"A ripe mango has to fall..." : care for people with HIV/Aids in a Buddhist Centre in Northern Thailand

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'

mangoh

People with Hiv/ Aids

in a Buddhist

in Northern Thailand

Bijdendijk

, for a Masters

Department of Anthropology

F

acuity of Political and Socio-Cultural Sciences

University

of

Amsterdam

Social Research Institute

Chiang Mai University

Under the supervision of

Dr Han ten Brummelhuis

Depa1iment of Anthropology

University of Amsterdam

tI

ome address:

J

Bijdendijk

Boetonstraat 40-lll

109 5 XN

Amsterdam

The Netherlands

1-20) 6 632 683

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Preface

After my nursing-education, and half a year of travelling in South-east Asia, I chose to study anthropology in

1988. Little could I suspect then how my diverging interests would come together in the topic of this thesis. In 1990, while on holiday in Thailand, I met with an American professor, who was involved in doing research on the topic of Aids in Thailand. This brief meeting proved to be of major importance. It made me realize how intricately culture, sexuality and Aids are related and how important it is for anthropologists to make their contribution to the study of Aids, which by then mainly consisted of biomedical and epidemiological research. Most of this research also focused on the prevalence and prevention of Hiv/ Aids; little attention was

given to the subject of care for the ill and dying.

In January 1994 I heard about Thai Buddhist monks setting up centres for people with hiv/aids

(pwhiv/aids). With my interest in Buddhism and my background in general nursing, the choice to go and work as

a volunteer nurse and take a closer look at the potential of such a centre in caring for aids-patients was evident.

Through contacts with Dr Chayan Vaddhanaphuti, director of the Social Research Institute (SRI) of the

University of Chiang Mai, my supervisor, Han ten Brummelhuis, was able to get in touch with a monk, Phra

Phongthep1, who had just opened a centre for pwhiv/aids on the outskirts of Chiang Mai (February 1994). His

centre became the location of my research. I wish to thank Phra Phongthep, because without his consent this

research would have been impossible. I also want to thank the staff for their cooperation and patience in teaching

me new words.

In Chiang Mai I want to thank Dr Chayan Vaddhanaphuti for his hospitality and invaluable advice on

'growing up as an anthropologist'. Dr Apinya Fyangfimsakul shared her knowledge and experience and gave me

moral support. Dr Chris Beyrer was a source of information and contacts. NAP AC is to thank for their financial

support. My special thanks go to Catherine O'Keeffe and the staff of Medicines Sans F rontieres for their understanding and friendship.

1

All names of patients, volunteers, doctors and others in this thesis are pseudonyms. However, I have chosen to use Phra Phongthep's real name. Firstly because it is impossible to hide his identity by simply giving him another name. There are very few places in Thailand where monks are involved in care for pwhiv/aids and such initiatives can hardly go by

unnoticed. Secondly, Phra Phongthep is well aware of the importance of publicity, and he has enjoyed both national and international attention of the media

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In Amsterdam I want to thank Dr Han ten Bnunmelhuis for his support and advice before, during and after the research. Andre Tuinier inspired me importantly while writing this thesis, and I am grateful for the comments given by Mirjam Schieveld, Irene Stengs, Beate Wesdorp and Saskia Verkade.

I am especially grateful to my parents for their love and strong support in all that I undertake and to

Jonas Helmers for his loving and inspiring faxes. I thank Jan Willem de Lind van Wijngaarden for his friendship

and advice. And I will always remember the people who were living at the centre.

Jessica Bijdendijk August 1996

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Introduction of the problem and the setting

fu the course of the last decade, the Aids-epidemic in Thailand has reached the stage in which coping with

Hiv/Aids and care and support for People Living with Hiv/Aids (pwhiv/aids) have become central and acute

issues. Large numbers of people have fullen ill and are presently dying. It is estimated that by the year 2000 the

total number of pwhiv/aids will reach 2-4 million, with approximately ~.8 million prevalent infections and

100.000 people dying of Aids in that year alone (Brown et al. in AIDS 1994 vol.8:sl35).

The North in particular plays a sad leading role in the epidemic. Seropositivity rates in the four Northern

provinces are as high as 41.3 per cent among intravenous drug users, 3 .3 per cent among pregnant women, 17 .1 per cent among men with SID, and 41.5 per cent among so-called 'direct' prostitutes. Chiang Mai appears to be

,---·-~ ·-···· .. ....--····--···

the most heavily inflicted area. (Ministry of Public Health Thailand (MOPH) Sentinel Surveillance for HIV

infection June 1993).

Immediate contact with people living and working in the North conveys how much the epidemic has

come to influence people's everyday life. Almost everybody knows someone living with Aids or has lost a fumily

member, a friend or a neighbour. The situation of poor pwhiv/aids (and their relatives) in particular is worrysome

if not outright dramatic. They often lack means of transportation to get to a doctor and cannot afford expensive

(long-term) medical treatment. The loss of income of the patients and the ones taking care of them, creates another serious financial (and emotional) burden for the fumily. When fumily ties are weak or non-existant, very

ill people are sometimes left to fend for themselves and there are hardly any places where they can go for help.

The increasing demand for care of growing numbers of Aids-patients is already overburdening hospitals

and hospital-personnel. fu Chiang Mai 50 per cent of the beds in the provincial hospitals are presently occupied

i

by pwhiv/aids. 1 It is only realistic to expect that this situation will become more acute in the decades to come. ·

This raises questions about the way Thai society is coping with this growing demand for care. Since it

was clear that the regular health care services would not be able to deal with the growing demand, the idea took

shape to use the potential of the community to take care of pwhiv/aids. Two institutions were seen as crucial in

organizing adequate forms of community care:

ili~"J~;_;ni}i)md th(~~~y·

This research focuses on care provided

for pwhiv/aids in a centre run by a Buddhist monk called Phra Phongthep. The centre is located in Chiang Mai, the capital of the North.

1

figure presented at 2nd International Conference on Home and Community Care For Persons Living with HIV/ AIDS Montreal, Cananda 24-27 May 1995.

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1.1 Buddhism and Aids

One of the general questions of this research is how a Buddhist nation is coping with the Aids epidemic. The

assumption is that Buddhism can have something to offer in relation with care for pwhiv/aids. Perhaps

meditati---e-.. ~--.

on, the performance of rituals or the help offered by Buddhist monks can bring relief to people in need. Instead of

perceiving culture as an obstacle, it is interesting to find out where and h91Y~it ~ .. l!~lly ~of ~:lp.

o»c,."\

The more specific questions that were generated, were influenced by my own ideas on Buddhism and my

contacts with a Buddhist movement in Amsterdam. They formed the starting point about the possibilities of a

'Buddhist app:~ch to Aids' and influenced my expectations about Phra Phongthep and his work.

