AIDS Hospice

One of several statues at the hospice.

Our final academic stop for the week was at an AIDS Hospice located in Lopburi, Thailand, about two hours north of Bangkok, deep in the countryside. The hospice is actually a temple, called Wat Phra Nam Phu, a beautiful sanctuary-like compound home to several hundred people and families living with HIV and/or AIDS.

The entrance to Wat Phra Bat Nam Phu.

In the past, no medical professionals staffed the hospice and no drugs or medical treatment were used at all -- spiritual support was the only means of comfort available to people lviing out their last days, weeks, or months with the disease. Recently, however, things have been changing. In an incredibly controversial move, the Thai government ignored US and international patent laws and made one of the best treatments for HIV/AIDS -- the triple antiretroviral drug cocktail -- available through its national healthcare system. This means that the death rate at Wat Phra Bat Nam Phu has plummeted from 3-4 a week to about 4 a month, and many people are calling the temple a (slightly) more permanent home.

A row of the homes for patients and families.

The stigma surrounding HIV/AIDS in Thailand is still strong, though places like this one are working to fight against it. Many of the patients were taken for a "trip to the countryside" by their families, and then dropped off in silence at the hospice gates, or even thrown out of the backs of cars or trucks. Others come to the temple to escape the censure and scorn of the outside world. Many were former commercial sex workers with few skills who find their former occupation now barred to them and have nowhere else to go.

The temple of ashes.
Foreground: Pao, tourguide.

One of the most moving testaments to the power of this stigma was found in the simple open-air temple pictured above. The stacks of white pouches are each filled with the ashes of a victim of HIV/AIDS who was abandoned at the hospice to die. After death, the bodies of each person at Wat Phra Bat Nam Phu are cremated and placed into labeled bags to be claimed by their family members. Those which have not been claimed after three months are placed in this temple below a statue of Buddha. I think the size of the stacks speaks for itself in showing just how far acceptance of victims of this disease has to go in Thailand.

One of the other controversial elements of Wat Phra Bat Nam Phu is called the "Life Museum," a kind of mausoleum containing the dessicated bodies and preserved body parts of those who have died on the compound. The corpses are tacked up on wooden boards in the open air, with small placards beside them listing name, former occupation, age at time of death, and means of contracting HIV. Before coming to the hospice, I had been under the impression that this gruesome display was meant to serve as a moral lesson to those still among the living -- behave yourselves and don't become HIV positive! -- but in fact the message was slightly different.

Interspersed with the bodies (which I chose not to photograph) were large posters with poems and lessons from Buddha concerning the fluidity of consciousness, the cyclic nature of life and death, the need to renounce material connections, and the ephemerality of the body as a vessel that carries us through the world for just a short time. I copied one of these poems into my notebook:

There's No "Me" "Me" myself doesn't really exist, So where well you find "my wife and kids"? Not to mention "my wealth" or "my stuff" Because I don't even have a "self" of my own! If those are the facts then whatever is it that Excites and sends body-mind moving around? It's just body-mind, haven't you noticed? Don't you know that body-mind is not "self"? It's merely wonderful, profound natural change That thinks, feels, speaks, and acts according to causes Just ordinary blind aggregates and elements Don't foolishly assume that "Me" exists.

I also copied the self-proclaimed message of the Life Museum itself:

The Spirit of those who have died here teaches us
how to think about our daily life today and in the future. We understand that life is all around us. But sometimes we forget that we are connected to all of life. Death is a part of life and we forget to accept this truth. Death leads to the birth of new life. We invite all of you
Who come to this place
To be silent
As you experience what you see here. This museum has many bodies That shows how death affects all of us Leading us to the truth That in this life we must do good for others.

There was so much good on view here in this place -- the good of the monks who work at the temple, accepting those whom the rest of society cannot even bear to touch, the beauty of the surrounding countryside, the serenity of this place which had been created with such care to attend to the spiritual and social needs of an already afflicted and persecuted population, the strong faith of the monks in the Buddhist philosophy of life, the generosity of the local and international tourists who donate money to keep the compound functional, the joy on the faces of two HIV positive girls playing ping-pong on the side of the road as we passed in a semblance of normalcy that would otherwise have been beyond them -- but it raised some deep ethical questions as well, and I left the hospice feeling moved but also troubled.

So much of the resources of the area seemed to be directed towards display and tourism -- perhaps a necessary move given the way the hospice is funded, but some of what we saw seemed almost too set up for display. In particular, we were given the option of walking through the clinical ward, a tiny corridor of cramped beds with people in their last throes of life. I stood outside, having nothing to offer these desperately ill people and unwilling to degrade their dignity still further by making them a spectacle for my personal edification. There are enough questions about displaying dessicated corpses in the open air as a method of public education -- what are we to say about the similar display of living human beings? On the other hand, does the "deterrence value" or "public good" of unvarnished interaction with people ravaged by this disease outweigh the individual violations of their integrity and respect?

I also wondered about resource allocation at Wat Phra Bat Nam Phu. Why did it take so long before drugs were made available to the patients there? (The government healthcare system had previously funded other antiretroviral treatments before the latest patent-violating move). There are echoes here of an old and familiar debate about end-of-life care -- at what point do life-extending treatments simply extend the patient's suffering unnecessarily? what does it mean to die with dignity? how strong is the physician's duty to save life at all costs versus allowing for a more painless death? -- yet in a way I think here the case is much clearer. The difference between treated and untreated AIDS cases in this day and age is not the difference between someone dying slightly sooner with less pain and someone dying slightly later with more pain. The difference is enormous, enough in many cases to transform AIDS from a devastating terminal illness to one which becomes almost a chronic condition: livable for many years, managed with medication. If the temple had strong religious reasons to forswear medication, then why did it recently decide to provide treatment and employ a minimal medical staff? (Very minimal, by the way: one nurse for five hundred patients, according to one person I spoke to, though that figure might not be correct).

Why were donated funds spent on beautiful Western-style toilets for visiting tourists and the construction (still underway while we were there) of a magnificent staircase and brass bell on display? The answers, I suppose, are to secure more revenue by attracting and wowing more donors, and for the greater glory of Buddha, respectively, yet each one leaves me slightly unsettled. Why bother trying to pull in more money if you're only going to spend it on further cosmetic improvements instead of on patient care? Buddha is not like God, who might be pleased with your offering and help save your patients, so too much ostentatious religious display is also mystifying.

There is no question that the monks and volunteers who work at Wat Phra Bat Nam Phu do wonderful work and have created a truly remarkable oasis for people who otherwise have nothing to live for. Yet there are questions about the means they have taken to this end, questions which still nag at me now, days later. If you are interested in learning more about the AIDS hospice, there was a story on PBS with several of the monks back in 2002, which you can check out here. An article skeptical, like me, of the commercialization of the site and exploitation of its patients, can be found here.

Lopburi countryside, taken from the bus window as we drove away.