In 1989, at the age of 11, my husband left his hometown of Ermita in Manila for a new life in rural Kansas. His is a story that has remained dependent on the memories of extended family members until just a week ago when we boarded a flight to the Philippines to meet my husband’s biological father, whose existence had largely been a mystery and who had located my husband on- of all places- Facebook. The timing was rather felicitous; soon after moving to Singapore we had seriously discussed making the trip to Manila to retrace the steps of a past left behind, if only to begin to fill in the cavities of lost information. Since my husband first left Ermita much about the district has remained unchanged, he tells me after an initial observation, although the traffic jams are far more severe, the squatters have relocated, and Rizal Park is now tourism-friendly. And, while much of our week centered around memory and reunion, that story is not mine, nor is it the predominant narrative we returned with. Before sitting down to compile this post, I asked my husband what impression he now had of the country he was born in. “I realize just how fortunate I am to have left when I did,” he said. “But I’m also really hopeful for Manila, too.”

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Commentary Development, Hope, Manila, Philippines

“Sometimes,” said Pooh, “the smallest things take up the most room in your heart.” When A.A. Milne penned that famous quote, the island country of Singapore- a little red dot on a big blue map, roughly one-fifth the size of Rhode Island- was still in its infancy and decades away from full independence. But, for such a compact nation with a relatively short history, the affection that both locals and expats hold for the Lion City is immense, as is its charm. My husband and I relocated to Singapore from New York about three and half months ago without any real expectations- we were ready for a new challenge in an innovative urban environment and that was about it. I’d never considered the possibility that I could actually enjoy being in a new country as much as I’d enjoyed being in China and yet I now find myself wondering if I’m just addicted to East Asia as a whole. The heart is a fickle and funny thing, but I am thus far enamoured with Singapore and I don’t think my sentiment will change anytime soon. After all, it hasn’t for the land that my feet first danced upon in the Eastern hemisphere- China.

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Commentary china, Entertainment, housing, setting up a business, Singapore, women

In response to Blog Action Day 2010, I am writing- along with thousands of others- to bring attention to this year’s issue, “water.” Ever one to break the rules, I’d like to take this time to make ripples on dry land instead. Sure, according to the UN and change.org, more people die each year from contaminated water than all forms of violence and war combined. Yes, even in this day and age, almost a billion people worldwide don’t have access to clean water. And, as I addressed in my last post, many of our oceans and rivers now serve as garbage dumps; death and disease from contaminated oceans cost our global economy $12.8 billion a year. Unsafe water is a very real challenge with devastating consequences, requiring extensive investment in our infrastructure and ecosystems if we ever wish to turn this problem around. But, how do we tackle an issue like water which, in its deep and boundless nature, tends to swallow our minds whole?

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Commentary base of the pyramid, blog action day 2010, BoP, jack sim, poop, toilets, world toilet organization

I recently returned from a short trip to Phuket, Thailand, where I spent some time in a “sea gypsy” village off the beaten path. Otherwise known as chao leh, the term “sea gypsies” refers to several small nomadic Southeast Asian indigenous groups who depend on the sea for their survival through fishing and the gathering of mollusks. Sea gypsies first made headlines following the 2004 Indian Ocean tsunami, which devastated coastal towns in Indonesia and Thailand, yet left those who were able to read the rhythms of waves and cicada chirps relatively unscathed (for more on how the sea gypsies survived, check out this video from 60 Minutes).

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Commentary chao leh, garbage, Koh Siray, sanitation, sea gypsies, thailand, waste management

I was recently invited to present a portion of my research on gender in HIV surveillance and prevention in China at the 10th International Women in Asia Conference in Canberra, Australia. Unfortunately, travel to participate in the event is cost prohibitive for me at this time, so I’ve decided to instead share a partial summary of my research and findings on the blog.

My research centered around 3 related questions that I wanted to explore:

• Are gender stereotypes compromising HIV prevention, education and surveillance in China and more specifically, are men exempted from treatment, policy and analysis?
• Have subsequent recommendations that call for empowering women to protect themselves from HIV/AIDS overshadowed the significance of the heterosexual male population in China while negating the man’s responsibility to initiate safe sex?
• These two questions were framed around the finding that despite indicators which show that men are now a significant driver in the spread of HIV/AIDS, women continue to be the focus in dialogue and prevention of HIV. In the case of China, I wanted to know “why?”

Over the past five years, China’s been contending with a rapidly spreading HIV/AIDS epidemic, which initially impacted typically “high-risk” groups (IV drug users, sex workers, men who have sex with men, and blood donors). Today, the virus has spread into China’s general population and heterosexual sex is now cited to be the main cause of transmission. Global HIV prevention efforts targeting heterosexuals have concentrated on women as the gender for stemming the disease.