I had been interested in Buddhism for a couple of years and knew the basic principles mainly in an

academic way, untill I eventually learned to meditate with the Friends of the Western Buddhist Order (FWBO).

The FWBO teaches two basic types of meditation, the mindfulness of breathing (Anapana Sati) and the

develop-ment of loving kindness (Metta Bhavana).2 Both these types of meditation have greater concentration and

integration of personality as aim or goal. They are called samatha meditation and are distinguished as such from

vipassana meditation. 3

My experience is that meditation in general brings about a greater sense of wellbeing, in particular a

greater sense of peace of mind. By training the mind, one tries to overcome the eventual difficulties of life by

turning inwards, chml:~gJli~ ~Y Qie mind r~.~ Jo.Qiin~~. that happen, instead of trying to change the

circumstances. When trying to cope with hiv/aids, or any other unchangeable fact for that matter, it can be useful

to tum inwards and l~m.JmoQler way pf r~ondiJ:l.g₂f~lll:iK<'ltld thinking. These personal experiences with

meditation and its effects on both one's state of mind and the interactions with others, made me wonder about its

potential for people with hiv/aids.

Another possible link I saw between Buddhism and coping with Hiv/ Aids, are its p~rcq>tions

()f

.and

( dealings with death. In Buddhist thought we find a constant emphasis on the transitoriness of life, the constant

changes that take place on all levels (from mental processes to (meta)physical ones). Human suffering is the result

2

Metta Bhavana is divided in four stages. Firstly you focus on developing metta for yourself Then you continue to develop loving kindness for a friend, a neutral person and someone you have difficulties with. The meditation is

comple-ted by developing loving kindness for all the people meditating with you, to ever expanding circles in which you can

include all living beings, all creatures of the universe.

3 _{Vipassana meditation is about gaining Insight and Wisdom, whereas samatha meditation cultivates Mindfuh1ess and}

Concentration (Tambiah 1984:41). The latter forms the basis for the fonner, but in general it can be said that in Themvadin Buddhist countries vipassana meditation is mostly practised.

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of not knowing or not wanting to know that everything and everybody is subject to change; on the contrary, we generally strive for a maximum of security and pennanence in our lives. Buddhist thought radically, almost mercilessly, confronts this human habit. Buddhist monks for example, are known to meditate on death, visualizing the ten different stages of bodily decay (Tambiah 1984:39; Obeyesekere in Kleinman and Good 1985:141).

Even though the idea of an unchanging soul that reincarnates was abolished by the Buddha, the idea of

Samsara, an ongoing circle of energy/processes, which cannot be left behind, unless Enlightened, is central.

However people in Buddhist countries interpret this, whether they fully understand the Teachings on Anatta or

not, there is a general belief that when this life is over, all is not over, in fact all is not lost. It is very well possible

"\-~•M-~~··•'''"-'"~•n'<'"'"'

that in a next life, one will have more luck, or better Karma. This belief, I presumed, can be a comforting idea for pwhiv/aids.

1.2 Aids in Thailand

Thailand officially registerd its first Aids-patient in September 1984 (Dep. of CDC MPOH 1991). Hiv (Human

hnmuno-deficiency Virus) was probably introduced during the late seventies, early eighties, infecting homosexual and bisexual men, IV-drug-users and female commercial sexworkers in rapid succession (Weniger 1991). Large

numbers of heterosexual men were infected with Hiv by a small pool of commercial sex-workers (CSW)4, whose

deaths have largely gone by unnoticed. 5

Biomedical research, challenging Weniger's model of 'waves', suggests however that several strains of Hiv were introduced to different populations in Thailand around the same time (Chantapong Wasi et al. 1995).

Be that as it may, the fact remains that Thailand is severely hit by the epidemic. Factors that have contributed to

the fast spread of Hiv are related to Thai sexual culture, which is permissive to men and restrictive to women.

Commercial sex is a feature of every day life, with concommitant high levels of sexually transmitted diseases. A

sad coincidence is the relatively high transmission e:fficiacy of the prevalent strain of Hiv in Thailand (Hiv-1

subtype E) (Kunanusont C et al. in lancet 1995;345:10878-83).

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I do not intend to blame commercial sex-workers for the spread ofHiv. They were mostly infected by already infected men, did not know there was a deadly virus around and certainly were in no position to protect

themselves. Sadly today this has not changed much, particularly amongst the poor, uneducated CSW.

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Many of the CSW's that were the first to be infected, were send away or left for home, when it became obvious they were ill (press release summer 1992, AIDS-conference Amsterdam; pers.com. Chris Beyrer Jan.1995).

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An impressive national prevention campaign started in 1989 (Jon Ungphakom and Werasit Sittirai 1994:s155), which had a measurable positive impact on the prevalence of (other) sexually transmitted diseases

(van Griensven lecture 6-12-1994). Unfortunately, it was already too late to prevent the spread of Hiv amongst

the general population. By 1994, Hiv is fumly rooted in the general population (Brown et al. in AIDS 1994

vol.8:sl3 l), and the main route of transmission has become hetero-sexual contact (Mann et al.1992:98).6

1.3 Social reaction to Aids

When discussing the problem of care for pwhiv/aids, it is not enough to present figures and epidemiological 'facts'

about Hiv. "Living with Hiv/ Aids" represents a reality which is socially and culturally constructed and justifies a

description of the ideas, feelings and images that surround Aids in Thailand. What are the consequences of having

to live with hiv/aids? What are the practical constraints that confront Thai pwhiv/aids, particularly when they

become dependent on others for help? And what are possible and acceptable solutions for meeting the growing demand for care in the Thai situation?

Even though Aids is becoming a more 'CQ!!!Illon' phenomenon, people living with hiv/aids still induce

< --··-.. .,.

great fears and are heavily stigmatized. Apart from the natural fear which any deadly contagious disease brings about in people, fear of Aids was purposely created in the first national prevention campaigns based on the assumption that this would change people's behaviour.

As a result, even well-educated people, who are able to understand the ways Hiv can, and more

importantantly cannot be transmitted, show reluctance and sometimes aversion to get close to pwhiv/aids. It can

be concluded that the fear of Aids induced in these first prevention campaigns still plays a dominant part in the

way society at large behaves towards people living with hiv/aids.

There is a considerable stigma attached to living with Hiv/ Aids. It was and still is presented as a result of

'deviant' behaviour, in which no self-respecting citizen would indulge. Only members of the so-called

'risk-groups'7 could get Aids. This idea prevails, also because it generates a comforting false sense of security for

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The use of condoms is still problematic, particularly within the marriage and other 'intimate' relationships (pers. corn. Chris Beyrer January 1995; de Lind van Wijngaarden 1995:87-88). The idea of 'risk-group' influences the perception of safe behaviour; men look for women outside the commercial-sex sphere, or choose very young girls/virgins (pers. corn. Mary Packard-Winkler May 1995).

