AIDS in India: When silence is not golden

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AIDS in India: When silence is not golden

Apr 15th 2004 , From The Economist print edition

Indians start voting next week to choose a new government. Its first

priority should be AIDS

ONE subject not being discussed in India's current election campaign

is AIDS. Yet, on the most conservative of estimates, 600,000 Indians

already have the disease and 4.58m are infected with HIV, the virus

that causes it. That means India ranks second only to South Africa in

terms of its number of infections—and that with only about 0.9% of

the adult population HIV-positive, compared with over 20% in South

Africa.

If India's rate were to rise by just a few percentage points, not

only would millions more Indians be condemned to live with—or, more

likely, die of—AIDS, but so would millions of their neighbours.

India's population alone is much bigger than the whole of Africa's.

Throw in that of Bangladesh, Nepal and Pakistan, and you have the

makings of a regional pandemic affecting nearly a quarter of the

world.

Fortunately, no country is condemned to follow Africa into an AIDS

inferno. As has been shown by Brazil and Thailand, both of which were

poised to experience an HIV calamity ten or 15 years ago, disaster

can be averted. How? The policies adopted by not-so-distant Thailand

probably have the greatest relevance for India. Our special report

assesses how India measures up against the Thai standard and finds it

is doing most of the right things, albeit slowly, late and often on

too small a scale. In two particular respects, though, much more is

needed: India's campaign needs more money, and it needs stronger

political commitment. The two are related.

Nowhere has an AIDS epidemic been headed off without hefty

expenditure. Thailand spends roughly 55 cents per person on

prevention and treatment, Uganda $1.85, but India only about 17

cents. On the face of it, India's money problem is being eased.

International agencies, the World Bank, bilateral donors and

philanthropic foundations have all pitched in with the promise of

large sums. India itself, though, has spent next to nothing. In part

this reflects the country's undoubted poverty, in part the low

priority that the government gives to health in general and AIDS in

particular.

In 2000 (the latest year for which comparative figures exist), India

spent only $71 per person on health, of which four-fifths was in the

private sector; indeed, on one measure government health spending was

only $4 per person. India was one of only eight countries whose

public-health budget took less than 1% of GDP.

This indifference to public health shows up in other statistics.

India has more tuberculosis infections than any other country—over

20,000 Indians catch TB each day and almost 450,000 of them die of it

each year. TB is the commonest cause of death among HIV-positive

people. India is also high in the league table for sexually

transmitted disease, a crucial factor in the spread of HIV.

And, according to a study paid for by the World Bank, 60% of

injections in the private sector are carried out with unsafe needles;

in the public sector the figure is 69%.

No wonder one UN agency thinks the number of Indian infections will

rise to 12m by 2015. The government itself, in the shape of its

National AIDS Control Organisation, has said that even if it achieves

its own objectives 9m Indians will be infected by 2010. America's CIA

predicts 20m-25m by that date.

AIDS is mostly spread by sex—in India over 80% of infections start

this way—and most governments find sex an awkward subject. India's is

no exception. It may be the land of the Kama Sutra, the land whose

temples depict a licentiousness seldom shown in public elsewhere. But

it is also a land so prudish that its film industry has only recently

started to show kisses on screen. Defence is easy by comparison.

India spent 3.1% of GDP on defence in 2000. It has nuclear weapons.

It also has a space programme. It even offers soft loans to African

countries to help them fight AIDS. But it is loth to launch an all-

out programme to promote condoms. It prefers instead to preach ABC—

Abstinence, Be faithful and use a Condom—a message whose crucial

component tends to get lost in transmission, say those with

experience of other epidemics.

In different ways, many Indians are doing their best to battle AIDS.

But if they are to have a chance of success, they need help from the

people at the top, and from others in every other walk of public life.

The prime minister himself needs to take charge of the campaign. He

needs to make all his ministers and civil servants include a message

about AIDS in all their speeches and pronouncements, as the chief

minister of Andhra Pradesh already does. Public figures infected with

HIV—at least one prominent politician is widely believed to have died

of AIDS—must stand up and encourage others to take tests. Cricketers

and Bollywood stars must do their bit.

No cheap way out

AIDS is an expensive disease, expensive to prevent and expensive to

treat. With a limited budget, more money for prevention means less

for treatment—and why, ask some, should scarce resources go to

treating homosexuals, drug addicts, prostitutes and other promiscuous

people who happen to have contracted AIDS? One answer is that without

the promise of treatment no one has the incentive to be tested, and

without tests the disease will spread. Then it will be apparent that

AIDS is also an expensive disease to neglect.

In much of the country, particularly the more prosperous parts, it

already affects other groups hitherto considered low-risk, notably

teenagers and monogamous wives. Were it to spread into the general

population right across the country, as it has in parts of Africa,

the world would have a new pandemic of hideous proportions.

Fortunately, India has some advantages. It has a vast information-

technology industry and its health-management companies and drug

makers are capable of carrying out tests and providing cheap drugs on

a huge—and as yet unexploited—scale.

America's secretary of state, Colin , said last week

that " HIV/AIDS is the greatest threat of mankind today, the greatest

weapon of mass destruction on the earth " . India should listen. Time

is not on the side of the wishful-thinkers, the makers of false

economies or those who think AIDS is too unsavoury a subject for

widespread public discussion.

This disease demands a lead from the top, and a commitment of public

money too. India cannot afford the alternative.

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