Ho Chi Minh Gets with the Program
How an SPH researcher helped shape AIDS law in Vietnam
The turning point, Lisa Messersmith recalls, took place on a cold, windy street outside a two-story government building in Hà Giang town, capital of Hà Giang Province in northern Vietnam.
It was 2002, heroin was flowing across the border with China, and the number of HIV/AIDS cases across the country had quadrupled in the past four years. In Hà Giang Province, more than half of the intravenous drug users were infected with HIV, the virus that causes AIDS. Medical anthropologist Messersmith and her colleagues had been sitting at a heavy wooden conference table in an unheated room inside the People’s Committee Building, trying to explain the benefits of a clean needle and syringe program.
Messersmith thought she sensed in the weary provincial party chief a willingness, perhaps born of desperation, to try such a program. She was less optimistic about the stone-faced security officials, who believed the best way to stem the flow of narcotics was to lock up users. Did they question her motives? Did they suspect a hidden agenda?
“I’m sitting across from the chief of police and deputy chief of police, who sat there quiet the entire time, didn’t say a word, and I thought, ‘Oh, boy,’” recalls Messersmith, a School of Public Health associate professor of international health and a faculty member of the BU Center for Global Health & Development (CGHD). “Finally, the party chief said, ‘We’ll think about it.’”
In 2002, the Vietnamese government counted 15,000 HIV and AIDS cases, far below the real number.
Then, as Messersmith left the building and was walking to her car to begin the bone-jarring eight-hour drive back to Hanoi, something unexpected happened. She heard the chief of police call after her, “Dr. Lisa, I just have one question: when can we start?”
That, she says, was the moment when everything changed. It would lead to new health programs and policies in Vietnam, and within five years, to a national AIDS law raising the profile of human rights in the communist country. Ultimately, according to one prominent Vietnamese sociologist, it would contribute to a closer relationship between Vietnam and the United States.
“It was such a show of a willingness to take a leap of faith,” says Messersmith, whose work in Vietnam was conducted under the aegis of the CGHD, the Ford Foundation, and Harvard University’s Kennedy School of Government. “They knew the drug addicts. They were so-and-so’s son or daughter. These were people living in a small province; everybody knows each other. They were concerned.”
A year and a half—and thousands of clean needles—later, Hà Giang Province saw a 24 percent drop in HIV among addicts.
Not yet friends
In 1998, Messersmith arrived in Vietnam with her husband and two small children to begin a six-year stint as the sexuality and reproductive health program officer for the Ford Foundation’s Office for Vietnam and Thailand. Relations between that country and the United States were just beginning to normalize. Pete Peterson had been installed as U.S. ambassador, the first diplomatic posting since the end of the Vietnam War in 1975. Peterson, whose plane was shot down during the conflict, had been held for six years as a prisoner of war at the notorious Hanoi Hilton. President Bill Clinton had begun reaching out a few years earlier, but in Vietnam, the communist party still held fast to the government reins. Phones were tapped, informants lurked everywhere, journalists were muzzled, and socializing with the American community was discouraged. And here was Messersmith, the daughter of a Vietnam War veteran, looking to give away money. It raised eyebrows.
At the same time, the country’s AIDS epidemic was ballooning, driven by rampant intravenous drug use, and to a lesser extent, the sex trade. The ﬁrst case of HIV was detected in Vietnam in 1990. In 2002, the government counted 15,000, but the number of HIV and AIDS cases reported each year in the southeast Asian country was far below the real number, says Messersmith. No one in the health sector was eager to follow the path of China, which had kept its burgeoning public health problem under wraps, resisted outside help, and would later see its blood supply become tainted, infecting tens, if not hundreds, of thousands of its citizens.
In southern Vietnam, heroin had been a drug staple since the 1960s, fed in part by the interaction between locals and American G.I. drug users during the war. In the northern mountainous culture, smoking opium was once the high of choice. But in the 1990s, an eradication program partially funded by the United Nations wiped out over 90 percent of the poppy fields. While older villagers continued to “smoke the dragon,” the youth turned to the cheaper, more potent heroin seeping in from China. Forget gateway drugs—young Vietnamese skipped straight to the tourniquet and needle. In the leafy Hanoi parks, Messersmith could watch young men openly shooting up.
