The roles of Buddhist temples in the treatment of HIV/AIDS in Thailand.

Although efforts are being made to decrease the number of new HIV infections in Thailand, less support is give to the growing population that is already affected by the disease. This qualitative study explores the roles of Buddhist temples in the treatment of AIDS in Thailand, specifically the perspectives of both Buddhist monks and persons who are living with AIDS on HIV/AIDS and the care provided at the temples. Three major themes were derived from the interviews: (1) temple as a last choice; (2) temple as a support group; and (3) the role of Buddhism and monks at the temple.

Keywords: Thailand, HIV/AIDS/Buddhist and Buddhist Temples

Introduction

Among the Southeast Asian countries, Thailand is considered proactive in HIV/AIDS education and prevention. However, Thailand still faces a serious HIV/AIDS problem. An estimated 670,000 Thais are living with HIV/AIDS and 55,000 people died from the disease in 2001 (UNAIDS, 2002a). Although the government's efforts regarding HIV prevention and education have reduced the number of new HIV infections, the number of AIDS cases is still increasing significantly. Between 1994 and 1997, the number of reported AIDS cases nearly doubled, from 13,923 to 26,713 (UNAIDS, 2002a).

Thailand's emphasis has been more on education and prevention and less on providing care for those who are in the terminal stages of AIDS. Hospitals and clinics are used only for short visits or to receive basic medical care. Most persons who are living with HIV/AIDS are unable to afford the medical care required, for either control of an HIV infection or treatment of AIDS. The Thai government has established no hospice programs (World Bank, 2000) to response to the increase of AIDS cases. Filling a need, several Buddhist temples have begun to provide terminal care for those with AIDS. However, the number of AIDS cases is too extensive for a few temples to handle and they are filled with patients, who come from all over Thailand.

The purpose of this qualitative and exploratory study is to describe Buddhist temple-based HIV/AIDS treatment in Thailand. The viewpoint of Buddhist monks who provide care for persons living with AIDS is explored, as are the perceptions of the persons who receive the care. Their approach to the treatment of persons with HIV/AIDS is unique and different from the approaches used in many other countries.

Literature Review

Because the AIDS epidemic has affected many working-age males, financial problems are plaguing many families. According to a research study conducted in Chiang Mai in 1994, most persons living with HIV/AIDS (PLHAs) in the research population spent about $974 on average on medical treatment (Kongsin, 1997). The treatment cost was about half of their salaries. In addition to the expensive medical care, both PLHAs and their caregivers lost income: the PLHAs could no longer work, and caregivers were forced to take time off from work to care for individuals in the terminal stages of AIDS.

The majority of PLHAs in Thailand spend their last stage of life at home, cared for by family members with the support of NGOs and community-based organizations (CBOs). According to Family Health International (2003), there are 465 groups for persons living with HIV/AIDS, with roughly 23,000 members in Thailand. These groups can provide only limited access to information about prevention, treatment, and care. Currently, many NGOs and CBOs in Thailand are collaborating with UNAIDS, WHO, and the Thai Ministry of Public Health to help PLHAs get access to information, treatment, and care and to help them develop networks within their communities.

Despite the efforts of NGOs, PLHAs, and the government regarding education and prevention of HIV/AIDS, HIV/AIDS is still seen as a dirty, dangerous, fearsome, and shameful disease. According to the research conducted by Kongsin (1997), more than half of the caregivers he interviewed reported that not only PLHAs but also caregivers became targets of social discrimination. Their neighbors avoided associating with them, and often they were actually forced to move out of their home communities. Songwathana and Manderson (1998) found similar indications from their research on perception of HIV/AIDS in southern Thailand. "AIDS was perceived as a disease associated with dirt, danger and death, although it was also considered to be a disease of Karma (rok khong khon mee kam) and a 'women's disease' (rok phu ying) associated with prostitution" (Songwathana & Manderson, 1998, p. 155).

