absorb what’s being said by others. I’m actually surprised at how much I do understand – partially because the concepts are familiar, and partially, I think because, when words fail you, it becomes incredibly clear how much of what we communicate doesn’t require words at all.

The Language of Advocacy

Listening to the advocates here in Thailand, I have been struck that they speak a different language than the advocates in the States. It is the language of human rights, of human dignity. Wassawut Yimchaem (Wut as he is called here), speaking at the Chiang Mai meeting, described his recovery process in the universal language of human dignity. “I learned to be in relationships; this is very important for any human being,” he said. “We are human beings; we have the same needs as anyone. We need love, friends, family. And like everyone, we have some things to work on. Some things bring us happiness, and some bring us pain. We have the right to live like anyone else. This is why we formed the Network.” Ott, like Wut, speaks the language of human rights – these are the fundamental values that drive TTAG and TDN. Their message is simple and compelling.

At dinner after Wut’s talk, I shared my observation that US advocates did not often frame their message using human rights language. “Of course not,” shared an Australian public health professional, now working in Cambodia. “The US still won’t sign the International Declaration of Human Rights!” It’s not a language that resonates in American politics. The consensus was that the US dialogue is more about right and wrong – bringing a relative morality to the argument. We should care about the poor because it’s the right thing to do; it will make us somehow a better person, a better society. The language of equity seemed closer, yet also distinctive from the human rights message. Yet, the advocates with whom I talked all agreed – no matter what the language, there was still plenty of work to go around, wherever we lived!

The Burden of Success

This past week I had the opportunity to join Karyn and Wut (a member of the Thai Drug User’s Network – TDN, for short) for two workshops they were presenting to a week long training course conducted by the Asian Harm Reduction Network in Chiang Mai. The sessions included health care and NGO representatives from Thailand, Cambodia, Vietnam, Myanmar, China, Taiwan, Indonesia and Pakistan. They had come together to learn more about issues of health and social care for people using IV and other drugs. Many worked on issues related to access to ARV and comprehensive health care for PLWHA who were current or former IV drug users. After listening to doctors and policy makers for the first part of the week, Karyn and Wut were there to bring the perspective from the ground – Karyn to provide background and history regarding the formation of the Thai Drug User’s Network, and Wut to share his story as an IV drug user, and as a founding member of TDN. As many people remarked after the sessions, they were the first presenters who really brought a clear vision of the challenges of actually doing this work. After all, what good was it knowing about the fifteen different drugs now available for HIV if only a quarter of them were actually accessible to most PLWHA in Thailand? What difference did it make if methadone clinics were set up if the protocols didn’t reflect the lessons that those who had tried methadone had experienced in earlier programs?

That Karen and Wut’s presence at the meeting was important was undeniable. It was critical that their perspective be heard. Yet, like many successful community advocates in the United States, TDN and TTAG are overwhelmed with requests to “tell their story”, so that health care professionals and policy makers can understand “what it’s really like” as they make decisions regarding the community’s future. One of the reasons that Ott founded TTAG was to grow the field of community advocates so that there would be hundreds of people around Thailand able to bring their voices to national and international policy and practice. Yet, there are still not enough. And advocates who are particularly persuasive, and who can speak with passion and clarity, are particularly in demand. In the two weeks since I’ve been in Thailand, Ott and Karyn have received more than half a dozen requests to speak or present. The requests come in from all over the world – the US, France, the Netherlands, Canada, India. They also field daily calls from people visiting Thailand who have heard about their work, and would like to have dinner and talk about what they’ve learned.

Ott and Karyn’s appeal, no doubt, is not only the unique skills each brings to their advocacy efforts, but also the ability they have together to bridge the cultural divide – each of them able to speak both from their hearts, as well as in the language of international program and policy. It is a hard decision each time they are asked to speak. Is there anyone else? How often can they be away without their own work suffering? How much visibility will come of this request? How important is it for achieving their goals? It is their dream that soon there will be many others throughout the world who can speak, so that their phone and e-mails won’t be packed with requests to be – once again – the ones who must tell the story one more time.

Bangkok Commerce

You can spot the hotel and tourist trade employees everywhere. They are the ones on the Skytrain wearing “traditional” Thai silk jackets and long silk skirts or slacks among the sea of denim and Mickey Mouse tee shirts. Perhaps they are even white gloved – an affectation that evokes images of British colonialism for me (yet in a country that was not colonized?). Their job is to create an “authentic” experience of Thailand for those coming to visit. They work in hotels like the Oriental, where I stopped for a late afternoon drink to get out of the heat while sightseeing over the weekend. It is a beautiful hotel, with river views and sprawling verandas. I was very glad to be there. Yet, apart from the views of the temples and the river ferries passing by, I could have been in the Grand Wailea in Maui or the Condado Beach in San Juan. The ambience was serene, hotel workers everywhere attending to those at the pool or on the decks. It could not have felt further from the teeming streets of Chinatown from which I had just come. There, everything and everyone was moving. Hawkers, street vendors, and thousands of people crowded the streets. Everyone was trying to sell you something – enough dried mushrooms to last a year (very good bargain!!), loose tea guaranteed to bring long life and vitality (a sample could be arranged….), balloons in packs of a thousand, garage tools, pots and pans, and any of thousands of options for lunch or a snack.