“When most people in Vietnam start using heroin, they don’t have their own syringe,” she says. “They’re sharing needles with more experienced drug users. Of course, many users are also sexually active. The efficiency of transmission by sharing needles is incredibly high, much higher than by sexual intercourse.”
The Ford Foundation, established in 1936 by the son of auto magnate Henry Ford, has distributed billions of dollars around the world, mostly focused on strengthening democracies and reducing poverty and injustice. When Messersmith touched down in Hanoi, there were no local nongovernmental organizations. “I spent a lot of time just building relationships with my Vietnamese colleagues, mostly government and party officials,” she says.
“They’d ask us what we wanted to fund, and I’d say, ‘What are your ideas, what’s important to you?’ It was about what they wanted to see happen.”
Early projects included a “condom café” in Ho Chi Minh City, formerly called Saigon, where young people could pick up protection and sexual health pamphlets along with soda and coffee. Later, Messersmith funded a workshop for researchers in Hanoi to discuss the existing literature on health and sexuality, which was on the skimpy side. She knew the topic tended to freeze the faces of health officials in public, and she decided to try something different. To open the meeting, she nervously approached the lectern in the conference hotel, and in her limited Vietnamese, recited “Jackfruit” by the 18th-century poet and concubine Ho Xuan Hu’o’ng:
I am like a jackfruit on the tree.
To taste you must pluck me quick, while fresh:
the skin rough, the pulp thick, yes,
but oh, I warn you against touching—
the rich juice will gush and stain your hands.
“Everybody in the room gasped,” Messersmith recalls. “Ho Xuan Hu’o’ng is such an important cultural and literary figure in Vietnamese history, yet she wrote about sexuality and gender so beautifully and openly. Bringing that richness of the culture into the conversation was like going from left brain to right brain. People were thrilled, happy. They started responding from the heart. It was an incredible transformation.”
Touching the hearts of health experts was one thing, the reality of the street was another. Within most communities, an HIV diagnosis was as fateful as the approach of a black-hooded figure with a scythe.
“It was really hard, really sad,” Messersmith says. “The worst part was the stigma and discrimination that people living with HIV face, especially early on in an epidemic. In Vietnam, it’s very much associated with illegal and marginalized groups and behaviors. People feel devastated when they find out they’re living with HIV. There was even stigma within the family. People didn’t want to eat with a family member who had HIV, or sleep in the same bed, or share clothes.”
At first, local health officials were unimpressed with research showing the success of needle exchanges in other countries that Messersmith’s small group of Vietnamese and American researchers presented. Messersmith wasn’t surprised. At the time, as today, the benefits of needle exchange programs were the subject of debate even in the United States, with opinions divided largely along political lines.
“I’ll never forget my first meeting with the vice minister of health at the time,” Messersmith says. “He said, ‘Dr. Lisa, this is all well and good and it may have worked in Australia, but until I see the proof here, we’re not going to do this.’”
But Messersmith suspected that the minister’s decision remained open to scientific evidence. She arranged for the Ford Foundation to fund a harm reduction program in northern Lang Son, a border province with China. Abt Associates, a global research outfit based in Cambridge, Mass., would lead the research. Local health officials recruited peer educators to distribute pharmacy vouchers for clean needles and syringes to fellow users and collect dirty hypodermics. Messersmith and her colleagues went back to the vice minister with the findings, which would show a notable drop—a 10 percent decrease in new HIV cases over 18 months—as well as in risky drug use behavior, including sharing of used needles and syringes.
Between 2002 and 2006, HIV rates among intravenous drug users dropped from 30% to 23.6%.
“This same vice minister took that study and basically went from province to province to promote it,” Messersmith says. “He ended up leaving the health ministry for the party’s committee on science and education and used the study as a platform to promote change in policies and started the discussion about whether harm reduction could be included in law.”