Modern health programs and practices serve as an interesting counterpoint to the age-old tradition of Buddhism in Thailand, where the Buddhist religion and philosophy play a very significant role in the daily life of the Thai people. The vast majority of the Thai population is Buddhist (CIA, 2002). The teachings and principles of Buddhism were and still are a major component of Thai culture and are inseparable from Thai values and behavior.

In Thailand, a temple traditionally was "a school, a welfare institution for the poor, a hospital, a traveler's lodge, a social center, a creation and preservation of artworks, a store for jointly owned property, an ancillary institution of the administrative system, and a forum for ceremony" (Ishii, 1986, p. 26). In addition to education, Buddhist temples in Thailand provide various types of medical care. In fact, the headquarters of the Association for Traditional Thai Medicine is located in the temple of Wat Po in Bangkok (Grady, 1995; Ishii, 1986). Many Buddhist temples teach both monks and laymen the techniques of making traditional herbal medicines, and give those medicines to the community. Most of the temples in Thailand can supply herbal medicines compounded by a monk. Buddhist temples in Thailand provide not only treatment of physical illnesses and ailments, but also psychological and emotional support for those "who feel unhappy, suffer nervous disorder or undergo mental breakdowns" (Mahidol University, 1996). Many Buddhist monks work as counselors providing spiritual and psychological guidance to those who come to the temple seeking assistance.

Today, many elderly use Buddhist temples as a place to live when they are unable to find family members or relatives to take care of them. Wat Tungsammakeedhamm, a Buddhist temple in Suphanburi province, provides 40 spaces for elderly persons, whether couples or singles. In addition to the elderly, Buddhist temples in Thailand provide living space for children whose parents are unable to take care of them, persons with mental or physical disabilities, and those who are unable to live comfortably in lay society for any reason.

In light of the temples' traditions of social and medical service provision, it should not come as a surprise that Buddhist monks were among the first responders to the growing HIV/AIDS problem in Thailand. One such was Dr. Alongkot Dikkapanyo, who founded Thailand's first hospice for AIDS patients in the temple of Wat Phra Baht Nam Phu in 1992 (Wat Phra Baht Nam Phu, n.d.). Presently, there are at least three other temples associated with hospice type care for AIDS patients in Thailand. However, that is not the only role that Buddhist temples play in the fight against HIV/AIDS. With the support of UNICEF (UNICEF, n.d.), the Sangha Metta (compassionate monks) Project, was established in 1998 to engage monks in HIV/AIDS education and prevention. The Sanga Metta Project travels all around the country, giving seminars on HIV/AIDS prevention and care to monks and community leaders. By 2001, the Sangha Metta Project had educated 1,500 monks and nuns in AIDS prevention and care (UNICEF, n.d.).

Methodology

This qualitative and exploratory study describes the roles of Thailand's Buddhist temples in the treatment of HIV/AIDS. An exploratory approach was selected for this study, because little research has been done on the roles of Buddhist temples in the treatment of HIV/AIDS. The researcher conducted qualitative interviews and assumed a role as an observer-participant. The researcher visited temples where care was provided to persons living with HIV/AIDS and observed the study setting. The study identified how Buddhist monks understand and accept HIV/AIDS and treat persons with AIDS. Also, the study identified how persons living with HIV/AIDS accept and understand their illness and perceive the treatment provided by the Buddhist monks.

The temples Wat Phra Baht Nam Phu in Lopburi and Wat Thep Charoen in Chumporn were selected with the help of the Thailand Ministry of Public Health. The prerequisite for selection for this study was that the temple provides housing and other life necessities exclusively for persons who are living with HIV/AIDS. Persons with HIV/AIDS who were under the age of 18 and/or were physically or emotionally incapable of handling the interview process were excluded from the study. The subjects who participated in the study were (1) Buddhist monks who provide care for persons living with HIV/AIDS, and (2) persons living with HIV/AIDS who receive care from these monks. The interviews were performed with a total of four monks, including two monks who were living with AIDS; seven residents (three males and four females) who were living with AIDS; and one volunteer doctor. Three monks (including the two monks who were living with AIDS) and three PLHAs (one male and two females) were selected from War Phra Baht Nam Phu. One monk and four PLHAs (two males and two females) were selected from Wat Thep Charoen.