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The idea of 'risk-group' is rightly replaced by the category 'risk-behaviour'. It focuses on the acts, that in fact determine the amount of risk, instead of the actors. There has been a recent development to use the term

'risk-circuit', as a recognition of the fact that behaviour and group are related.

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people who do not consider themselves a member of such 'risk-groups'. As a result pwhiv/aids who 'come out' run

a high chance of losing their jobs and becoming socially isolated.8 Many of them are personally held responsible

for their misfortune.

1.4 Coping and culture

In such a social climate, it is not surprising that many pwhiv/aids choose not to tell others about their situation as

long as they can avoid it. But apart from these practical considerations, which inhibit the social acceptance of

pwhiv/aids and thereby the possibility to cope with the problem together with others, there is another strong

incentive not to share the knowledge one is living with Hiv/ Aids.

Jhai.s:µltµre highly values smooth and pleasant interpersonal relations. Under all circumstances, one is

/ - ,,_, __ -;

taught to 'keep face', not to show one's ~u!rie ~ling, but to keep a 'cool heart' (cajjen). Openly discussing

---feelings of anger, disappointment, frustration or distress is 'not done', in order not to offend the ego of others (particularly higher ranking others) and self

In times of distress this culturally valued behaviour results in a split between inner experience and

outward presentation. Since sharing of inner feelings is discouraged, people also lack the words to ex.press them.

"Thai people are overconscious of feelings but are hindered in communicating them clearly and in a direct and

spontaneous manner" (Meyer 1988:264).

When communicating feelings and problems proves to be so difficult, counselling (at least based on the

western style of'talking and feeling things through') of pwhiv/aids and their relatives becomes no simple matter. Early on in the epidemic, support groups like the Hotline Center encountered exactly these type of problems.

They started to help people ''to recognize their own thoughts, ex.press their own feelings and to get to know

themselves better" (Wol:ffers 1992:50).

Culture is an important factor in determining the way people will cope, also because it is the framework of meaning and interpretation that influences the perception of 'living with Hiv/Aids'. Depending on this

perception, people will find a way to deal with the fact their lives will be (much) shorter and involve more

suffering than they had imagined. It is important to know therefore how people perceive the fact they are living

with Hiv/ Aids.

As far as coping is concerned, apart from learning new ways to communicate, there are always culturally accepted ways to deal with stress. Western-style counselling and coping mechanisms, which focus exclusively on

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This stigma often pervades to relatives as well, which can serve as a reason for them to abandon a family-member

with Hiv/ Aids.

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the individual, intrapsychic experience, are more often than not inappropriate in the Thai setting. But what is?

What are appropriate ways of coping with difficulties and stress and how can this knowledge be applied to the

development of culturally sensitive counselling for Thai pwhiv/aids? In this paper I will formulate some tentative

answers to these questions.

1.5 Methodology

I started the research in January 1995 and became the formal research-assistant of Dr. Apinya Fyangfunsakul.

She had been involved in research at Phra Phongthep's centre since July 1994. Her research was part of a larger

research-project which focused on several aspects of Aids at different locations in the North. This project was

A

coordinated by the Social Research Institute (University of Chiang Mai) and financed by NAP AC (Northern Aids

Prevention and Care, a Thai-Australian NGO). It was arranged with Phra Phongthep that I should work at the

centre on Mondays, Wednesdays and Fridays from 8.00 till 17.00.

Early on in the research, I decided to focus my attention and effort on the provision of bed-side nursing ,,_,~.,,~''"'-, "~''" _,,.·~."" care, and creation of the necessary conditions for this type of care. There were very practical reasons for this decision. Firstly, I noticed an urgent need for bed-side nursing care, particularly in the case of dying patients. Secondly, I assumed that basic-nursing care was possible to achieve in the relatively short time of the research and under the restricted circumstances at the centre. And, thirdly, this was an area of nursing in which the

nurse-ass.istant working at the centre did not show much interest. In this way I could avoid interfering with his work too

much.

Concerning the language-barrier, we planned to involve a research assistant (interpreter) and a Thai research-nurse. The latter proved very difficult to find as a result of :financial limitations. We :finally managed to find a 45-year old woman, who was willing to work with pwhiv/aids, spoke English and had experience with

conducting interviews, but Phra Phongthep was not in favour of her involvement. 9 As a result· I had to rely

completely on myself

My Thai was not sufficient to be able to understand the finer details of what was going on and ask all the

,-,-~oo" _,,_~~'"''w"' ~ "'N'~~"~'' """",~>'" -· ,,, •-'> •"'"' <M '~" ~'' ' ' "~' ~< /

questions I would have liked to ask.10 _On_top_{of that, most people at the centre spoke Northern Thai, which differs}

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The reason he gave me for this decision was that he thought that she was not good enough as an interpreter. At the time of her introduction, Phra Phongthep might have been more concerned about his public image than ever, because one of the patients had just committed suicide. Perhaps a foreign student with an interpreter was not acceptable to him at that moment.

10

This was another reason for focusing on the practical part of the research, the provision of (bed-side) nursing care.1.1

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substantially from central Thai. The most important sources of my infonnation are therefore my observations and

experiences working as a nurse. In a lesser degree, the information results from a couple of discussions I had with

the monks, the staff and some of the patients.

I kept a diary in which I noted down what happened on the days I worked at the centre, and what type of

interactions took place. I started to keep my own files on all the patients whom I nursed, reporting on their health,

general progress, their medication and the subjects we discussed. Keeping a personal diary and writing letters to

---····'"•· ~·-"·"~ ''"

~·-~-~_.-·-my :fumily and boyfriend, proved to be useful instruments to reflect on ~·-~-~_.-·-my own reactions to a sometimes

extremely stressful situation.

1.6 Overview

In chapter two I will give a short impression of the Thai Health Care system, which will serve as the background

against which we can view Phra Phongthep's initiative to support pwhiv/aids. Since he was the central figure at

the centre who determined for a large part what happened at the centre, he is the subject of the third chapter, in

which I describe not only his personal background and motivation, but also provide background information on the social status of monks and their involvement in societal issues and politics.

Chapter four is a description of the centre, its short history and the daily affairs as they took place during my research. Chapter five initially focuses on four cases and the specific needs for care and nursing care problems that came to the fore in these cases. From there I continue to highlight more general nursing care

problems and conclude this chapter with a short inventory of these problems, and what was done about them.

Since my training as a nurse proved to be such an important factor in evaluating the needs for care of the

patients and the work done at the centre, I will reflect on my own standards for adequate care in chapter six.

In chapter seven I present four other Buddhist initiatives in order to compare them with the practice of

Phra Phongthep. In chapter eight I present my conclusions and recommendations.