There are a few reasons for this:

• Biologically, HIV infection through unprotected sex is two to eight times higher for a woman than it is for a man and forced sex exacerbates this difference.
• HIV can be easily passed from mother to child during pregnancy or through breastfeeding.
• STD prevention initiatives are often combined with prenatal care and reduction of unwanted pregnancies- which is traditionally seen as a woman’s responsibility.
• And, there is a long-held belief that sex cannot be initiated without a woman’s consent, placing women in control of negotiating intercourse.Therefore, it may be assumed that women hold the most power in preventing the spread of HIV/AIDs and should remain the primary focus in surveillance, prevention and education.
  However, men are driving the spread of the HIV/AIDS virus as well. In the context of China, examining the question of gender in HIV surveillance and prevention is particularly important. First, China is contending with 23 to 40 million males of marriageable age who cannot find wives, known as “bare branches” or guang gun. As this demographic continues to grow, fueling the supply of young transient migrant workers, the demand for sexual commerce also increases. Migrants who then acquire infection of HIV through the purchase of sex may carry the disease across borders and infect their spouses when they return home.
  Second, based on my review of literature and surveys, men who have sex with men (MSM) in China play a significant role in heterosexual HIV transmission risk. These men are labeled MSM in surveillance, but if you take a closer look at the data, you will see that many of them are married or have girlfriends and also purchase sex from both men and women. Because of the stigma on homosexuality in China, these men lead double lives.

  In the process of conducting a review of literature and a comprehensive analysis of 38 surveys on HIV knowledge, prevention and risk in mainland China published since 2006, I identified several factors in the surveillance process which may play into why actors continue to address HIV prevention as a woman’s responsibility beyond those originally stated and why men must play a larger role. Regarding my analysis of surveys, I focused on who the primary informant group was, if there was any secondary informant group, and I looked at survey design, method, findings and potential gender bias considerations.

  Some of my discoveries and conclusions are as follows:

• The high-risk behavior of men in China is pushing the HIV virus into the general low risk population. However, there is a lack of information on HIV perceptions, knowledge and risk behaviors among this demographic as members of the general population. (This conclusion has also been made by many others: check out Gender Policy and HIV in China: Catalyzing Policy Change)
• Men who solicit sex workers and men who engage in sex with both men and women are major- and largely overlooked- drivers.
• Bridge populations- those who engage in unprotected sex with both high risk and low risk groups compromise a meaningful proportion of survey respondents. However, bridge populations are not directly assessed in surveillance in China. Many male respondents who report to be married or in committed relationships also engage in sex with other men and/or purchase sex from women and/or men.
• Surveys targeting the “general” or low risk population do not typically ask questions about potentially high risk behaviors and surveys incorporating both male and female respondents do not typically analyze responses by sex and age.
• Terms like MSM (“men who have sex with men”) and FSW (“female sex worker”), popularized primarily by Western actors, do not entirely capture the populations they are targeting in China. Employing these terms in literature may limit understanding and create misconceptions. There was a great quote I found during my review of literature, “the term MSM masks more than it reveals.” In the case of China, I think it is particularly true.
• Among surveillance teams, it is considered easier to access female sex workers in China then it is to access men who have sex with men or who purchase sex from women.
  And, China’s 100% CUP initiative (“Condom Use Program”) primarily targets FSWs, not men generally.
• Regarding spouses of men who purchase sex and men who are in MSM relationships, epidemiologists and social scientists have begun to investigate populations of wives at risk and call for increased awareness and enforcement of condom use, especially among those wives with husbands who work remotely for long periods of time. But there is inherent ineffectiveness to some degree, particularly when perceived contraction risk is low while risk of violence, economic instability, and marital disruption is high. Studies from other regions of the world show strong evidence that condoms are unwelcome in the marriage bed by the husband.
• Looking just at survey data, the majority of surveys specifically target FSW and MSMs. There was only ONE survey that I found on behaviors of the general male population and it was the least comprehensive by far.
• If statistics derived from high risk groups during surveillance show that up to one-third of MSMs socially identify themselves as married heterosexuals and up to 30 percent of men in China purchase sex, then it may be assumed that a proportion of the general population can also be considered at increased risk for HIV contraction.

So, I uncovered these potential gaps in surveillance and concluded that there is significant space for the inclusion of the general male population in China in HIV surveillance and prevention. I therefore designed two new surveys to a) capture more insights on HIV/AIDS risk, knowledge and behaviors of the general population and b) find out a little bit more about attitudes on HIV prevention methods by workers in China engaged in stemming the spread of HIV- doctors, nurses, epidemiologists, and social workers- while maintaining a level of cultural sensitivity on questions regarding the purchase of sex, condom use and MSM behaviors.

As I stated in the beginning, I do hope to continue with this project in some manner, either by conducting these surveys with a team or lending my insights and interest to an organization that may find my help useful. If you have any ideas, I would love to assist an organization working on this issue in any capacity that I can!

Thanks for reading, and if you have any comments, questions or if you’re a member of an organization working on HIV in China that could maybe use an extra pair of hands or another voice or perspective, I’d like to hear from you.

Commentary china, gender, HIV, MSM, research