The researcher collected data by means of in-depth, semi-structured interviews, which consisted of broad, open-ended questions. Data were also collected by observation of nonverbal behavior during the interview process. A research assistant took notes during the interviews. A translator and cultural interpreter, a nurse who worked at the Ministry of Public Health, was used to conduct interviews with subjects who were unable to understand English. The interviews were conducted in a quiet, private place of the subjects' choice. Each interview took between 40 minutes to one hour. The interviews recorded in Thailand were taken back to the United States and retranslated by a native-Thai speaker to assure the accuracy and content of the interviews.

The collected data for this study were subjected to cross-case or cross-interview analysis. The answers from different subjects were grouped by topics or common questions from the interview guide. The collected data were analyzed word for word and each concept was coded. Coding consists of creating a symbol or abbreviation to be applied to a group of words or answers from the subjects. As coded data are compared, patterns, themes, and categories emerge from the data (Patton, 2000).

Findings and Discussions

More than half of the subjects (8) were male, primarily because the monks who were interviewed for this study were perforce all males. At this time, females are unable to become monks in Thailand. All subjects except two monks and the one volunteer doctor had been diagnosed with AIDS. The ages of subjects who were living with AIDS ranged from 24 to 41 years, with a mean of 31 years. Heterosexual contact was the major mode of transmission among the subjects. Of the nine subjects who were living with AIDS, seven were infected through heterosexual contact. A majority of the heterosexual contact occurred within marriage and/or consensual relationships. Only one subject identified a sexual relationship with a prostitute as the source of his infection. The length of time during which the subjects had been living with HIV/AIDS ranged from 2 months to 8 years. Most of the subjects stated that they did not get tested until their partners' or their own symptoms appeared.

Wat Phra Baht Nam Phu is located on the outskirts of Lopburi, a small rural town 75 miles north of Bangkok in Thailand and is surrounded by cornfields and small mountains covered with tropical trees. A large Buddha image stands on the crest of one mountain. Many smaller Buddha images are placed all over the temple.

Wat Phra Baht Nam Phu has one main building with about 40 beds for terminal AIDS patients who are no longer capable of taking care of themselves due to the complications of AIDS (Wat Phra Baht Nam Phu, n.d.). That building was filled to capacity when the study was conducted. The terminal AIDS patients, who wore only diapers, were observed from the open glass windows and sliding door. The smell of disinfectant and medicine leaked from the open windows.

The Wat also provides single- and double-occupancy bungalows for about 250 persons with AIDS who are less critically ill and are capable of self-care. The bungalows were built all over the temple grounds surrounding the main administrative building. Each bungalow has a bathroom and a couple of small windows. A bed is provided for each resident. The temple also provides larger bungalows in which a family can live together. Male and female residents are not allowed to live in the same bungalow unless they are legally married. A coordinator for the temple mentioned that it is not uncommon for residents to meet and marry at the temple. The bungalows for monks are separated from those of the other residents. A kitchen and cafeteria in the center of the temple are where the residents receive meals three times a day. A little store, which sells snacks, candies, and sodas, is also located in the center of the temple. Around the cafeteria and store, many tables and chairs are placed for the residents to sit and eat.

In addition to the PLHA housing, Wat Phra Baht Nam Phu offers educational opportunities. Two large meeting rooms in the temple are used for HIV/AIDS education for school-age children and any interested visitors. A big parking space was built near the entrance gate to accommodate large groups of visitors. The temple also has two museums that are open to visitors, the After Death Room and the Bone Museum. In the After Death Room, bodies of persons who died of AIDS at the temple are preserved in formaldehyde and displayed. Cremated remains of persons who died of AIDS are preserved in the Bone Museum and await family members to come to pick them up. All the museums, meeting rooms, and the store are located in the center of the temple, along with the administration building. All the administrative work, such as the financial dealings of the temple, is done in the administration building.