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Chapter 2 Health care

in

Thailand

With a population of around 60 million people, 1hailand runs a reasonably well functioning health-care system. Apart from hospitals and health-centres which are under supervision of the govemement, there is

also a considerable private sector, in which doctors work after their regular hours in the public sector. I will

give a short overview of the organization of the latter, because this is the system that Phra Phongthep and the

patients rely on for help. I will focus on hospitals, financial matters, national health care policy and the social

status of and division of labour between doctors and nurses.

Following I will pay attention to the more specific problems of medical personnel in dealing with the

Aids-epidemic and an example of how these problems can be solved. Another relevant matter, which plays a large part in the treatment of not only pwhiv/aids, is the general situation concerning the use and distribution of medicine.

2.1 The public sector

In total the hospital beds of the public sector amount to 75.000. Each province has a provincial or regional

hospital, having respectively 150-500 and 500-1000 beds. Most of the 621 districts have a district hospital (also called community hospital), which normally have 10-60 beds (Hommel 1991:6-7). Every subdistrict has a health-centre, which serves 7-10 villages and is staffed by an auxiliary midwife and a jmiior sanitarian. The health centre mainly provides preventive and promotive health services (ibid., p.8).

The central guideline forthe health policy of the govemement is "Health for all", and primary health

care has been recognized as key strategy for health development (following the Alma A1a Declaration of

1987) (ibid., p.11). The government has therefore invested in building an infrastructure for health in the community, and in developing appropriate health care programs implementing the 10 essential elements of primary health care. The government has also built more connnunity hospitals and health centres and presently focuses on developing an efficient referral system (ibid., p.12-13).

"At village level a number of Village Health Communicators (VHC) have been elected by the

villagers (some of them have been selected by governement personnel) at the ratio of 1 per 12-15 families.

From them one will be elected to be the Village Health Volunteer (VH), who acts as chief' (ibid., p.8). Their

task is to observe and monitor health problems in the village. They work without payment, but they receive free medical treatment from government medical services in return. Since the start of this program (1988), 62% OfVHC's and 25% ofVH's have dropped out (ibid., p.9).

It may be concluded that on this level medical services are quite linllted. The health centres (that cover 7-10 villages) miss the equipment and personnel to be able to provide (nursing) care for people at

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home (cf le Grand 1989:11). People living in the more remote areas may have to travel up to four hours by car to get to the nearest community hospital.

A health insurance system does not exist and basically everyone, except government workers, has to pay the expenses for medical care personally. It is possible to apply for financial support from the

government in case one is unable to pay all the costs. "The medical costs of the poorest patients are paid

completely by the government" (ibid., p.14). Costs of transportation are not included however, which is why

people will only go to see a doctor in emergencies and fail to return for follow-up care (ibid., p.15).

The total Aids budget for all ministries was US$ 46 million in 1994 and the prospect for 1995 was

US$ 55 million (Jon Ungphakom and Werasit Sittirai in AIDS 1994 vol.8:sl57). The major part of this

budget is spent on prevention and the improvement of testing and counselling services. Care, in particular for

the dying, is a subject which does not receive the funding it needs (personal communication Chris Beyrer, May 1995).

There are 14,000 physicians in Thailand, of whom only 1,500 work in the rural areas (le Grand

1989:11). In return for the grant they receive from the government, they are committed to work anywhere in

Thailand for three years after completing their education. TI1ey are educated in the tradition of modem

western scientific medicine. In general they do not believe in traditional healing methods (like for example

herbal medicine) and there is little to no overlap between these two health care systems (ibid., p .14-15). Both

doctors and patients are focused on finding a cure for the encountered illness; palliative care is non-existent

in official health care institutions.

Thai doctors in the public service have to work hard for relatively low salaries. A forty-hour week is

the official standard, but due to high workload pressure, they often work 50 to 60 hours. In general they have

very little time to exan1ine their patients, and particularly at the smaller hospitals the means to establish a

diagnosis are lin1ited.

2.2 Nursing Care

As a result of a structural shortage of doctors, many of a doctor's more simple tasks, like drawing

'c""-···-~ ... .

bloodsamples, admitting N-drips and stitching up of superficial wounds are delegated to nurses. A nurse ,,~_,,,)

does not only perfonn these medical operations, but she often diagnoses and defines a preliminary plan of

treatment as well, including the prescription of certain medicine. As a result they have less time to completely

fulfill their nUJ"§inK<il!ti~· A division of labour between doctors and nurses certainly exists, but there is a

considerable overlap of activities.

The education to become a registered nurse takes four years and is taught at universities and

university hospitals. In theory nurses learn to plan the care for a (group of) patient(s) and to formulate the

goals they want to achieve. In practice however they work in teams, which work on the basis of performing

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Another point that receives attention in the theoretical part of their education, is the importance of counselling and attention for the psychological and social fuctors that play a part in the patient's experience.

However it is not common for patients to talk directly about these matters with nurses. As I mentioned

before, a dominant element of Thai custom is to hide personal feelings behind a smile and correct behaviour.

If at all, difficulties are shared with close relatives or friends, certainly not with strangers.

Nurses do not receive practical training in counselling and attention for the psychological needs of patients does not have priority. Relatives often function as mediator in these matters between patients and

nursing staff Based on these facts we could say that nursing comes down to performing medical-technical

tasks, often under high workload pressure.

As a result, reh!tiy,es p~y .a very important role at the hospitaL also on a more practical level.

:-;>:;!:'!fifj/f!f!ii:!';';,;::, ,,, ,, "''' '''"'' ,,,,

Nurses have little time to assist patients with eating, drinking or finding a comfortable position in bed. So

called bed-side nursing is for a large part performed by family-members. Care for bedridden and dying

patients is traditionally provided by relatives.

2.3 Nursing and Aids

Like in The Netherlands

(c~oeksema iJrfRa~ehsch!~~ ~?~~'')990:279)

professional health care workers

f { !. I ' r f'

initially reacted with fear

td

Hiv/Aids. In Thailand it seems as if it is still the uppermost feeling, even now,

about a decade into the epidemic. Based on my own observations at several hospitals and talks with a couple

of Thai doctors and nurses, my impression is that most of them are more scared than l1~~!Y:

Reluctance to treat pwhiv/aids is understandable when medical professionals feel unable to protect

themselves appropriately. Doctor Sawat, who was involved with the centre during the first months of my

re-search, explained that surgeons prefer not to operate on pwhiv/aids; the case of one of the centre's patients,

who was refused an operation and send back with an acute appendicitis, is a clear example. He was operated

on only after dr. Sawat had intervened. There are other medical procedures which are also not performed on

pwhiv/aids, like deep IV-drips, bloodtransfusions and intubation with a Iaryngoscope.

Dr. Sawat himself had had the ambition to become a surgeon, but had decided to change his specialisation to internal medicine, because being a surgeon these days was simply too dangerous and stressful. Over the last three years he had had a continuous fear of being Hiv-positive after a couple of 'needle-stick-accidents'; he had even once tested fulse-positive.