While the response at the provincial level was encouraging, Messersmith and her Vietnamese colleagues knew that given the bureaucratic hurdles and general discrimination against people living with HIV/AIDS, it would take more than buy-in from the health sector to move the country forward. The cobblestones of deeper, more fundamental change ran through the powerful Ho Chi Minh National Academy of Politics and Administration, the party’s leadership training institution, a place where aspiring officials convene to tackle master’s- and PhD-level topics such as philosophy, Marxist-Leninist theory, political economy, and international relations. “They were running the show,” Messersmith says. “I knew if they could be sensitized and learn more about what the issues were, they could be change agents.”
Building on the trust and goodwill she’d banked in Hanoi and at the provincial level, as well as the relationship the Ford Foundation had established with the academy over other issues, Messersmith and her colleagues met with top leaders to discuss not only AIDS policy, but other sensitive issues, including the rights of people with HIV, gender issues, and the engagement of civil society.
“They first said, ‘We don’t do health, we do political science,’” Messersmith says. “And I said, ‘Well, thank you for your consideration.’ I’m never discouraged. If I took no for an answer every time, I don’t know where I’d be. It took a few tries, and by the second or third meeting they were convinced.”
Sofia Gruskin thinks she knows why. In 2004, along with several other researchers from BU, Harvard, and Abt Associates, the associate professor of health and human rights at Harvard’s School of Public Health joined Messersmith’s Vietnam AIDS Policy and Planning Project, a joint Vietnamese-international venture that has trained nearly 1,000 national and provincial policy makers. Gruskin says Messersmith’s empathetic approach was key to winning people over.
“Lisa’s incredibly smart,” Gruskin says. “But it’s about her personality. She doesn’t try to work from outside, which is what a lot of foreigners do. She has taken the time to really understand how the Vietnamese system works, and she works from within. As a result, she really is able to make, and support, change in some spectacular ways. What I’ve learned about how she engages is what I’m trying to replicate in other places.”
The shadow of the war
Messersmith traces her interest in public health to a café counter in the West African country of Burkina Faso, where she chatted with Ghanaian sex workers in the mid 1980s. As a Peace Corps volunteer from a middle-class household, she was fascinated to learn about their lives and the families that depended on their trade, their bodies. She made her way to other far-flung posts, including Mali, Nigeria, and Bangladesh, to tackle HIV/AIDS and sexual and reproductive rights as a grad student and researcher focused on program and policy development.
From 1994 to 1995, while a research associate in the Johns Hopkins School of Hygiene and Public Health department of international health, she served as the Women and AIDS advisor for USAID in Washington, D.C., and from 1996 to 1998 was the country programme advisor for UNAIDS, the joint United Nations program focused on the global epidemic, in Bangladesh. When the chance to work in Vietnam presented itself, she jumped.
“I’m an anthropologist,” Messersmith says. “So for me another culture, another country, another language was very exciting. But I also had this deep emotional connection to Vietnam.”
Her father had served as a field surgeon in 1969 in the 24th Evacuation Hospital in Long Binh during the Vietnam War. John Messersmith had been deeply affected by the destruction he witnessed as well as the wounded bodies he had to operate on, to try and save. He later became a prominent trauma surgeon in Boston. Messersmith remembers that when her father died, many people he’d saved showed up at the funeral.
The brutal 20-year conflict that pitted America’s communism containment policy against Vietnam’s anticolonial struggle killed somewhere between one million and three million Vietnamese soldiers, guerrilla fighters, and civilians. By the time the United States withdrew its combat forces in 1973, more than 58,000 service members were dead. Just three years later, North and South Vietnam were reunified.
Messersmith’s father died just after she settled in Hanoi, but her father-in-law, a retired Army officer, visited in 2000 for the first time since serving as a province advisor in 1966 and 1967. The family toured various sites, including the ancient Cham ruins in the central part of the country, a sight her father-in-law had seen only from a helicopter gunship because the territory had been controlled by the Viet Cong. The tour guide, it turned out, had been a guerrilla fighter, a teenager at the time.
“I’ll never forget this man helping my mother-in-law up the stairs to the temple,” Messersmith recalls. “It was amazing, some 35 years later. He was showing my father-in-law his wounds from the war and they were talking and shook hands. It was very emotional. My father-in-law was an Army colonel, and it had a profound effect on him.”
Among a Vietnamese population of 90 million, almost 300,000 live with HIV/AIDS.
