Special Report: Glimpses from India, 2002

October 3, 2002

[The October issue of A & U, a magazine focused on HIV/AIDS issues in

the US carried the following article. Moderator]

Nell Warren's Left Field

With the Barcelona AIDS conference come and gone, it's a good time to

keep a global vision. Growing globalism puts many Americans in the

awkward position of having opinions about countries that we glimpse

only in fleeting TV footage. Many of us have strong opinions about

what other countries should be doing about AIDS, yet often we lack

the personal experience for an informed opinion. Thus our perceptions

about those countries are often galaxies away from the gritty reality

of daily life there. Few U.S. media people have the open-mindedness

of Rolling Stone reporter Rian Malan, who spent a year in South

Africa and found himself unable to document some things about their

AIDS epidemic that are accepted as gospel by most Americans.

India is a case in point. She is no longer the India that Americans

glimpsed in 1940s newsreels, when Gandhi's resistance movement ended

British colonialism and Muslim Pakistan seceded. With a half century

of transformation, India is now the world's second most populous

country, a nuclear power rattling her missiles at Pakistan. Indian

soil supports more than 860 million people with an agricultural

output now third in the world, after the U.S. and China. Vibrant new

industries like software, fertilizer, and pharmaceuticals put India

firmly on the world trade map. In recent decades, U.S.-India

relations are strained, as the U.S. often sides with Pakistan.

Yet the past still weighs heavily. For Americans whose measure of

multiethnic is New Orleans, Indian culture is ancient, non-Christian,

densely layered as the Himalayas themselves, embracing countless

ethnicities, fifteen languages, several hundred dialects, and dozens

of spiritualities, including Islam, Hinduism and Buddhism. Census

figures still note the different castes and tribes. The traditional

hijras (transgendered sex workers)—many still ritually castrated in

the old temple traditions—are part of the social landscape, numbering

as many as 1.5 million. India battles to end poverty, but it still

lingers. This means that public-health concerns are overwhelming,

whether nutrition or malaria or water-borne diseases carried by

India's vast rivers where pilgrims still bathe. Indian health—or lack

of it—will impact the Far East deeply.

On Colours, a recent India Today broadcast dwelled on the phenomenon

of widespread self-medication. " Every person is a doctor in India, "

the newsanchor said drily. Trying to avoid high doctor fees, most

Indians buy prescription drugs over the counter and tailor their own

treatment—a practice that the Indian government discourages. But

little is said about AIDS.

For updates on Indian AIDS, one of my resources is my friend Ashok

Row Kavi, who tells me that this is still a subject that many Indians

prefer not to discuss. Ashok is co-founder of Humsafar Trust, the

country's only NGO dealing with gay male health. Living in Mumbai

(Bombay), he is a tireless human-rights fighter with strong opinions.

Last year, in an e-mail to me, Ashok glowed about Humsafar's success

in a street program: distributing bottles of clean drinking water

daily to Bombay sex workers. He says that the basic Indian social

unit is still the family, not the individual, pointing out: " Eighty

percent of the gay men in Bombay are married. There is a huge gulf

between married gay men and single gay men because single gay men can

have a gay identity, as you have in the West, which presupposes

individuality. "

As he was packing for Barcelona, I interviewed Ashok by e-mail.

Nell Warren: In your view, how does the Indian AIDS epidemic

differ from that in sub-Saharan Africa?

Ashok Row Kavi: The dissimilarity of the two epidemics is becoming

clear in the new millennium. The gender ratio of HIV infected in

Africa, for example, is nearly one to one (that is, mostly as many

women as men are being infected by HIV). But in India, eighty percent

of those infected are still men—ten years into the epidemic! In other

words, HIV is a male sexual health problem, and women and children

are a " vulnerable segment " of the population. The biggest single risk

factor for women in India is that they are married to men. When I say

this, a lot of people get furious with me for saying misanthropic

statements but it is true. When you want to fight malaria, you study

the female anopheles mosquito's habits. Similarly, if you wish to

fight HIV/AIDS you need to study the sexual habits of the Indian

male, and you have conquered half the problem.

What do you feel are the most pressing problems facing AIDS workers

in India?

Quick and fast access to resources —financial, health facilities.