All of this may be the result of a lack of specified information on universal precautions that prevent the spread of Hiv in medical and nursing operations. But as the following case shows, this need not be; it is very well possible to inform, motivate and support medical personnel so that they can do their work without unneccesary fear.

At a small district hospital just outside of Chiang Mai, one of the doctors realized the need for extensive training for the whole team of doctors, nurses and social workers, in an early stage of the epidemic.

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He started informing the staff on all aspects of Hiv/ Aids in 1989 and adapted hospital-routine (cleaning and

hygenic measures) to standard universal precaution. After one of the social workers was infected with TB,

they installed an airfilter in the counselling rooms, which proved to be effective.

Apart from taking practical measures and providing adequate infommtion on Hiv/ Aids, this doctor

recognized the need for his personnel to discuss their own psychological problems in working with

pwhiv/aids, particularly in this part of the country where infection rates are relatively high. Once a year he

organized an outing for the whole staff, which of course brought expenses, but he considered it to be very

important for them to be able to relax together and take a break from the often demanding work.

This hospital had adapted on all fronts as a result of the vision of one of its doctors, who was also in the position to forward these changes. It is a good example of the integrated approach that is necessary to prepare a hospital and its personnel for working with Hiv/ Aids. Perhaps such initiatives are not yet taken everywhere, which partly justifies the still existing fear amongst professionals.

The fact is that Hiv/ Aids is much more widespread under the general population than it is in western

countries. Virtually all health care professionals will knowingly, or unknowingly come into contact with

people with Hiv/ Aids. The need to protect themselves is much more real. Doctors and nurses therefore feel

justified to know the Hiv-status of their patients, with or without the latter's consent.

2.4 Use, sale and prescription of medicine

Western medicine were introduced in Thailand in 1820 (le Glfilii.(l989;1

f4).

_{Since then the use of traditional}

/ \ •. ,~""'"''-·•>""•,. /(''h·' 1/' /;,,,

s

medicine has declined and recent attempts to revive this ancient tradition, have renIBined unsuccesful (ibid.,

,~'---p.17). Modem, western medicine are preferred both by doctors and patients and it is possible to buy almost any drug without prescription.

As a result, there is a large tendency to skip an often too expsensive visit to the doctor and ask for

advice at the phannacy or local grocery instead. This causes serious problems, in particular for the growing group of pwhiv/aids. The use of antibiotics is widespread and they often function as painkillers, which no doubt creates strains of resistant bacteria.

~

I general there seems to be no control on the combination of drugs that people take, which could

A

pose serious threats to a person's health. Le Grand concludes "that health problems are not caused by a lack

of drugs, but that the overconsumption and improper use of drugs ~f2'one of the major health care problems,

both in self-care and prescription" (ibid., p.12). At the centre, this casual approach to drugs often proved to

be a llIBjor problem; patients were litterally loaded with plastic bags with different drugs. No (generic) names, no dosages or at best an illegible scribble.

The government tries to improve this situation by implementing laws and regulations. During the

first half of 1995, it was for example in the process of passing a law which orders that all generic names

(23)

Thai nurses do prescribe certain medication, but not all. The standards I found (at the Home-Based and Community-Based Care project of the Swiss Medicine sans Frontieres) for medicine which can be prescribed by nurses, were mouthwash, vitamines, antihistamine cream, cough syrop, calamine lotion

(a-gainst dry and itching skin), and paracetamol.

Phra Phongthep handed out medicine when he went on home visits. He would always try to find out

if the patient had received adequate treatment from the doctor, by checking the drugs against the patient's complaints or the diagnosis. It was clearly a situation in which he desperately wanted to do something and

patients expected to receive help, in whatever form. He never left them without leaving at least two plastic

bags behind; one with vitamine pills and one with paracetamol.

Summarizing it may be said that the organization of the health care system leave things to be

desired, in particular for poor people living with Hiv/ Aids. As health insurance is non-existant or very

expensive, and despite special government support programs, the costs of medical care and transportation

are a heavy burden on patients and their relatives. The latter also play a crucial role in the care for the

seriously ill and dying. When they are not able or willing to give their support, hospital personnel is not trained and often reluctant to take over from them.

Helping pwhiv/aids cope with the consequenses for their personal and social life, is a point which is

recognized (pre- and post-test counselling is provided for), but in practice counselling of patients and

relatives remains problematic (Jon Ungphakom and Werasit Sittirai in AIDS 1994 vol 8:s157).

Many doctors and nurses are still afraid to treat pwhiv/aids, and in situations where it is difficult to

observe universal precautions as a result of lack of information and/or protective materials, this fear is

justified. It means that pwhiv/aids do not always get proper treatment. This could be attributed to other factors as well.

The large emphasis on cure in combination with the patients' expectation to receive treatment (in the

fom1 of medication) when they go to see a doctor and the easy access to drugs, all contribute to the overconsumption of certain drugs (analgesics and antibiotics in particular). This causes further problems in

~public

health and high medical costs. It also means that a switch from cure to care is difficult to make; it is

]

₁

~

easier to prescribe more drugs than to face the fact that further treatment (ain1ed on curing) is no longer

(24)

(25)

Chapter 3

Phra Phongthep

We have seen that pwhiv/aids in present day Thai society face quite a few difficulties. Phra Phongthep encountered them as soon as he started to work with pwhiv/aids. Before we take a closer look at how he tried

to help those who lacked family or :financial support (or both), I want to introduce him, his background and

his ideas on relevant matters like the role of monks, his interpretation of Buddhism and his views on

contem-porary Thai society and Aids. 1

3.1 Charisma

Phra Phongthep is in his early forties, but looks younger than his age. He is quite tall for Thai standards and

has a curious, challenging look in his eyes.

He is considered to be an attractive man. His presence cannot to

be missed; he has a loud and clear voice and when he is in a good mood, he likes to make jokes and to tease people a little. He is unconventionally outspoken about other people or the situation around him, particularly

when they do not correspond with his ideals or sense of justice.

He

is eager to solve problems quickly, and has a lot of mental and physical energy. fustead of

waiting for the situation to change, he will take the initiative and thereby pulls others with him. Once

convinced of the necessity of a project, he shows confidence in tackling problems like fundraising, getting the right equipment and contracting people to do the work

At all times he remains conscious ofhis image and that of the centre. He knows he attracts attention

with his involvement in (care for people with) Hiv/Aids. He knows what type of images can convey his message directly and clearly, and makes creative use of that knowledge in composing the slides for his

standard presentation.2 Where ever he goes, his camera is never far away, ready to take a shot of a revealing

situation.

