Johns Hopkins Magazine -- February 2000
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Chris Beyrer's brand of public health routinely takes him into unstable lands, where misery abounds and other researchers dare not venture.
P U B L I C    P O L I C Y    &    I N T E R N A T I O N A L

Lighting the Heart of Darkness
By Melissa Hendricks

One day in 1994, several motorized canoes puttered up the Salween River, a deep torrent of glacial melt that races down from the Tibetan Himalayas into the heart of the Burmese jungle. A gloomy canopy of trees shrouded their passageway. The riverbank was still and quiet. But an inscrutable force lurked in the shadows. The Burmese junta had recently swarmed through the region, hunting for rebels, in the process forcing local residents from their homes. The little boats passed villages of bamboo and thatch huts, each one a ghost town, its residents having fled to escape the soldiers. At times the rat-a-tat-tat of distant gunfire punctuated the eerie silence.

The boats carried armed members of the All Burma Democratic Student Front, one of several insurgent groups that had been battling the junta for years, hiding out in the rainforests. Recently, the military had burned a camp where several thousand Front members had been staying, and stolen their medical supplies, forcing the rebels to move deeper into the rainforest, to an area brewing with malaria. Hundreds of the insurgents were now severely ill, but they lacked even a single tablet of quinine.

Healthy members of the group had gone to seek help. They had obtained several boxes of malaria medication, which the small boats now ferried back up the river to their new camp. Also in one of the canoes, hunkered down low out of the sight of sniper fire, was the physician who had secured the drugs for the student rebels, a passionate young man with smiling eyes named Christopher Beyrer.

After six hours journeying up the Salween, the boats stopped at a small beach, and the passengers began to disembark. Suddenly a dozen young men and women emerged from the woods, shouting. They led the travelers to a hidden trailhead, then down a long rugged trail that ended at a camp where several thousand people were living in hastily constructed shacks.

Inside the dark huts, the doctor found hundreds of people huddled in blankets and shivering despite the thick, steamy air. Many stared glassy-eyed, teetering on the verge of coma.

Beyrer did not spend a lot of time attending to the sick. The rebels had doctors among their own who could do that. Instead, he sat down with the group's leaders and began asking them questions. How many people were camped there? How many were sick with malaria and other diseases? What supplies did they need? He carefully recorded everything they told him, planning to tell the world what he had seen. Dodging sniper fire is not something Christopher Beyrer does every day. He's not a particularly James Bond-type of person. But Beyrer, an AIDS researcher, believes that observing public health from an office or laboratory does not unveil the full extent of what is happening in the field.

"You know, papers in the medical literature are short," he explains. "They can't capture the personal stories of Buddhist monks who are caring for the patients, of prostitutes who are trying to deal with the epidemic, and all the other tales that don't really fit in peer-reviewed journals."

Formally, Beyrer is an epidemiologist at the School of Public Health. He directs the Johns Hopkins Fogarty AIDS International Training and Research Program, which is sponsored by the National Institutes of Health. Hopkins's piece in this multicenter program involves 19 faculty members from Public Health who teach scientists from developing countries to conduct AIDS prevention research.

Informally, Beyrer is a sort of freelance human and medical rights advocate who studies the political, social, and cultural aspects of the AIDS epidemic, as well as its medical side. So along with publications on the molecular subtypes of HIV in Thailand, strategies for preventing HIV, and preparations for an HIV vaccine trial, his CV lists papers and book chapters on health and human rights in Burma and Cambodia, the policy implications of the HIV and heroin epidemics in Burma, and the torture of Tibetans by the Chinese. Beyrer has been a medical advisor to the Dalai Lama and is friends with Nobel Peace Prize winner Aung San Suu Kyi, the democratically elected leader of the Burmese people whom the military regime has barred from holding office. But most of Beyrer's eclectic projects, in one way or another, relate to preventing AIDS. So even as he delivered anti-malarial medications to the student rebels on his trip up the Salween River, Beyrer also gave them several cartons of condoms, warning the group that they were near a raging HIV epidemic.

As medical advisor to the Dalai Lama (center), Beyrer (second from right) visited Dharamsala.
Friends and colleagues praise Beyrer's professional versatility and say he executes his many roles with compassion, intelligence, and integrity. "He's very good working with scientists, public health people, NGOs [non-governmental organizations]," says Kenrad Nelson, director of epidemiology at Public Health. "He has tremendous international experience. He's also a very creative, warm, and interesting guy."