For much of the largely young population in Vietnam, the shadow of the war has faded, but the wrenching piece of history bound members of Messersmith’s international research team.
“The American men in our group and the Vietnamese men felt strongly about having to explain themselves as to who they were during the war,” Gruskin says. “One guy in our group had chosen not to go to war and was quite proud of that fact. The Vietnamese couldn’t understand that. Someone else in our group had been a fighter pilot who had bombed the hell out of them, and they understood that a lot more. It was quite different from what you’d have expected. Those frank discussions were critically important to the partnership. I do credit Lisa and the trust she built.”
When Messersmith’s Ford Foundation tenure in Vietnam came to an end in late 2004, the government’s appreciation for her work was made unambiguously clear: she was awarded the People’s Medal of Health, “an incredible honor,” she says. Even after moving back stateside, Messersmith remained the public health figure that Vietnamese government officials wanted to consult as they began developing legislation around HIV/AIDS.
Nguyen Chí Dung, a professor in the sociology department at the Ho Chi Minh National Academy of Politics and Administration, who worked with Messersmith on the AIDS Policy and Planning Project, says her impact exceeds needle exchange programs, spreading awareness, and even national AIDS policy and law.
“Her valuable support for the improvement of the social life of the Vietnamese people is unquestionable,” he says. “It’s fair to say that she considerably contributed to the development of the relationship between Vietnam and the United States.”
The law comes around
The movement shaped by Messersmith and her Vietnamese and international colleagues led to the eventual enactment of a national AIDS law, which became effective in 2007, the same year she left a post at Harvard University’s Kennedy School of Government to join the Center for Global Health & Development. The legislation legalizes needle exchange programs, protects people with HIV/AIDS from being forced to disclose their medical status, and criminalizes the denial of education, employment, and health care.
“That law is a real progressive piece of legislation for any country,” Messersmith says. In fact, she says, the United States today could learn a lot from the changes made in Vietnam, where between 2002 and 2006 HIV rates among intravenous drug users dropped from 30 percent to 23.6 percent.
“Vietnam is family-oriented and traditional,” she says. “It’s about taking care of the family and the community, as well as the communist ideals of taking care of each other. It’s a cultural approach more than a political one.”
It’s also a mind-set that comes naturally to Messersmith. In 2006, she coordinated a study tour for several members of the Ho Chi Minh National Academy to visit HIV/AIDS programs in Boston, New York, and Washington, D.C. In Boston, they met with health officials, including the dean of the School of Public Health. And even though it was an official public health visit, Messersmith couldn’t help but make it personal.
“We brought them to my home for a traditional New England clambake,” she says. “The vice president of the academy, who I always thought was quite stern and a little bit scary, not only became a huge advocate for the work and very technically involved for someone in such a high-level position, but he told me that after that trip he felt that we were a big family. That was huge. It really changed our relationship with them.”
Today, almost 89 percent of injecting drug users in Vietnam report using sterilized needles the last time they injected, according to UNAIDS. While other numbers remain troubling, Messersmith says the accuracy of reporting AIDS statistics in Vietnam has grown tremendously. Among a Vietnamese population of 90 million, almost 300,000 live with HIV/AIDS. There is increased awareness of, and access to, antiretroviral drugs and therapies.
“What you can show is changes in process, in the system,” says Gruskin, who believes that it’s premature to talk about the full impact of their work on health outcomes. “There’s much more attention to the policy environment, more recognition of conflict between HIV laws and their laws that say it’s illegal to carry a condom because it shows you’re a sex worker. They’re aware of this stuff and trying to engage with it.”
At the CGHD, Messersmith continues her work in Vietnam. She is director of the Vietnam AIDS Policy and Planning Project, whose work has led to a decreased association of AIDS with “social evils,” increased integration of gender into policies and programs, and greater recognition of privacy and confidentiality rights. She is also the principal investigator on two studies: one looking at the health and social service needs of women living with HIV/AIDS, the other assessing the magnitude and types of discrimination experienced by people living with HIV/AIDS.
“It’s fantastic to see something go from research results to programs and policy and law,” she says. “After all, this is not about politics. It’s about saving lives.”
This article was originally published in the summer 2011 issue of Bostonia magazine.+ Comments