He is skillful in maintaining public relations, which serves a twofold objective; on the one hand the raising of (:financial) support, on the other raising broad awareness about the Aids-epidemic and its consequences. He is a good speaker and clearly enjoys lecturing people on the subject, jolting them awake

with an occasional glimpse of the grim reality of Aids. Since the start of the centre (January 1994), he has

received a lot of attention in the media, national as well as international, and from other organiz.ations working in the Aids-field. By the time I arrived he was reasonably well-known amongst most people who

1 _{This presentation of Phra Phongthep is also}

based on transcripts of an interview by Ampachaa dd 18-10-1994,

and a fomml interview dd. 29-04-95 with J.W. de Lind van Wijngaarden as interpreter.

2

(26)

were one way or another involved with Hiv/ Aids.

His big drive and passionate commitment could also result in people disapproving ofhim, a fact he

was conscious of. He described his own character as 'cajr6on' (hot headed), and he knew people found him

an agressive monk. "Doctors are afraid of me, because I cannot stand seeing injustice. When I go to hospitals

and see doctors and nurses acting not right, I attack them." In general if something happened that he strongly

disapproved of, his explosive character could get the better ofhim, but it would not last for long. I would like

to call this the 'negative' or 'problematic' side of his charisma.

3.1 A technical egineer

Phra Phongthep was born in 1952 in Samutprakan, a village on the river, near Bangkok. He comes from a

family of eight, four boys and four girls. His family eventually moved to Bangkok, where he received

highschool education. After highschool he did a one and a half year training in electronics, and passed with

high (90%) grades. At the age of twenty one he was enlisted in the army and became a medical orderly,

because the idea of armed battle did not appeal to him. At the military hospital he had his first experience

with illness and death and learned how to lay out a corpse. Before he ordained as a monk, he used to work for an NGO.

Phra Phongthep is a naturally curious person, always willing to learn more. He is fascinated by modem medicine, which manifested itself in a considerable collection of medical books in his office. Judging

from his critical comments on the medical profession, it sounded like he had read them. In general he has a

large interest in the technical and mechanical details, like for example the ins and outs of setting up a

laboratory. And although he was reluctant to speak it, his knowledge of English is above average and I

suspect much of it was due to self study.

His private life remained more of a secret. I know that he had had a long-term relationship with a

woman, but that he had never formally married her. Neither did they have any children, even though he

showed a great fondness of them. Why he actually decided to leave his 'wife' to become a monk, even though mmours go she wanted him to stay, I never fotmd out.

3.3 Ideas on Buddhism

Phra Phongthep started to consider ordination seriously in 1978-1980.3 It took until 1986 however before

this event took place, which could be attributed to the fact that he regarded ordination as a serious matter. There are different motivations to become a monk, not all of which stand the test of the ultimate aspiration of Enlightenment (cfMulder 1990: 114-115).

3

I have not been able to elicit a clear statement from him on the reason(s) why exactly he wanted to become a monk or trace such statements in the inteIViews by others.

(27)

Phra Phongthep acknowledged this by making a distinction between bitadchingching and bt'tad-paiwanwan (real ordination vs ordination ahead of time). Reasons to enter the monkhood can be very

diffe-rent compared to the Christian tradition (T erwiel lecture dd. 19-01-96). Some do it because it offers them an

opportunity to occupy a certain position in society, others are inspired by the Buddhist Teachings and

therefore want to lead their lives (or part of it) as monks.

For about a year after his ordination he lived at two different temples in Chiang Mai until he finally

moved to Wat Umong where he stayed for seven years. This temple, just outside of Chiang Mai, is famous

because it is associated with Phra Phutthathat (Buddhadhasa), a monk well-known for his unorthodox

inter-pretations of Buddhism and views on human society.4

Phra Phutthathat was a preeminent reformist~ and maintained that the Buddhist Scriptures hold

important messages not only for monks but for the laity as well. He stressed that it was possible also for

lay(wo)men to reach Nibbana, and that this goal could be reached in this life (Jackson 1989: 118). He argued

for a society based on Buddhist principles, which would bring prosperity for all (ibid., p.48-50). Although

Phra Phutthathat's line of thinking could be perceived as highly politically controversial, which it was and

still is, he managed to stay out of Sangha- and national politics (ibid., p.128-130).

Phra Phongthep's ideas were clearly influenced by Phra Phutthathat. His rationalistic approach of

Buddhism and dislike of rituals and mystifications are a good example. He perceived the traditional way of being a monk, "selling prayers and rituals" to the laity in exchange for Dana, as a type of market exchange,

and he strongly disapproved of this tradition. At the centre this attitude also became clear. Neither Phra

Phongthep nor Phra Jotika (his assistant-monk) performed rituals.

Although Phra Phongthep's notion of "~l:lc:klh!~ can be called reformist in the sense of Phra

Phutthathat, his activities as a monk differ from Phra Phutthathat. Whereas Phra Phutthathat confined

himself to writing critical books on Buddhism and society, but refrained himself from actual political

involvement, Phra Phongthep lives up to his opinion on the responsibility of a monk: "A monk is the friend of

society. By living from the almsbowl he transforms the laymen's gifts into activities for the ones who need

help." Setting up his centre to accomodate people with hiv/aids, who have no other place to go, should be

seen in this light.

4

When he passed away in 1994, it was a national event. Jackson describes him as "the most influential contemporary Buddhist philosopher monk in 1bailand" (1989:126). He is also of all Thai monks the one whose ideas are best known abroad. He is particularly popular amongst westerners (lecture on 'Modern Thai Buddhism' by

prof. Baas Terwiel dd. 19-01-96).

5

What is called reformist Buddhism is based on a thoroughgoing demytologisation of the religion's doctrines and a reduction of metaphysical entities to psychological states of mind (states of wisdom or salvation). There is an emphasis on human life in this world here and now, which creates a religious validation of the hope for socio-conomic development and material prosperity. Reformists return to the original Buddhist scriptures in the Suttapitaka and Vinayapitaka and they perceive nirvana as an accessible goal for all, laity as well as monks (Jackson 1989:47-49). It is essentially a middle-class phenomenon (ibid., p.121). Note that this interpretation can be the basis of either conservative or progressive political ideology.

(28)

Phra Phongthep was quite critical of Thai society. He called Thailand an underdeveloped comrtry and did not consider mere economical development as real development. "Real development is about

develo-ping the human mind/heart (cidcaj). Building telecommunication installations is not development." He was

convinced Aids is the outcome of a society going the wrong way. In general he had little hope for the future

of humanity.

He saw the causes for the problems in society as coming from city-life. "Simple people do not make big problems. But many people nowadays have become selfish and are consumed by craving for materia-listic things. As a result a lot of unfair things happen to people, to animals and to the environment." He showed indignation when he talked about people who rather destroyed their products, to keep the prices up, than give something to the poor. He once showed me an example of a patient at the centre, whom he suspected of taking advantage of government support. This man had obtained a health-care card, which are

meant to be for poor people, while in fuct he came from a wealthy fumily. Phra Phongthep clearly

disap-proved of this man's actions.