"He's the person outside of Burma who knows most about HIV and drugs and their relationship," says Tom Malinowski, who was formerly a speechwriter and on the policy staff for the U.S. State Department, and is now a foreign policy speechwriter at the White House. "He's not just an activist. He understands the public health problem."

But not everyone in the public health field is keen on Beyrer's way of operating. "Some people feel it should be apolitical," says Nelson.

Beyrer believes that avoiding the broader political and social issues costs lives. Civil war, ethnic conflicts, and other political crises lead to human rights abuses and fuel public health disasters such as the AIDS and heroin epidemics now raging in Southeast Asia, says Beyrer. Protease inhibitors and condoms are not all that is required to fight AIDS. There must also be political solutions. If it's Monday, Chris Beyrer must be in Asia. He's always jetting off somewhere. He was scheduled in January, for instance, to visit two remote provinces in Laos, to conduct a workshop in China in preparation for an AIDS vaccine study, and to meet with Thai colleagues. So it's rare to catch him at a moment when he's not returning from or going to somewhere overseas.

This past fall, Beyrer alighted for a few days in Baltimore and took an afternoon break at his home to talk about his job and his life's adventures.

He lives in a loft apartment in a renovated canning factory on the outskirts of Baltimore's Fells Point. It encapsulates his peripatetic life, like the home of a ship captain who has sailed many times to sea and back. Colorful tapestries from India and Vietnam hang over the exposed brick walls. Stone and wooden Buddhas rest on bookshelves. As an early evening storm prematurely darkens the room, Beyrer flips on the light in his kitchen, illuminating a wall covered by framed photographs. In one, a Buddhist monk tolls a bell while another washes silver cups in front of a sun-drenched yellow wall in India. In another, Beyrer and two other men stand behind an enormous stone jar in Cambodia's ancient Plain of Jars. In a third, Beyrer holds hands with a brilliantly smiling Dalai Lama.

"I got interested in Buddhism and basically in Indian philosophy, believe it or not, as a teenager," says Beyrer. He read Western philosophy, went through a Camus period, a Virginia Woolf phase. "But all at some level really disappointed me. They were not wise enough about why the world was so full of suffering and also not practical enough."

Then he read a book by Eastern philosopher J. Krishnamurti, who asserted that the only real revolutions are within. This made sense to Beyrer, who continued to read and embrace Eastern philosophy. When he went to college, at Hobart and William Smith, in Geneva, New York, he declared a major in Asian studies, and planned to go to graduate school for anthropology.

As he talks, Beyrer cruises through his living room, apologizing for the household tasks that have gone undone while he was away in Malaysia. He picks up some stray papers, feeds the fish, puts a kettle on the stove for tea. Outside, the storm rattles the skylight.

Senior year found Beyrer studying an Eastern medical practice called ayurveda, in Sri Lanka. He lived with a family that practiced Buddhism. He learned meditation, awoke to the hypnotic chanting of the sutra. The grandmother of the household cut off his waist-long hair. By the end of the year, he had decided he would forgo graduate school and become a Buddhist monk.

At age 22, he moved to a remote Buddhist monastery called Hemis, in Ladakh, at the edge of the Himalayas. While the Chinese had squelched Buddhist practices in Tibet, Ladakh was under Indian occupation, and the monks were permitted to practice their religion.

In the ancient stone monastery, Beyrer learned techniques of visualization, breathing, and yoga that Buddhists use to seek enlightenment. "The entire goal is to realize the inherent non-existence of the self and to cultivate compassion for all sentient beings," he explains.

Beyrer's mentor was His Holiness the 14th, Drukchen Rinpoche-the abbott of Hemis and also mayor, justice of the peace, and arbiter of all local disputes. Beyrer would sit at the foot of his throne while Rinpoche attended to secular affairs, and wait for the chance to learn more about Buddhism. To Beyrer, in a world filled with violence, where almost everyone seemed confused, the obligation to be more compassionate rang true.

But all was not peaceful in paradise.

Refugees fleeing Chinese persecution were streaming out of Tibet. Many stopped at the monastery. "They had tremendous health problems," says Beyrer. Tuberculosis, malnutrition, vitamin A deficiency. They told about walking for weeks and weeks.

Beyrer helped the monks care for the refugees while continuing with his Buddhist training. But during their daily discussions, the abbott began to query Beyrer: When was the young man planning to return to the United States to attend medical school? Beyrer was surprised. He had never discussed the notion with Rinpoche. After all, he was going to be a Buddhist monk!