Indeed, as I travel to different neighborhoods around the city, it is the unrelenting and ceaseless commerce that amazes me. There is not anything that cannot be sold from a piece of sidewalk or a cart – from knock off designer watches to gems and Buddhist amulets. Walk the streets of Sumhamvit, and tailors summon you in every door, calling “Madam, madam” after you as you walk down the street, “can make you something very nice, twenty-four hours, no problem…”. Stop for a second to look at a pillow cover or embroidered cloth at one of the thousands of booths that line the streets, and the calculators are already in hand, ready to offer you a better deal than the vendor in front or behind them. Even the temples have their own kind of commerce, as people approach you, introduce themselves as students, and offer to assist you in finding your way through the gate of the wat at which you’ve already arrived.

I find myself searching my memory for a comparable American experience and wonder – the Lower East Side at its height? Jackson Heights on a Sunday afternoon perhaps? My hosts confirm that many of the street vendors are farmers displaced from the countryside – an immigration of sorts fueled by a changing economy and need to make a living. In that sense, it is, in some ways, Thailand’s version of my own grandparent’s migration, and the urgent tenacity to make it in a new world.

The Changing Faces of My Neighborhood

I've traveled the streets of my neighborhood -- a district that is part of greater Bangkok -- at many hours of the day and night now. It is never the same. Street vendors appear and disappear -- their wares sold only at dawn, or in the late evening hours. Whole discount markets emerge from almost no-where as evening falls, only to be gone the next morning as I taxi by to work. Even sidewalk restaurants are temporary -- there for lunch, gone for dinner. The facility with which businesses come and go seems almost a metaphor for the Buddhist foundations of the culture -- nothing is permanent, everything is emptiness. I'm delighted to find new things each day, but sometimes mourn the vendor whose morning dim sum is nowhere to be found if my timing is off. The locals understand the patterns well. The stalls of the indoor food market are crowded in the AM when the stands are filled, empty in the evenings when things are closing down.

Poor and rich seem to live side by side in this part of Bangkok -- my apartment building, filled with middle class Thais and some foreigners (many of whom seem like they might be missionaries) has a garage filled with new cars, and people coming and going with briefcases and laptops. Next door is a tin shack shanty town filled with the families of workers who are building a large new house on the lot next door. Their lives are lived publically -- food cooked outside, and televisions hooked up to outside lines and shared. There is a University not far away, and the Internet shops are packed with teenagers playing video games day and night. And though I've not ventured there yet, one of the biggest cinemas showing Western and Imax films is further up the street, with a shopping center filled with Western fast food restaurants. All of this lives peacefully side by side.

I'm far from the center of the tourist sections of Bangkok as well as the older parts of the city. I've not found a wat (temple) in my wanderings yet, or a place to get a good massage (though I've ventured downtown to other districts to have my first experience of Thai massage). I've been surprised at how few monks I've seen on the streets. I suspect it's a bit like living in Queens in NY (as I do) -- life as many New Yorkers live it, but not necessarily what people think of when they imagine Bangkok. But it's home for the next couple of months, and I'm learning more about its changing faces every day.

TTAG: The Work

It's been less than a week since I began my work with TTAG. I've spent much of the last few days immersing myself in the organization's background -- reading funding proposals, talking with Karyn and Ott (the co-founders) about organizational challenges, observing a recently formed Community Advisory Group at HIV-NAT at the Thai Red Cross, whose purpose is to provide a voice for community representatives and advocates in the decision-making regarding clinical trials and other research taking place in Thailand. While there are subtle cultural differences in the way that work takes place, I'm more impressed by how universal the challenges are of making a place for the community at the decision-making tables. The advocates here are seasoned, savvy, and well connected internationally, so even the alphabet soup of acronyms of partner organizations are familiar -- GMHC, Doctors without Borders, USAID, CDC, WHO, etc. There seems more at stake when you're talking about clinical trials being conducted in your country by US pharmaceutical companies without guarantees that the Thai government will have the right to produce the drugs for their own markets. Yet much of the dialogue and context in which TTAG operates is not dramatically different from that of US advocates operating within the context of the Bush Administration.

TTAG is, itself, an interesting marriage of East and West -- Karyn, a bilingual international human rights advocate from New York working side by side with Ott, an HIV positive, former IV drug user, and community activist. They've used an incredibly effective strategy of building international networks to move both the local policy agenda, as well as bring the voice of PLWHA to the international policy conversations. The international nature of their work means that they work literally day and night -- on the phone with the US, Australia, Canada and Europe in the early morning and late at night, in meetings and doing their work here in Thailand the rest of the time. Their powerful alliance has brought them much acclaim and attention; critical for giving their work visibility but also becoming a challenge to manage. Requests for visits, articles and speeches come in every day, while the work on the ground here in Thailand still requires their political acumen to move forward. The small staff needs much support, and Ott and Karyn need help figuring out how to create an organization that doesn't demand so much of them. It is, for this, Ott says, that I am here, to find the miracle that will allow him to attend to the international work and not worry that things aren't going well in their local peer leadership and community building efforts. To find a way that the work at which he and Karyn have been so successful will not compromise their health. We've joked that my MOU with TTAG didn't promise miracles. So now begin the hard conversations to see what can be done, little by little, to build an organization that is not so dependent on its founders, and whose work can flourish and be sustained.