Another point of critique he had was on the Thai system of education. He did not have fuith in it and

thought himself more lucky than his brothers and sisters, many of whom were well-educated. I think he means to say that they lacked moral education, or a development of mentality, which he as a monk of course did enjoy. During our period of working together it became clear that he appreciated my initiative to do

things without waiting until I was told. This is very different from the way Thai people work~ they wait until

a superior gives them an order. He liked to see more people think and act for themselves and believed the education system plays a pivotal role in this matter.

He considered his daily confrontation with illness, suffering and death a good experience in

Dhamma, a "good experiment about oneself." He was outright fu~c:itiated by what is left of the humanJlOOY

,.-o ' --._,_ ''-"••~-- -~ '''""""'"-' ""''"' ',,_,,,.,,,,, ''" ,,,

"'"u•--~--~--after death and attended many autopsies in hospital. He would contemplate on the human body comprising

only flesh, muscle, bones, skull, nothing more. "In the past this body used to crave many things. Before death

these corpses were able to laugh, grieve, crave ... Soon we will be just like them, we can not avoid it. If so,

why shouldn't we prepare ourselves for death?"

He would joke about the matter oflife after death: "If you can not deal with or control your own life

now, why worry about a next one? You have to learn from past experiences in order to make the best of

today and the future. If you manage this you do not have to be shaky. Because we don't know if we will be

alive tomorrow, we should be prepared and mindful all the time. This is a social problem. If only people

would be interested in life, in a contemplative way. But monks and people in general are not interested, they

just live like that6."

His ideas on the question about the human soul whether it is reborn, was typically Buddhist. Also the Buddha gave the advice not waste time on things you cannot know. Phra Phongthep told people

repeated-6

(29)

ly not to bother about it and gave the following advice: "Just look at the body -if you dissect it untill the

smallest parts, what is it? All of this is illusion, because the most fimdamental part is this -in all of this there

is nothing else but the interaction between the smallest parts. After death you go back to this process. And

the law of cause and effect rules everything."

It may be clear that Phra Phongthep takes the contemplation on death and other Buddhist ideas (e.g.

on life after death and the (non)existance of a soul) to heart, and not only that, he is convinced it is useful to

prepare ourselves for death, not only individually, he also sees the advantages of this type of preparation on a

societal level. He showed a great concern about the moral decline of human society, and he had very strong

opinions on moral and just behaviour of both monks and laity. This comes to the fore as well in his ideas on

Aids in contemporary Thai society, which received full attention in the slideshow that he used for the

promotion of his work at the centre.

3.4 Ideas on Aids

This slideshow consists of 76 slides and a 20 minute prepared speech.7 It was tape recorded and played

whilst showing the slides. Phra Phongthep took the pictures himself or when he was in them, had arranged

them to be taken. The speech consisted of his comments with each particular slide. This slide show was

performed at the centre at an average of four to five times a week. Phra Phongthep would also show it on

funerals, at schools and other informative meetings on Aids. I will confine myself to the vital points Phra Phongthep wanted to make in front of his audience.

Firstly he wanted to raise awareness on the scope of the problem in Chiang Mai by mentioning how many people died of Aids every day in the major hospitals, and under what type of circumstances. He

pointed out that because of fear people with Aids were rejected and abandoned. As there were not enough

people to care for them, ''their lives ended in suffering, in body, mind and spirit."

t. '~·v•/\

>t

·t)"f

He mentioned ~~~!~.i~!~~:<:.':".~~~ as an important r~§.~~91'the rapid spread ofHiv, and held the

government responsible because it had in the past been more concerned with income derived from tourism

and foreign investment, than preventing the spread of Hiv.8 He also recognized the consequences of the

recent societal changes, in particular the loss of warmth and security in fumily life. Many young people run away from home and become involved in commercial sex, which inevitably leads to their tragic death from Aids. There were a couple of slides of dead people.

After this brief exploration of the problem, he focused on the role of monks, who should help to

relieve the suffering of fellow human beings, in exchange for the alms they receive. He explained that the

centre's philosophy was baised on humanism, loving kindness ~ and compassion (Karuna). He

7

It was translated into English by Katherine Bond

8

Ungphakom and Sittirai mention this in their article "The Thai response to the HIV/ AIDS epidemic" in AIDS

(30)

described the activities of the centre as follows: "It is a recovery centre which provides both physical and

spiritual healing for people with Aids who are impoverished or have been rejected by society."

He then showed slides of a couple of people who had come to the centre and had either miraculously recovered from their complaints, or had died peacefully in a supportive environment. Phra Phongthep

stressed the importance of friendship and moral support in these stories and called them the ":first types of

y-'"•-,,~,-,~m- ,~,,--,,, ."''"' .t'd'•' N, -"'""'·"'''''·"'-''A>'•••'•<,.,,,_, '•'" '' _,,,,,'' '°' ' ' • ' " '"''

medicine" a person would get at the centre.

People with Hiv/Aids were actively involved in providing care for others, on condition they were

willing and able to learn. Phra Phongthep stressed the fact that medicine and IV-drips were administered in

accordance with physicians advice and instructions and that herbal medicine were used in case of mild

symp-toms or as a supplement to improve the immune system. Following it was shown that people were also stimulated to engage in activities like gardening, sports, hobbies, painting and chanting to put the mind at ease.

Phra Phongthep expressed his. criticism of reg1:J:lar hospital~. by telling the audience about health-care

&p'·r''"~-~ '~ ,.,. ,., ' ' '"-'"'···"

professionals who sometimes exploited relatives of Aids patients, by charging exorbitant fees for the

preparation of corpses.

At the centre this happened for free, or for around 100-200 baht (that were the real

costs). fustruction on the laying out of a corpse was included in the show.

From this presentation the impression was created that the centre provided adequate care in a friendly, non-discriminating atmosphere and that everything was done to help people live positively and

actively as long as possible, with an open eye for p~chological and spiritual needs. The show ended by

repeating the philosophy of the centre once more; 'We hope that through sincerity, love, compassion and good will towards each other, we can work together to solve these problems."

Here ends my presentation of Phra Phongthep, his ideas, his evaluation of Aids and contemporary society,

his vision of a more human community, helping people at what could easily be the worst time of their life.

But it is not sufficient to merely present him. He operates in Buddhist Thailand, where the social status of

monks is considerate but their role is also quite rigidly defined. fu order to be able to 'place' Phra Phongthep, there are two subjects I need to address. Firstly the social status of monks in general and secondly the phenomenon of political monks.

3.5 The social status of monks

Monks occupy the highest position in the Thai social hierarchy, in fact even the king has to show his respect

by making a wai9 to a monk, which traditionally will not be returned (ferwiel lecture dd. 19-01-1996). This

'natural' respect is partly respect for the yellow robe as a symbol of the Buddha and it is very clearly shown

9

The Thai way of showing respect and greeting by bowing the head to meet the thumbs of lx>th hands, palms pressed together and fingers held upwards. The lower the head, the more respect is shown •

(31)

)

by bodily conduct; one of the first things you learn as a foreigner is to sit with folded legs in front of a monk

(and a statue of the Buddha), and to be always in a lower position than a monk. This is only one example of

the many overt expressions of respect for monks.

