India's Invisible Poison

Alex Ninian

WHICH is the worst country in the world for AIDS? It somewhat depends on what you mean by 'worst', but it could be India. It may not have the highest percentage of population infected, but, frighteningly and tragically, its rate of increase is accelerating. And many of the patterns of India's unique way of life are the patterns of its advance.

In the disastrous HTV areas of central and east Africa, at least the rate of increase is slowing and in Europe and the US the increase is even further over the peak, but in India the figure of the infected, at 1 per cent of the population, or 10 million, is doubling every two to three years. It is possible to envisage a future HIV-positive total greater than the population of Britain.

'Tackling the problem is like the march of 1000 miles', says Dr L.S. Gilada of the Indian Health Organisation in Bombay, 'and we are just taking the first step'. Most field workers and analysts agree that the first step in any AIDS epidemic is to overcome the 'denial' stage. This was stressed at this summer's AIDS conference in Africa. I met a lady of upper class Indian society who told me 'it comes from European women on package tours who sleep with the local tour guides'. Others of the chattering classes refuse to believe it exists at all or say it is confined to 'sex workers' and lorry drivers. It is easy to understand these attitudes in a country totally circumscribed by the rules of religion, by the tight disciplines of the family and where more than half the population live in villages with closely observed social mores.

Yet the fact is that the disease, although mostly among the poorer off, is raging through all areas and all classes of Indians.

I met Dr Shankar Das, an earnest young campaigner who is a field worker as well as a researcher at the Tata Institute of Social Sciences in Bombay, where I met him. 'The villages may have strict rules of behaviour', he says, 'but the other side of the coin is that the villagers are nearly always poor. One of the clearest patterns is that the menfolk escape their poverty and go to the towns sometimes hundreds of miles away to earn money'. Tens of thousands of them live in the slums of Bombay and Delhi and other big cities and save their money to send home to their wives and families. They only go home once or twice a year. 'They leave their wives behind, but not their libidos', says Dr Das. 'They go to the red light district, get AIDS and take it back to the villages, and now, tragically, they produce children born with it'.

In the villages the ignorance is often such that many HIV-infected people do not know they have it. Symptoms such as stomach trouble, pneumonia and TB are taken to be the ultimate illness rather than the underlying immune deficiency. Even medical statistics are superficially reporting a 'TB epidemic sweeping India', and a corollary of this is that the 1 per cent figure for the HIV-positive may in reality be several times higher.

The same pattern is seen among lorry drivers who, traversing a vast country over 1500 miles in length and breadth, are away from home for weeks on end. The typical Indian lorry carries a gaudily painted sign Goods Carrier. 'It ought to say "AIDS carrier"', says Dr Das.

When the away-from-home workers and lorry drivers visit the red light streets they are entering a world where the so-called sex workers are infected to the tune of 65 per cent.

That great Indian phenomenon of caste appears all over the social map of AIDS. Although caste officially does not exist, everyone knows not only their own caste, but that of everyone else. Despite a proliferation of positive discrimination measures and disapproval of the term 'untouchables' - they are now called Dalits - most Untouchables still rank amongst the poorest and their sheer poverty leaves them vulnerable to abuse. There are some sects among them whose women for generations have never been anything but prostitutes. Even Dalit women with 'proper' jobs in houses, offices or on the land are subject to abuse by landlords, bosses and farm-owners.

A colleague of Dr Das reminded me that the custom of Devadasi continues not only in the great temple cities like Kanchipuram and Madurai in Tamil Nadu, but here in greater Bombay. He had worked with Fakira in the sleazy slum of Kamathipura where among the population of prostitutes every second one is HIV-positive. In a centuries-old tradition some village parents pledge a young daughter to the goddess Yalluma. In days gone by the girls were servants of a temple and, although used by the holy men for sexual services, the girls were well educated, well dressed and well looked after, as were the parents. But now the system is so corrupted that immediately following the village dedication ceremony the girls fall into the hands of pimps who spirit them into the big city brothels.

Fakira has learned the lesson of safe sex following the death from AIDS of several of her friends and she works with the voluntary groups who visit the red light district to fight the disease. The message is a practical one - 'if you stay healthy you will earn more for longer' -- and she hands out this advice along with free condoms.

So if you were an Indian unfortunate enough to contract the disease, what is likely to happen? Until recently it was almost standard practice that you would be turned away from hospital. Many cases were reported in the national press. Prakesh Chaud, a 38-year-old drug addict, was found by voluntary workers lying in the road with a swollen leg. They took him to Delhi's prestigious All India Institute of Medical Sciences (AIIMS) where doctors refused admission because they suspected he had AIDS. At another hospital the doctor walked away because he was finishing his shift, and at a third, called the DDU Hospital, they said they had no facilities, and finally after 17 hours they had to leave the man in acute pain, untreated, in a refuge. Another young man, named Malsum, after a similar number of rejections was finally admitted to AIIMS, but when he tested positive he was put in an untended isolated ward with a placard on his chest and another above his bed announcing his condition, with the result that staff re fused to go near him, and he died two days later.

The National Aids Control Organisation (NACO) is the central national agency set up to co-ordinate the country's fight against the problem. It has recently produced recommended procedures and protocols for the admission and treatment of HIV patients in public hospitals but they are still widely ignored.

If someone is one of the 'lucky' few who gets through all the obstacles and is given medical treatment, it will be restricted to treatment of the symptoms. It is official policy that treatment can be provided in public hospitals for the liver problems, the pneumonia and, mainly, the TB which comes with reduced immunity but no public money is allowed for treating the basic syndrome. The so-called anti-retroviral therapy (ART) which is transforming the control of the illness in Europe and the US is unavailable in the public sector in India. It can be obtained privately but, as Dr Shankar says, 'at [pound]400 to [pound]500 per month not one patient in a thousand could afford three months of treatment'.