There are about 20 volunteers at Wat Phra Baht Nam Phu, including one-full time nurse and one volunteer doctor from Belgium, who help to provide basic medical care to the residents. A nurse from the local hospital comes to the temple every day to assist the doctor and bring necessary medical supplies. There are about 17 monks at the temple who perform funeral ceremonies. Most of the monks, 14 or 15 out of 17, are infected with HIV. There are no nuns at Wat Phra Baht Nam Phu. About three to nine people die from AIDS every day at the temple. A total of about 7,000 people have died at the temple since 1992.

The temple provides care and support for outpatients as well as inpatients. Currently, more than 10,000 persons who are living with AIDS are on the waiting list to move into Wat Phra Baht Nam Phu. Family situations and financial issues, as well as the individual's stage of AIDS, are considered in determining eligibility for admission.

Wat Thep Charoen is a small temple located in the southeast region of Thailand, 20 miles north of the center of the city of Chumporn. A Buddhist monk, Pra Kruu Wilard, founded the Wat Thep Charoen hospice program in 1996. About nine years ago, Pra Kruu Wilard was stunned to find a person who was dying of AIDS on the street, abandoned by his family and dying alone. Though recognizing his lack of knowledge about HIV/AIDS, Pra Kruu Wilard decided to take the lead on providing care for persons with AIDS. The following year, he went to a meeting held by the Department of Religion and was offered 20,000 baht to built a hospice program for AIDS patients. The hospice is isolated from the other temple areas and is surrounded by many lush tropical trees and flowers, which can be viewed from inside the building.

The hospice provides 10 beds in the main building for individuals in the last stages of the illness. There is also a small office space in the building, which is used to store medical supplies. The temple offers two concrete buildings, which contain about 20 single-occupancy bungalows for those whose illness has not progressed too far and are capable of self-care. Each bungalow has a bathroom and a couple of small windows. The two buildings with bungalows and the main building for terminal AIDS patients are sited next to each other. Next to the bungalows, there is a large sitting Buddha image and open floor space for residents to meditate and pray. There is a small kitchen, where meals for all residents are prepared.

When the interviews were conducted, there were a total of 15 PLHAs (9 males and 6 females) at the Wat Thep Charoen hospice program. They were between the ages of 20 and 38 except for 2 children, who were 2 and 9 years old. Most of the persons who were in the terminal stages of illness lay on their beds and did not move much. During lunchtime, meals prepared by other residents were carried to their beds. Residents assisted those who were unable to feed themselves.

There are seven monks and three nuns at War Thep Charoen. However, Pra Kruu Wilard is the only monk who visits the hospice program and provides care for persons living with AIDS. Pra Kruu Wilard stated that rest of the monks and nuns are not interested in providing AIDS care. There are six workers who provide basic care for the persons living with AIDS at the hospice, but there are no doctors or nurses onsite. Workers take the residents to the local hospital if medical attention is required. A diagnosis of AIDS is a prerequisite to being admitted to either temple's hospice program. Applicants are required to show a medical record issued by a medical doctor.

Three main themes emerged from analysis of the interviews conducted at the temples. Despite the different geographic locations of the hospice programs, it appeared that the subjects had had many similar experiences and reactions personally, from family members, and in their home communities.

More than half of the subjects who were living with AIDS identified their primary reason for coming to live at the temple as discriminatory acts and attitudes of their neighbors and communities. Despite the efforts of the government and NGOs regarding HIV/AIDS education, many people in Thailand still have misconceptions about HIV/AIDS. In Thailand "people still think it is taboo to talk about. People think it is a shamed disease. It is not transmitted easily, but people are scared of HIV/AIDS," stated a 24-year-old monk with AIDS. HIV/AIDS is perceived as a disease associated with prostitution and injecting drug use. "Some of the patients are innocent. They did not do anything wrong. They have got AIDS from their husband, not from prostitution or IDU," stated a 24-year-old female subject with AIDS.