Education around sexuality. Social reforms to empower women. Help and

visibility for sexual minorities. Most important, massive investments

in primary public-health services. Just twenty-five kilometers

outside Bombay, there isn't a decent primary health center, whereas

Bombay has the most sophisticated medical services in the world. This

is ridiculous.

Is there any recent improvement in the civil-rights climate facing

gay people and AIDS work in India?

Well, yes and no. As gay visibility rises, so does the prejudice

against gays. India is a huge mosaic of minorities. The largest and

most monolithic minority is, ironically, the Sunni Muslims who are a

little over 100 million strong in India. But India is also the home

of the oldest living civilization on earth. Its philosophy is

liberating in that it does not have the ingrained religious

homophobia that is a genetic inheritance in the Judaic siblings—

Christianity and Islam. The sad part is that homosexuality in Asia

has still no construct as a " political identity. " And yet the high-

risk behavior of behaviorally homosexual men is what puts them

directly in the path of higher rates of HIV transmission. Thus we

fight two ogres [instead of] one as in the West. The first is the

fight for an identity and the second is to say that this identity

itself puts us at risk. India never had laws against homosexuality

till 1889 when Lord Macaulay slapped on Section 377 of the Indian

Penal Code that talks of " unnatural sex. " Of course, unnatural sex

means oral and anal sex with man, woman, or animal. [These laws] are

still on the statute books.

What, in your opinion, are other pressing health problems that can

weaken an Indian citizen's immune system?

The Humsafar Trust has offered health services to over 2,000 gay and

transgendered men in metro Mumbai. Over the last fifty years the

Indian State has made herculean efforts to eliminate bacterial STIs

[sexually transmitted infections] and it has succeeded to a larger

extent. The viral STIs are totally out of control. Herpes simplex is

[at] forty-seven percent prevalence, HIV is twenty-eight percent

prevalence, hep B is over eleven percent, hep C is nine percent. So

you see the first thing is sex education and awareness. And, of

course, poverty is the greatest disease. Poverty makes you do things

that put you at higher risk. What do you expect when you can't access

condoms, for example, if you are into sex work?

Are you happy with the Indian pharmaceutical Cipla's move to ignore

the patents of multinational corporations (MNCs) and manufacture

cheaper generic AIDS drugs in India?

I completely agree that it takes piles of money to research and get

drugs into the market. But the way they rip you off with high pricing

is obscene. And that goes for Cipla, too. Cipla has the highest

growth rate among pharmaceutical companies in India and, believe me,

they don't sell cheap to Indians either. It's just cut-throat

competition and may the best man win. What Cipla is doing is saying

that the international patent laws are too loaded on the side of the

MNCs. Even in America, if you look honestly, the pharma companies

have benefited from public money invested in research in institutes

like the NIH and CDC. It's time for the global pharma industry to

have a public policy that is transparent and honest. Licensing of

life-saving drugs must be beneficial to the ultimate beneficiary—the

consumer.

The real horror is going to come in 2005 when India bends down to the

WTO pricing policies. The simplest anti-dysentery medicine is going

to cost ten times the present price. People are already switching

over to herbs and roots from the indigenous Ayurvedic brand of age-

old Indian medicine. And now those companies are making a killing.

Rape-seed husk, used in Isabgol, for example, is now costing twice as

much. It was used in anti-dysentery drugs in villages for over 3,000

years and MNCs are just now catching onto its qualities.

How independent do you feel that India should be in charting her own

course?

I don't wish to blame foreigners for our mistakes. We Indians always

do too little too late. We procrastinate, we pontificate, we preach,

and we presume problems will go away. For example, the first $35

million [from USAID] was left unutilized in the early 1990s. Now the

largest ever USAID grant ($40 million) is about to be dispersed and

already two years have lapsed.

Controversy rages as to how many Indians are affected. In its

latest " Report on the Global HIV/AIDS Epidemic 2000, " UNAIDS

estimates that 310,000 AIDS deaths occurred in India in 1999. But

India's National AIDS Control Organization (NACO) says that only some

11,000 AIDS deaths occurred in that period. " These figures are just

too high and not based on any sound epidemiological evidence, " said a

health-ministry official, commenting on UNAID estimates.

But the biggest issue, as Ashok points out, will surely be treatment

cost. India may be better situated than South Africa to dig in her

heels and insist on concessions from the World Bank and

pharmaceutical companies. Indeed, as she develops her own AIDS

policy, India may well assert her fifty-year independence in

surprising ways.

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