In a world filled with violence and confusion, Buddhism rang true for Beyrer. The goal: "To cultivate compassion for all sentient beings."
But as the weeks went by, says Beyrer, "I really started to feel that this was a wonderful experience for me, but I wasn't necessarily doing very much for the Tibetans. Eventually, it seemed to me I had no choice. I needed skills and capabilities to give back to the people who were giving so much to me."

So he headed back to the States and enrolled at the State University of New York College of Medicine, in Brooklyn, and came head on into the AIDS epidemic, a challenge that would change his life.

It was 1984. Brooklyn was one of the epicenters of AIDS. Hospital wards were full of very sick AIDS patients. Yet there was no AIDS test, just a simple clinical diagnosis.

AIDS took on a personal importance to Beyrer, when, as a medical student, he fell in love with a man named Ed Luther, a Shakespearean actor and a poet who shared Beyrer's interest in Buddhism. During Beyrer's final year of medical school, Luther tested positive for HIV.

For the next several years, Beyrer cared for Luther, while trying to juggle his work and medical training. Fortunately, Beyrer himself did not become HIV-infected.

At the same time, Beyrer was developing a career. He volunteered to spend a two-month stint working for the health department of the Dalai Lama's government-in-exile, in Dharamsala, caring for thousands of refugees who had descended upon the Tibetan settlement. Then, in 1990, he began a residency in general preventive medicine at the School of Public Health. Never the underachiever, he also pursued his master's in international health at the School of Public Health and worked as a fellow in the School of Medicine's infectious diseases division.

Luther was too ill to work, so Beyrer moonlighted at two AIDS clinical studies to help pay the bills. He also shuttled Luther to doctors' appointments in New York, where he was insured. And every week, he'd learn about another friend who had died. "I and one other guy in a large circle of friends are the only ones who are now living," Beyrer says, shaking his head.

In the fall of 1991, Beyrer went to Trinidad, to do a preventive medicine rotation at the Pan American Health Organization. But while he was there, Luther's condition deteriorated. Beyrer rushed back to New York.

"He died on September 25, 1991," Beyrer recites. "At 11:51 in the morning. In my arms on the AIDS ward at Mt. Sinai Hospital in New York."

Beyrer pauses. The rain is still pounding and the shadows are casting a gloomy pall on the dark brick walls. Beyrer has forgotten the tea. He starts to rise but sits back down. It has steeped far too long.

After Luther died, Beyrer lost five more friends to AIDS in the span of six months. "I just couldn't go on," he recalls. He retreated to a house on Fire Island that a friend had offered, and began to write a memoir and to think.

But then a phone call pulled him out of his seclusion. Friends invited him to Washington where he learned that Hopkins was looking for someone to direct two new HIV-related programs, based in Thailand. Beyrer interviewed for the job and was immediately hired. In 1992, he moved to Chiang Mai, Thailand, as field director of the PAVE (Preparation for AIDS Vaccine Evaluations) and HIVNET (HIV Network for Prevention) projects.

Beyrer (top, white shirt) surveys a group of Hmong displaced persons in northern Laos in 1995.
Little did Beyrer know when he arrived in Thailand that Chiang Mai was a center of the Burmese democracy movement in exile. Nor did he comprehend the extent of political repression in Burma and the toll it was taking on ordinary citizens.

When Burma gained its independence from Britain in 1949, it was said to be the shining jewel of Asia, replete with rubies, jade, and timber. It had one of the highest literacy rates in the continent and excellent universities and medical schools. It also was home to a rich amalgam of cultures-more than a dozen major ethnic groups.

But the military took power, and over the years various regimes have brutally clamped down on civil rights, squelching free speech and freedom of the press, and brutally repressing dissenters.

The United Nations, U.S. State Department, and human rights advocacy groups have reported large-scale human rights abuses on the part of the Burmese military including persecution, torture, rape, and forced labor. Ethnic minorities have been the targets of much of the violence and abuse. The ruling junta, which now calls the nation Myanmar (although the U.S. still refers to it as Burma), has tried to downplay or deny these claims.

Two years before Beyrer arrived on the scene, voters had elected into office a government headed by Aung San Suu Kyi, an outspoken critic of the regime and advocate of non-violence. Surprised at the outcome, the regime placed Suu Kyi under house arrest in Rangoon and jailed members of her National League for Democracy. Suu Kyi, who was subsequently awarded the Nobel Peace Prize is now permitted restricted visits in Rangoon.

Beyrer had begun meeting members of Suu Kyi's government-in-exile, and it was through those contacts that he found out about the rebels stricken with malaria in the Burmese rainforest. On that journey, he for the first time got to see who the rebels were. "These were students, journalists, poets-Burma's best and brightest," he says. "They were holding out in the rainforest against terrible odds, all in the service of democracy."