In some way the most harrowing part of the whole pitiful story is the special situation of young pregnant wives. Rashid Marchant of the Wadia Hospital in Bombay has headed up a study in this area over the last few years. Almost invariably they are young women who have been protected and chaperoned in the traditional way of the Indian family, to ensure no sex before marriage and old-fashioned faithfulness within it. They have only ever had sex with one partner, their husband, yet over 2.5 per cent, or one in 40, is HIV-infected, and the number is doubling every few years. The ghastly consequence is children being born already infected by the virus. Marchant has shown that tiny doses of AZT before and after birth drastically reduce the incidence of this from one in three to one in 20, but he reports that no public funds are available and his experience is that fewer than one in four infected pregnant women can afford the [pound]130 for the complete treatment.

International researchers who have studied AIDS in Africa, Europe and the US, say that in India, the epidemic is exhibiting the signs that indicate it is only in its earliest stage, and it is likely that it has a long way to go. Yet the proportion of population affected is already three times that of the US and ten times that of Europe. The answer has to be prevention.

NACO makes brave pronouncements about arresting its spread by working through schools, hospitals, sex workers and village councils, but brave pronouncements do not do the job. India's public infrastructure is flimsy, undermanned and underfunded, and much of the job has to be done by dedicated, selfless volunteers. I met several of these committed souls in a bare room with wooden chairs in a suburb of Delhi. They are the Aids Awareness Group, or AAG and my directions were to 'go past the Kamil cinema, turn right; go to the Safdarjang Enclave at the dead end, find the shop with the public telephone and ask Harish to direct you to AAG'.

The saintly Elizabeth has mustered a team of men and women, young and old, who are prepared to do the real work on the ground at the sharper end of events. Prepared, that is, to go out at all hours of the day and night to the lorry drivers' haunts, the slums, the hospitals, the brothels and the jails. When they have a cause to fight, Elizabeth persuades lawyers to work for nothing.

Prevention is their main mission although they visit hospitals to assist and counsel HIV patients. 'Use a condom. Use clean needles', is the message carried with messianic fervour. They have long since lost patience with those who say that free condoms encourage promiscuous sex, and free needles encourage drug taking. 'You only have to see the racked bodies and the destitute families and the dying children to know what must be done. Use a condom. Use clean needles.'

They highlighted another specially Indian social pattern, with highly moral aims but with a perverse flip-side with opposite results. The almost universal custom of preventing young women from having sex before marriage means that young, single men turn elsewhere, often to the brothels. On their regular AIDS-prevention visits, AAG have found at weekend daytimes, queues of schoolboys down to 15 years old in the red light districts.

Dr J.S. Gill, Emeritus Professor of Public Health, is among the voluntary workers and despite a brilliant academic background takes his turn visiting hospitals to counsel patients and help AIDS awareness among staff. A retired naval officer joins Elizabeth and her team visiting Tihar Jail to promote AIDS awareness, medical testing, staff training and free legal aid. Others visit the G B Road brothel area of Delhi five times per week to distribute free condoms and promote hygiene and AIDS awareness. A volunteer doctor and nurse accompany them to provide treatment for sexually transmitted diseases.

'The status of women in this country is at the heart of things', says Elizabeth. 'Mostly they are just chattels or property, with very few rights and little status. In matters of sex with their husbands they don't even have a say about the use of their own body, and if he comes home diseased or infected no questions can be asked; it is just too bad'.

Their research also shows that HIV has devastating effects on the relationships as well as the economics of India's traditionally family-based society. For each one HIV victim, a large number of other lives are ruined. On average, each victim is the direct breadwinner for four other people and indirectly a provider for many more. Money and human relationships are cut off for children, spouses, younger brothers and sisters, mothers, fathers and other relatives.

So what can be done about AIDS in India? There were some signs last month that the Indian government will do more to cope with it. Well, everyone knows what needs to be done. Ignorance and illiteracy need to be reduced; the status of women improved; poverty reduced -- the poverty which drives men away from their villages and their wives, to earn money in the city. And with poverty, the privation of the lowest castes must go. Attitudes must change, and there needs to be more information, publicity, education. There need to be more doctors, more nurses, more beds. It all takes money. The Indian government spends only 0.7 per cent of its small GDP on health and the central agency, NACO, has to depend on aid from the US, UK, the UN and the World Bank to the tune of about [pounds]40m per annum. This is about 4p per Indian, or [pounds]4 per HIV victim.

Clearly the thing that could and would make the biggest immediate impact within the money available is practical, on-the-ground work, done by dedicated, selfless volunteers like those of AAG, working in the schools, brothels, drug dens and jails. Their numbers could be multiplied by pump-priming money and better social recognition. I would give every one of them a medal.

Alex Ninian is a travel writer whose articles on India and other countries have appeared in numerous British and American publications.

AIDS - THE GRIM TOTAL

* It is estimated that there are 34.3 million people living with either AIDS or the HIV virus at the end of 1999.

* Seventy per cent - 24.5 million - of these live in sub-Saharan Africa. 8.6 per cent of the adult population of sub-Saharan Africa is HIV positive.

* 520,000 or 1.5 per cent live in western Europe.

* 900,000 or 3 per cent, live in North America.

* The proportion of HIV adults (aged 15-49) is 0.11 per cent in the UK; 0.61 in the US.

Source: World Health Organisation; UNAIDS.

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