Members of the general public avoid associating with persons who have HIV/AIDS. "People who know about my AIDS, they look at me differently and give me strange look," said a 26-year-old male subject. People avoid patronizing a restaurant or food vendor stall that is owned by the family of a person with HIV/AIDS. Persons with HIV/AIDS are usually unwelcome as restaurant or food vending workers, because of the misconception that HIV can be transmitted through sharing food. "I went back to work with my friends at the market, but my friends did not like me working there," said a female subject, who had formerly cooked and sold noodles at the market. A volunteer doctor echoed that point when he observed:

   Suppose there is a patient with very bad skin disease. Family and
   hospital take care of him. Of course, it is skin disease and
   everybody can see it. So in the village, everyone understands that
   he is a HIV positive. Suppose his mother and father make kap kao
   (rice meal), nobody would go to eat there, because all the village
   people know and they are afraid. So he has to come here [temple] and
   help his father and family to survive. He has a good family and
   hospital, but still has to come here.

The respondents' statements indicated that the decision to leave their families and live at the temple is a complex one for persons with HIV/AIDS. Many subjects expressed their concerns about the possible effect on their family if they stayed with the family in the community. One 32-year-old male subject expressed concern about his neighbor's discriminatory attitude, which was directed not only toward him but also at his brother and his family:

   When I was staying with my family, some of the neighbors did not
   like me staying there. I did not want to cause any trouble for my
   family. One of my brothers offered me to stay with his family and
   I thought about it. But my brother has wife and children and I did
   not want to cause any trouble for them.

Even when the subjects had a family to take care of them, many expressed unwillingness to depend on family members. "My family took care of me very well. They did everything for me. I did not like it. I wanted to take care of myself. It is too much for them. I have AIDS and they don't and I belong here," stated a monk with AIDS. This monk also expressed his concern about being a burden on his family. Another subject said, "I don't have a choice. Good or bad, I have to stay here. If I have a choice, I rather want to live with my family."

Many communities in Thailand do not have the appropriate resources, and are neither ready nor able to provide support systems for persons with HIV/AIDS. As a result, some PLHAs are pushed out of their communities and left without any place to go except these temples. One subject with AIDS called the temple "heaven for AIDS patients."

Being able to share one's thoughts and feelings with other persons who have AIDS was another major reason identified by the subjects for their coming to live in the temple. Many subjects expressed how difficult it was to live in the community, because they were "different" from others. The subjects noted that being the "same" as others helps one to live comfortably, free of shame and worry. As a 26-year-old female subject put it, "The most important factor is that everyone is same. Outside [the temple], I am not happy. Here everyone is same. I am not accepted outside by society, but here I feel happy." Another subject said, "Every morning, I get together with my friends who are in the same situation as I am." Yet another subject even mentioned that he was uncomfortable around his family, because they did not have AIDS. He stated:

   I worry and think about my family. Sometime, I feel that I don't
   want my family to come to see me. It is not fair for them that they
   have to see me like this. I don't want to worry about what they
   think when they see me. Whatever I am right now, I feel normal when
   I am surrounded by people with AIDS. But I feel not normal when
   they come to see me.

Most of the subjects had developed some close friendships with other PLHAs in the temple. They told the researchers that having friends in the same situation helped to process their difficult feelings. "When we talk about each other's feelings, it makes both of us feel better," a subject said. "I have many friends here. I have three very close friends in my ward. We cook and eat together."

The volunteer doctor expressed how amazing it was to see persons with AIDS help one another and cheer each other up. He described one instance when all the residents gathered and sang a birthday song for a resident who was dying in the sick ward. It became clear that the Buddhist temple in Thailand provides a place where PLHAs can form informal support groups. Being able to live with others, who are in the same situation, and being able to share difficult feelings and moments, are crucial support mechanisms for persons who are living with HIV/AIDS.

