The Other AIDS Crisis : INDIA

[Guest guest]

The Other AIDS Crisis : INDIA

NEWSWEEK INTERNATIONAL By Ian Mackinnon and Adam Piore

3,860,000: The number of men, women and children in India carrying

the AIDS virus at the endof 2000, according to the World Health

Organization's latest figures

June 11 issue - AIDS is not new to india. For many years the disease

was confined mostly to drug users and prostitutes, which made it easier

for the rest of the country to pretend it didn't exist. And with a raging

tuberculosis epidemic and periodic outbreaks of the bubonic plague,

there's been no shortage of health crises. But while nobody was looking,

AIDS crept into the general population. Currently 0.7 percent of all

adults are thought to carry the virus; health officials consider 1 percent

an epidemic. Now India is at a crossroads. Even the most favorable

prospect is downright chilling. Public-health officials are happy to

contemplate a mere sixfold increase in infections by 2004-about 20

million adults. The alternative is even grimmer. If infections are allowed

to climb beyond 5 percent of the adult population, scientists believe the

chances of keeping the disease from greatly accelerating, at the cost of

millions of lives, would be slim. India, in other words, is teetering on the

brink of becoming another sub-Saharan Africa. " It's like a fire, " says Dr.

Salim Habayeb, the World Bank's lead public-health specialist for South

Asia. " In the beginning, it's easy to control because you can go to the

source. We are trying to put out the fire before it is too late. "

BUT WHAT IF society keeps that source under wraps? India may be the

land of the Kama Sutra, but sex is not a topic for polite conversation.

Public-health officials have long despaired of this taboo because it

makes the task of raising the public's awareness of sexually transmitted

diseases all the more difficult. Some swimming-pool owners maintain

separate hours for women and men. Marriages are often arranged. And

sex education is virtually nonexistent. But in the big cities, in truck stops

that dot the country and in towns where migrant laborers toil far away

from their families, an underworld of illicit sex supports 2 million to 5

million prostitutes. Most Indians prefer to ignore it. So when the first

AIDS case surfaced in Chennai (formerly Madras) in 1986, the

government argued that AIDS was a Western disease that wouldn't

affect their uniquely moral society.

It was a big mistake. Insidiously, the disease spread into high-risk

populations-prostitutes, IV drug users, patients with sexually transmitted

diseases. It spread from brothel to brothel, through the blood supply and

shared needles. It spread from the cities to the country. Eventually it

spread to innocent women like Manisha Talwar. Her in-laws banished

her and her 2-year-old son to the streets after the death of her

husband. She found out five months later that he had died of AIDS-and

had passed it on to her and her son, Rajan (not their real names). The

in-laws had hidden not only her husband's illness from her but also the

results of her own blood test, which showed positive for HIV. " I felt as if

a mountain had fallen on my shoulders, " says the tiny, dark-eyed

woman. " I cursed my husband. If he knew he had AIDS, he had no

business ruining my life and his child's. "

There were warnings of the epidemic to come. In the region of Manipur

on the Burmese border, the number of HIV-positive drug users rose

from 5 percent to 50 percent during a two-year period in the late

1980s. " Back then I barely knew anything about HIV, " says Tuanz, a

former addict from the region who is HIV-positive. " By the time we knew

about AIDS it was too late for precautions. " In Mumbai (Bombay), nearly

40 percent of the city's prostitutes were infected with the virus by 1991.

In southern Tamil Nadu province in 1992, tests revealed that only one

quarter of blood supplies were tested for the virus, and that 15 percent

of local cases reported were caused by contaminated blood.

That year the government began accepting aid from abroad. The World

Health Organization and the U.S. Centers for Disease Control helped

design a program to combat the epidemic, and the World Bank

contributed $85 million. The Indian government began lobbying each of

the country's 32 states and territories to participate.

The efforts showed some modest gains. In the six years that followed, a

national infrastructure of state-run cells sprang up to fight the disease

out of virtually nothing. In provinces and territories around the country,

local chapters of the newly established National AIDS Control

Organization (NACO) set to work distributing kits to test donated blood.

The popular practice of professional blood selling was banned and

thousands of unregulated, privately run blood banks were shut down.

Parliament passed legislation establishing standards for condom

manufacturers. Thousands of public-health workers were trained to

identify and spread the word on AIDS; 180 NGOs received AIDS

instruction.

In some areas of the country today the problem seems almost on the

verge of control. Awareness programs aimed at prostitutes in Calcutta's

Sonagachi district in 1992 caused condom use to soar from virtually nil

to 70 percent in two years. HIV infection among prostitutes topped out

at only 5 percent. (By contrast, 70 percent of Mumbai's prostitutes are

now HIV-positive). Andhra Pradesh's Chief Minister Chandrababu Naidu

has driven home the message by putting his imprimatur on a Chocolates

and Condoms stand and giving every wedding couple a gift of condoms

and AIDS prevention leaflets.

But India is a vast, heterogeneous country, and much of this success is

local. In the countryside, where 80 percent of Indians live, many still

have not heard of AIDS. Part of the reason is India's culture of denial.

While big cities, stricken with the epidemic, worked furiously to stanch

the spread, a third of India's provinces and territories chose to use only

a tiny fraction-if any-of the money allocated by NACO. Another one third

used scarcely more than 50 percent. Many people downplayed the

significance of the disease and even accused the World Bank of

exaggerating the threat to justify its projects. Others went so far as to

challenge the existence of AIDS. Even today some public officials still

argue that measles, TB or hunger are more pressing problems.

Meanwhile, more and more people contract HIV. " I'm very worried and

disillusioned, " says Subhash Hira, a University of Texas professor and

director of Mumbai-based AIDS Research and Control Centre. " State-

level heads have no sense of urgency. "

The problem will soon become impossible to ignore, and not just in the

big cities. Among women seeking neonatal care (generally considered

the best indicator of infection among the general population), the

proportion who carry HIV in some regions is already 4 percent. " They're

on the edge of a pretty big disaster, " says Sweat, a professor of

international health at s Hopkins Medical School.

The World Bank and the Indian government have already increased their

efforts substantially. In 1999 India began the second phase of its

program, tripling the budget to more than $300 million. In the second

phase, public-health officials will open hundreds of new clinics and will

run TV and radio ads. The goal now is just to forestall the worst: to

keep HIV from reaching 5 percent of India's adults. When sub-Saharan

Africa reached this threshold, says the World Bank's Habayeb, the

infection rate took off: the graph of new cases was " almost

vertical. " " When it exceeds 5 percent, you need not millions but billions, "

he says. " It's not that far to 20 percent. And the only way to stop it is to

go on war footing. "

It's hard to imagine how the epidemic will be stopped with anything less.

The obstacles are legion: illiteracy, poverty and a ruling class that has

shown little interest in this disease of the poor. Immunologists point to

places like Botswana, where AIDS deaths have created a shortage of

teachers, decimated the service sector and shut down local

economies. " Imagine if one in five people you know suddenly died, " said

Ken Mayer, a professor of medicine and community at Brown University

who has studied AIDS in India. In Karnataka, locals have erected a

shrine to India's only AIDS goddess- " Aidsamma " -at a temple near

Mysore. Let it not be India's only hope of staving off disaster.