Back in Chiang Mai, he wrote news and feature stories about what he had witnessed in Burma, and published them under a pseudonym in two English dailies. He remained in contact with Burmese exiles and did relief work for the opposition. He also made contact with Burmese opposition groups in Laos and Vietnam.

At the same time, he continued to direct the AIDS vaccine studies. Through those projects, he began to uncover the impact the Burmese military regime was having on people's health, particularly that of sex workers in the bars and brothels of Chiang Mai and Bangkok, Thailand. Among his discoveries was that an extraordinarily high percentage of the sex workers were not from Thailand, but from the Shan States, hundreds of miles away in northeastern Burma.

After working in Chiang Mai for several years and traveling throughout Southeast Asia, Beyrer used what he had learned to write a detailed account of the epidemic. War in the Blood: Sex, Politics and AIDS in Southeast Asia (Zed Books, 1998) is about to go into its second printing.

Secretary of State Madeleine Albright used the chapter on Burma for talking points. The United Nations General Assembly referred to information in the chapter on human rights abuses in Burma in drafting a recent resolution. A congressional caucus on the rights of women and Asians also cited information in the book on prostitution, bondage, and trafficking of sex workers in Asia.

The Burmese, says Beyrer, while not directly referring to him by name, denied that the HIV epidemic is as vast as he reported. The Burmese declared that fewer than 25,000 HIV cases have been recorded, while Beyrer, applying United Nations estimates, stated that the figure is more than 400,000. In Burma, where condoms were illegal until 1993, the AIDS control and prevention policy is one of denial, says Beyrer.

Beyrer photographed this group of Mon refugee children during a trip he made to the Thai and Burmese border last year.
Beyrer's seventh floor office at the School of Public Health overlooks the fringes of an impoverished East Baltimore neighborhood-abandoned rowhouses, boarded-up storefronts, homes in disrepair. A busy commerce also takes place on certain street corners and back alleys of this neighborhood. It involves the sale and purchase of "China white" or "number four."

Many of the dealers and consumers of this super-pure heroin probably have no idea where it comes from. But chances are it was grown in a poppy field in Burma, which reportedly supplies 80 percent of the heroin sold along the eastern seaboard of the United States, and 40 to 60 percent of the heroin worldwide. The story of AIDS in Southeast Asia would not be complete without a chapter on the impact of number four.

Over the past few years, Beyrer has visited opium-growing regions in Southeast Asia, and tracked the trafficking routes that lead from the infamous "Golden Triangle" to cities like Baltimore and Miami. Heroin has played an insidious role in AIDS in Southeast Asia where, in every country except Cambodia, the epidemic began in drug users.

In March 1998, Beyrer traveled to Manipur, a state in the northeastern corner of India, along the Burmese border. He planned to verify allegations that it was the entry point for heroin coming from Burma. He also wanted to interview local people who would know something about heroin and AIDS. Accompanying him was a crew from the BBC with whom he was working on a documentary about Burma's heroin trade.

Manipur was under strict security laws. It had been the site of civil war for decades, since declaring its independence from India. Armed Indian national and Manipuri state forces and a dozen insurgent groups were doing battle. "There were more guns, more fear, more violence than anyplace I've been," says Beyrer.

Given the repressive state of affairs, says Beyrer, "obviously, if we'd said, 'We're a film crew and a medical doctor and we're going to do an investigation of heroin and AIDS,' we couldn't get in." So Beyrer and the crew pretended to be birdwatchers on a visit to Manipur, a famous site for certain rare species.

After an initial slow start (Beyrer and his companions were arrested as soon as they got off the plane, but were eventually let go with the help of local contacts), the team conducted about 40 interviews with local AIDS authorities, drug treatment counselors, heroin users, and dealers. Beyrer verified that heroin was entering Manipur via the Moreh Road. His contacts there and in other parts of Asia also confirmed that the Burmese military regime was condoning, if not aiding, drug traffickers.

Findings such as these are incorporated in the documentary, which aired in the United Kingdom. The goal, says Beyrer, was to deter would-be drug users by showing the full ramifications of the heroin industry. "Heroin is a white powder, and I have often thought when I've seen it that it really is made out of the bones of poor people," Beyrer says in the film and concludes: "The ultimate end of where your [drug] money is going is to support one of the worst dictatorships left in the world."

Beyrer's travels rarely have one purpose. And his trip to Manipur was no exception. In addition to filming the documentary, he was gathering information for a unique study that would tie together several pieces of the heroin/AIDS puzzle.