All but the volunteer doctor and one of the subjects identified themselves as Buddhist. Both temples in the study had an arranged time for the residents to pray in front of a Buddha statue. Participation was not mandatory, but most of the subjects attended and prayed with a monk. Most of the subjects mentioned that they had not prayed or meditated before they came to the temple. All the subjects who attended the prayer sessions stated that prayer made them feel better. "Praying and listening to the Buddhist teaching make me calm and accept the situation. Make me think that this the way of life," stated a 32-year-old male subject. Another 32-year-old male subject said, "It makes me feel better. It relaxes me and I don't think about pain when I am praying."

Two subjects reported that they did not pray. One subject, who identified herself as both Christian and Buddhist, said:

   Teacher from Australia introduced me Christianity and told me not
   to worry about death and God will take care of me. I am Buddhist,
   but also have Christian belief. It is not something that everyone
   here has to meditate or pray or practice religious activities.

Both temples admit anyone who otherwise qualifies, regardless of religious affiliation or lack thereof. The temple hospice programs do not require admittees to be Buddhist, nor do they mandate participation in Buddhist activities. One subject who identified as non-Buddhist mentioned, "I don't have time for that [practicing Buddhism]. In the morning, I have to work at the store and I have to welcome visitors. So I don't have time."

In the temples, however, the teachings of the Buddha are used to address the mental health needs of persons who are living with AIDS. The monks often apply the concepts of the Buddhist teachings to explain the pain, suffering, and death associated with AIDS. Death and birth are considered natural phenomena and part of the life cycle in Thai Buddhism. "People are born, get old, suffer, and die. It is natural thing," a monk stated. "I am not scared [of dying]. People who do not have AIDS could die too. Nothing could stop that. When you are born, you die," a subject said.

Although some subjects were able to perceive suffering and death as a part of life, others had a difficult time accepting their situations. A few subjects disclosed suicidal ideation. One monk who was living with AIDS said that being a monk and learning the teachings of Buddhism had stopped him from proceeding with his ideation:

Researcher: Have you though about suicide?

Subject: Yes. I think about suicide all the time. It is easy to die.

R: How many times did you think about suicide?

S: Many times.

R: Do you still think about suicide?

S: Right now, I don't think about.

R: Why you don't think about suicide?

S: I learned to be a monk and I know what is bad and what is good. I read and learn from other monks about the teachings of Buddha.

The majority of the subjects comprehended that the suffering from AIDS was the result of Karma. The subjects believed that AIDS was caused by their bad behavior in past lives. "In Buddhism, we believe that people who do good things deserve good life. When people die, people who did good things will deserve good life. If you did bad things, you go to bad place," a monk who was living with AIDS stated. The chief monk at Wat Phra Baht Nam Phu talked about how AIDS was caused by Karma:

   Most of the Thai people believe in luck and they consider themselves
   unlucky to have AIDS. So questions they ask is "why me?.... Why I
   have bad luck?" What I explain to them is that it is nothing to do
   with bad luck or good luck. But it is Karma and what you do. They
   don't want to blame themselves and they want to blame something
   else. It is very easy to explain Karma. What they do affect their
   family lives and children.

Believing in the concept of Karma helped some patients to accept their illness as part of life, which is considered as suffering in the teachings of the Buddha. Karma means that they are not the only ones suffering; all who live in this life are suffering. The only way to escape from Karma is to practice the teachings of the Buddha.

Although most believe that their AIDS was caused by bad behavior in their past lives, many subjects also identified their behavior in their present lives as a cause of AIDS. One monk observed, "Maybe, I did not do anything in my past life. But maybe, I did something bad in this life and came back to me quickly." A subject who had been infected through injecting drug use stated, "Before I was born, I don't know anything about my past life. But I know what I did in this life."

The teachings of the Buddha are used as a tool to assist persons who are living with HIV/AIDS to understand and make sense of what AIDS is and how to cope. However, the effects of AIDS are extraordinarily large and pervasive. Each person goes though different stages of understanding and acceptance of AIDS. Some take longer than others to process their feelings.