As I indicated earlier, this high social status has far reaching consequenses for the actual interaction

--·-··-···~· "• --·"-µ .. ,, _

_,-,~~-between monks and lay people. The latter is in no position to either question or raise objections to decisions

taken by a monk, let alone give his opinion or advice. Nobody in his right mind would offend a monk in this

way. The Sangha itself however, is a highly hierarchical institution (cfSomboon 1982:40), which provides the authority to senior monks to give directions or orders to a junior monk. There is a special judicial body

that deals with monks who have committed an offence.

Even though the tradition to spend three months as a monk before marriage is declining amongst

young men, to become a monk is still a more common or normal thing to do than in Christian societies.

---~-~ ·~----. _,_ ---··

··-·"--~--··"-Monk.hood offers many youngsters, particularly from the poorer rural areas, the opportunity to get some education and a way out of poverty. Monks who make use of their special talents, ranging from extra ordinary spiritual powers in the making of amulets to the ability to gather lay support (and money) for their activities, stand a good chance to make a succesful career, even to become famous.

As a monk it is possible to make use of this powerful position, although it would be wrong to give

the impression monks do not stand corrected when fotmd guilty of breaking the precepts they have vowed to

, , / \ , / ' ' ' J ' ' ' " '

keep. Although this is difficult, particularly when he has a large group of followers or occupies a high

position within the Sangha, it is not impossible, as the case of Phra Yantra indicated. This charismatic monk

was forced to disrobe in 1995, after many months of trial, in which he was found guilty of having had sexual

relationships with several women. And even when a monk does not stand corrected in such a dramatic way,

if people are convinced he does not live according to the rules, they will pay respect to the yellow robe, but to

no more than that.

3.6 Political monks, recent developments

It is no exageration to state that the Aids-epidemic poses a serious threat to Thai society, disrupting already

fragile social relations (family) and commooities. Some monks, like Phra Phongthep, perceive an urgent need here for their support to the laity in these trying circumstances. They see new roles for themselves. However,

their practicial involvement with societal problems will always be controversial. Monks who become too

overtly involved with 'this-worldly' matters in a way that goes against the established political order and the fundamentals of Buddhism, run a considerable risk to become isolated in the Sangha as well as society at large.

Ideally a monk does not become involved in such matters like politics or Aids. The traditional view is that by doing so a monk desecrates himself, the Sangha, and in fact Buddhism as a whole. This is a

serious matter, because of the ideological link between Buddhism, the nation and the king. This tradition of a

(32)

'holy trinity' in Thai nationalism, was strengthened during the regime of King Chulalongkom and King Wachirawut, as a safeguard against colonialism (Somboon 1982:2). And it was strengthened again during the regime of Sarit Thanarat (1957-1973), to legitimise his authoritarian form of government. This link and

its consequences for popular judgement of monks still prevails today.

The phenomenon of politically engaged monks is relatively new to Thailand, where ''the vast majori-ty of monks have kept free of political activimajori-ty since the establishment of the strong Chakkri dynasmajori-ty (1782)"

(Tambiah 1976:461). Since then the well-being of the royal family and the Sangha have been intimately

linked. The Sangha provided the legitimation of the king by accepting and explaining his right to rule on the

basis of his past merit. The Thai king "came to be endowed with a semi-divine status" (Jackson 1989:41)

and in return granted favours to the Sangha. Jackson calls this 'Royal Buddhism'.

Royal sponsorship of the Thammayut Order during the reign of King Mongkut and the reigns of his

immediate successors, King Chulalongkom and King Wachirawut has been the divisive element in political

conflicts within the Sangha. Thammayut monks were associated with the ruling power, whereas Mahanikay

monks were identified with the interests of the 'Thai people' and with the struggle for democracy and social

justice (ibid., p.65) This identification "dates from the period of the 1932 revolution but has received renewed emphasis and popularity since the student agitations of the early 1970s and the rise of the middle class" (ibid., p.66).

Here we can find a recurring theme, the dispute about the Sangha's dual alle~ce, both to the ~)

,_.,.,~,.~,--""~_..,," -,,.,. "'' •"•<'«'" .·~. '"·"=;• •. ~.,,,~ ""·'- i,,,,,." .,,,,,, .. /

that officially protects and sponsors it and to th~ common peq>le who daily give alms food to the monks and

• ... , ' " ' ' ' ' .

who financially and materially sponsor their local temple or meditation centre (ibid.). This dispute about

where the loyalty of monks should lie can be traced back to these days and continues to be a point of

discussion today.

It no doubt contributed to the emergence of so-called political monks in the seventies (Somboon

1982:9), which is the backgroood against which we should view Phra Phongthep's activities. By exploring

the role of political monks and the way this role transformed over time, I want to show that there ~x:isted a

J

model of the monk as reformer or develop1llent worker, which Phra Phongthep could adapt to. But we

should first return to the sixties when government policies aiming at the development of the comrtry-side with the assistance of the Sangha were developed.

Regardless of a general difference of opinion amongst government officials and (high-ranking) members of the Sangha, whether monks should or should not be involved in commllllity development work,

since 1963 both Buddhist universities have had training programs for monks who were to be assigned

upcountry to encourage social welfare and train provincial monks in modem welfare work (Mulder 1973:13).

This government-program was spurred by two diverging developments. On the one hand a sincere

wish to support the peasant population in combating rural poverty and ooderdevelopment, and on the other

"A ripe mango has to fall..." : care for people with HIV/Aids in a Buddhist Centre in Northern Thailand

'

mangoh

People with Hiv/ Aids

in a Buddhist

in Northern Thailand

Bijdendijk

, for a Masters

Department of Anthropology

F

acuity of Political and Socio-Cultural Sciences

University

of

Amsterdam

Social Research Institute

Chiang Mai University

Under the supervision of

Dr Han ten Brummelhuis

Depa1iment of Anthropology

University of Amsterdam

tI

ome address:

J

Bijdendijk

Boetonstraat 40-lll

109 5 XN

Amsterdam

The Netherlands

1-20) 6 632 683

Preface

Contents

Introduction of the problem and the setting

i

ili~"J~;_;ni}i)md th(~~~y·

()f

Chapter 2

Health care

in

Thailand

(c~oeksema iJrfRa~ehsch!~~ ~?~~'')990:279)

td

f4).

s

~public

]

1

~

Phra Phongthep

He is considered to be an attractive man. His presence cannot to

He

>t

At the centre this happened for free, or for around 100-200 baht (that were the real

)

J

₁