The Other Aids Crisis

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 Michael Sweat, a professor of international health at Johns 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.

The Other Aids Crisis | News