In Thailand, a Buddhist monk is highly respected and admired, not only as a religious figure, but also as a teacher, an advisor, a leader, a healer, and a counselor. Both monks who founded hospice programs--Alongkot Dikkapanyo at the War Phra Baht Nam and Pra Kruu Wilard at War Thep Charoen--stay at the temples and interact with persons with AIDS as much as they can. The study subjects said that the frequency of their talks with a monk ranged from two to three times a week to once a week.

Since the Thai financial crisis in 1996, both temples have encountered financial difficulties, and the monks are often busy engaging in fund-raising activities. Although the monks are currently unable to spend as much time as they used to with the residents in the temple, their effort and hard work for the temple are appreciated. A female subject stated that one of the reasons she was able to process her difficult feelings about accepting her illness was the monk. She said, "I saw a chief monk who works very hard to provide us food and place to stay. He works hard for us. He provides us food, medical care, and things we need. He is tired, because of us." A 32-year-old male subject also said, "I feel sorry for the chief monk who works very hard to collect donation to take care of us." Many subjects were encouraged by the monk's dedication to providing care for persons with AIDS.

   If he has time, he goes to the sick ward and walks bed to bed. Right
   now he is pretty busy so he cannot do as much as he used to. But
   when he has time, he mixes the nutritional drink for the patients
   and gives to them and talks to them.

The chief monk at Wat Phra Baht Nam Phu, Alongkot Dikkapanyo, does not separate monks who have AIDS from other monks. He expects everyone in the temple to work and live together. Although the monks who are living with AIDS are treated the same way as the other monks, it is difficult for them to perform the same duties. To protect themselves from getting various AIDS-related infections and opportunistic infections such as tuberculosis, most of the monks with AIDS avoid going into the sick ward and interacting with persons who are in the last stages of AIDS. One monk who participated in this study was unable to perform any monastic duties, such as praying, because of his illnesses associated with AIDS.

Many subjects stated that they talk to the monks about everything, including their symptoms and the teachings of the Buddha. The chief monk, Alongkot, said, "I focus on the present time and not past or future. Each case is different, so what I talk and how I talk is different depends on the patients." The monks' encouragement has helped many subjects to process difficult feelings and accept their disease. A 24-year-old monk with AIDS stated:

   At first, I was scared and could not think about anything else. I
   thought that there is no future anymore. Right now, the chief monk
   encouraged me that I am still valuable person that I can work and
   have something to do. I can help other AIDS patients when I am
   healthy and strong.

Despite the fact that most of the subjects said that talking to a monk makes them feel better, many subjects claimed that there was no difference between talking to a monk and talking to other people. Many PLHAs come to the temple looking for a place where they can express their feelings without fear or shame. It is not necessary to be a monk to provide such an environment. "Patients do not care whom they talk to. They want to talk to anyone," the chief monk noted. One subject stated, "Both talking to you and talking to a monk makes me feel better. When I talk to you or a monk, I enjoy and forget about my pain." "One of my best mental supports is a visitor," said the subject, who enjoys dancing for visitors.

Conclusion

In Thailand the focus on HIV/AIDS has largely been on prevention and education. Much less is known about the social supports for PLHA and the difficulties they and their families face in providing care, especially at the end-stage of the disease. This study has described how several Buddhist temples have become hospice-centers for PLHA and have created an environment of tolerance and support for PLHA. It is clear that the PLHA find solace not only from the monks who care for them but also from their peers. While these temples cannot alter the ultimate course of the disease, they do provide a sanctuary for PLHA to die with some dignity and not alone.

Finally, the approach to care provided by the Buddhist temples in Thailand demonstrate alternative and viable models of treatment and terminal care for PLHA that do not conform to general western approaches such as hospice. The Thai temples are evidence of a local, grass roots service model that is adopted to accommodate the unique culture and tradition. Grounded in the interplay of culture and religion, the temples provided PLHA meaning and support. Other alternative models of care no doubt exist globally and it is important to identify what other culturally appropriate models of care exist that can allow PLHA to remain in their communities and with their families. In the battle against this terrible disease we need a diversity of approaches to treatment and care.

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TOMOKO KUBOTANI

DAVID ENGSTROM

San Diego State University

School of Social Work