At first glance, Thailand is a strange location to carry out medical trials. The CIA rates the country as merely an "emergent democracy"; the last military coup was only eight years ago; and there were Bangkok riots in 1992, when 91 died or went "missing". Corruption is de rigeueur, while police are accused by Amnesty International of "extra-judicial killings". Much of its profile relies on sex: first with young women and later with children.
Since the coup, however, quick cheap, experiments on the Thai population have been added to the country's attractions. Dozens of projects are currently in progress, run by foreign pharmaceutical companies and sponsored by the CDC and WHO. With an estimated 800,000 Thais infected with HIV, Aids is the big one, with tests of drugs, immune-system stimulants, and top of the list Francis's AidsVax trial.
It makes sense to test products where the risk of Aids is greatest, but my attention was drawn to potential problems during a conference in a Bangkok hotel. The topic was Aids vaccines. Francis spoke. And a doctor pointed out that some volunteers in an AZT trial were mothers from remote hill tribes. "They come across the border from Burma." he said. "They don't speak Thai, so there is the question of whether they can understand enough to give informed consent."
The question was brushed aside ("They keep coming back.") and might not have meant much if I hadn't also met an activist from the northern town of Chiang Mai. Despite grilling 11 people who swallowed tablets daily, he complained that he couldn't discover even the name of the product or the pharmaceutical company involved. This man was a former heroin user, so I asked him where VaxGen was recruiting. "Go to Khlong Toei," he said. "By Port Authority Building. That's where they'll get people for the trial."
Khlong Toei is a slum; a sewage-stinking wasteland; a cauldron of disease and drug use. The better-off live in concrete hutches, with wire-fenced windows and balconies. Next down in the social scale are wooden-shack coops on plots of flood-prone ground. Then there are kennels: festering shantytown alleys of plank, sheet-iron and debris sheds. The "streets" are dim corridors, with boardwalk floors, cluttered with children and dogs. At night frail figures shuffle around, suffering from Aids, tuberculosis or both.
Thailand was once praised for anti-HIV efforts in disease hot zones such as this. But evidence suggests that since the 1992 coup priorities have changed. In 1992, a health minister complained that talk about the virus had "seriously affected tourism". And now, official figures show that Aids prevention has been slashed by one third against comparable public health programmes.
The biggest cuts have been in initiatives aimed specifically at drug misusers. "There used to be a project for clean needles in the early 90s, but now it's gone" a spokeswoman for a Khlong Toei charity, the Duang Prateep Foundation, told me. A health department official said the same thing. His time-frame: "about seven years ago". Targeted education, known to be most effective, has also been axed, he said.
Nobody could explain the thinking, but the effect on the junkies can be measured. Blood tests reveal that HIV prevalence peaked among female prostitutes in 1993 - when 30% were positive - and has since fallen back to 21%. Among rent boys, prevalence peaked in the following year at 18%, and is now half that figure. But prevalence among heroin-injectors has leapt from 31% in 1994 to a staggering 47% now.
Were these changes evidence that the government were allowing the junkies to be put at greater risk to make them useful for experiments? (Health department officials told me that if AidsVax is marketed, they expect a billion-dollar manufacturing plant.) I couldn't find out. People wouldn't talk when I raised such contentious concerns. Even Bangkok's Medicines Sans Frontieres staff went silent when asked about the trial.
Francis is convinced that nothing is amiss, and his collaborators voice no worries. "All have assured me that this has been done ethically," he told me, when eventually we met. "We are going out of our way not to increase the vulnerability of an already vulnerable population." The trial was conducted in Thailand, he said, for scientific reasons. Different parts of the world are linked with different HIV subtypes, with their myriad subsidiary strains. B subtype strains, for instance, are most common in North America, Europe and Australasia; A, C and D in Africa. In Thailand, there's a mix of B and E strains and, for technical reasons to do with E strains, the company argues that success is more likely there "than anywhere else in the world."
But there are aspects of the project which suggest that the junkies may be involved in an unusual way. A parallel trial among gay men at American clinics is having problems finding and keeping volunteers, due to scepticism towards the venture. But at Kachit's clinics the programme has features which may help to avoid these snags. The junkies get methadone, an oral heroin substitute, plus $10 expenses for each of up to 17 visits. The risk is the appearance of offering drugs and money as inducements to this desperate group.
There's also a feature of the experiment's design that seems self-contradictory. If the methadone liquid got people off injecting heroin, the volunteers' risk of infection would slump and they would be of little use to the vaccine trial. In fact, documents drawn up with the CDC and WHO show that that 7% of clinic users are expected to become HIV-infected each year. So, despite the oral methadone, they keep injecting heroin. They may even buy it with VaxGen's money and have an increased risk of getting Aids.
The logic of the trial creates a dilemma for Francis. The moral uncertainties about using junkies as guinea pigs might be offset by humanity's greater needs. But there would need to be plausible scientific grounds to think that AidsVax might work. And on that the VaxGen experiment is open to even greater doubts.