Heroin trafficking from Burma into China, India, and Vietnam had increased during the '90s. And public health officials along heroin trafficking routes had been desperately trying to call attention to rising heroin use by local people and an alarming increase in HIV among IV drug users.

Beyrer hypothesized that the link between heroin trafficking and emerging HIV infections was so tight that drug trafficking routes would even predict the path of the epidemic. And he believed he could demonstrate this scientifically.

In fact, much of the data Beyrer needed to complete his study already existed.

Drug enforcement officials and narcotics control experts had gathered reams of surveillance showing heroin trafficking routes around the Golden Triangle. On the other hand, medical experts had painstakingly recorded HIV rates.

"Interestingly enough, the two groups of people have almost no communication," says Beyrer. So he put together both types of data.

For one part of the project, he gathered information (including satellite photos) about where opium poppies were being grown and the routes heroin traffickers were taking. He and his colleagues conducted confidential interviews with those who were intimately familiar with the source and distribution of heroin. He used this data to generate a map of overland heroin trafficking routes in South and Southeast Asia.

For the second phase of the project, Beyrer and collaborating epidemiologists and virologists mapped the direction of the HIV epidemic in South and Southeast Asia. They tracked the path of HIV infection by identifying where different genetic subtypes of the virus occurred, a strategy that is part of a new field called molecular epidemiology. A subtype is like a virus's calling card, or ID number. By connecting the dots of where a particular subtype occurs in a region, scientists can map the route of infection.

Beyrer then compared the map of heroin trafficking to the map of the paths of HIV infection. "And it turns out that they each map the other very predictably," he says.

The maps showed that four relatively recent outbreaks of HIV-1 among IV drug users in South and Southeast Asia were linked to heroin trafficking routes. HIV was being spread along these routes at least partly through needle sharing, says Beyrer. Petty drug dealers were crossing national borders to purchase heroin and were borrowing needles and syringes to test the dope before closing their deals.

Beyrer and his collaborators (Myat Htoo Razak, Khomdon Lisam, Jie Chen, Wei Lui, and Xiao-Fang Yu) reported these findings in the January 2000 AIDS.

"I'm trying to use the power of epidemiology to help move the politcal debate, to empower the disenfranchised," says Beyrer.
The study, says Beyrer, validated local public health officials' reports-that HIV rates were skyrocketing with the appearance of heroin in their regions. For example, in recent years, Chinese physicians had become alarmed at a rising HIV rate among IV drug users in a remote region of China near the Kazakhstan border. How could they be getting infected? The explanation became clear with the results of Beyrer's studies. The Chinese/Kazakhstan area is a major heroin trafficking route, and the HIV-infected patients carried subtype B/C of the virus-the same subtype seen in Burma at the start of the trafficking route.

The study, says Beyrer, also underscored how rapidly HIV follows the spread of heroin trafficking. In the last three years, heroin traffickers established a new route through Laos, North Vietnam, and China. In less than a year, the HIV infection rate among IV-drug users in Pingxiang, China, one city along that route, soared from a first case to 22 percent.

From a public health perspective, says Beyrer, "If you know a drug route, you should know the towns and cities where you need to do prevention." If heroin traffickers are carving a path through a region, then governments and health authorities should prepare to prevent the double scourge of drug addiction and HIV that inevitably follows, through safe needle programs, AIDS education, and drug treatment programs.

Beyrer presented his results to representatives of the State Department, CIA, and Drug Enforcement Agency. State Department officials were extremely impressed, says Tom Malinowski, the former speechwriter for Albright. He says Beyrer's findings bolstered Albright's talks with nations bordering Burma in which she warned of the health and human rights threats posed by that nation in order to encourage them to be more forthcoming in denouncing these violations.

Such results are heartening to Chris Beyrer. "I'm trying to use the power of epidemiology, the tools of public health," he says, "to document, describe, and realize health and human rights issues, to help move the political debate, to empower the disenfranchised."

Which brings him back to Buddhism. "I feel there is no separation in my work and in my Buddhist practice," he notes, adding, however, that he struggles to adhere to the non-competitive principles of the faith while working in the ultra-competitive environment of academic research. He often reminds himself that his goal is to alleviate suffering, not get promoted.

Buddhists believe that everyone has been reborn many times, so many times that every person has been the mother of every other person. The lesson is to treat everyone with as much compassion as one would treat one's own mother. Beyrer has his own personal version of this teaching, that he keeps in mind when he works with HIV-positive patients and volunteers. "I think of Ed," he says. "I try to see everyone as him."