Rajasthan: Migrants Bring AIDS to Villages

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Migrants Bring AIDS to Villages

By VIJI SUNDARAM

India-West Staff Reporter

KANCHANPORE, Rajasthan – For several weeks after her husband died,

35-year-old Vimala, unlettered like many of the women in this tiny,

dusty village in the outskirts of Jaipur, turned to the family's

only piece of livestock, a buffalo, to feed her four children and

herself.

She would get up early every morning, milk the animal, boil the

milk, add a little yogurt to it and set it aside. In a couple of

hours, the hot Rajasthan desert sun would turn the milk into solid

yogurt. A pot of yogurt made the difference between her family

eating roti and sabji that day, or starving. And being a little less

dependent on the kindness of her brother.

Vimala's frail and callused hands would churn the yogurt into frothy

buttermilk. Carrying the pot of buttermilk to the shade of a nearby

tree, she would sit and wait for customers, while at the same time

keeping one eye on her children playing outside her hut.

The woman's entrepreneurship came to an abrupt halt one day, when

her neighbors discovered that she was HIV-positive, the virus that

causes AIDS. They did not want to buy " contaminated " buttermilk.

Vimala, who has since educated herself about AIDS, these days

counsels men and women in her village about the disease. In

hindsight, she wonders if it was perhaps the same virus that had

claimed her husband, Shivdayal, five years ago, leaving her with

their four children, the oldest, a girl then around 10, and her

youngest, also a girl, then six months old. " Tuberculosis finally

claimed him, " she told India-West in Marwari through an interpreter.

" But who knows what other illness he had. " In her blue sequined

lehnga, pink blouse and red-and-white odini, Vimala looked like any

other traditional Rajasthani woman. But her persistent cough, sunken

eyes and bony frame pointed to a serious illness.

Tuberculosis is one of the most common causes of death among HIV-

positive people. Shivdayal, a tile-cutter, took off for Mumbai a

couple of years after his marriage, hoping to find better

opportunities there. His job didn't pay him much, and agricultural opportunities

were very limited in his village. He had seen his neighbors try unsuccessfully

to scratch a living from the parched earth. Mumbai, with its vibrant

construction industry, he was told, was where money could be made. It was also a

hot bed of AIDS.

Migration is a vital factor in understanding the unfolding of the

AIDS epidemic in India. In much of rural India, it is the

traditional survival mechanism. Natural disasters such as an Orissa

cyclone or a Rajasthan drought displace hundreds of people, swelling

the ranks of migrants. It is estimated that India has some 200

million people who are classified as migrant workers. When times are

tough, either entire families move out of their hometowns to seek

better opportunities, or the males alone leave, noted Joe ,

program adviser for Asia with the Association Francois-Xavier

Bagnoud. " In Rajasthan, it's mostly male migration, " told

India-West, in a telephone interview from his home in Australia.

AFXB is a non-governmental organization with headquarters in

Switzerland. It has a presence in all 35 states of India. The group started work

on HIV in Rajasthan in June 2000.

It has a testing and counseling center in Sumerpur, an outreach

program and collaborations with local blood banks, including the

zonal blood bank at Umaid hospital in Jodhpur, and is now rapidly

duplicating these successes across India.

Migrant laborers who move for work to areas where they do not know

the local languages and don't have roots or a family, turn to sex

workers to assuage their loneliness. When they return home for a

short vacation, perhaps once a year with a savings of about Rs. 200,

they run the risk of silently passing on an acquired infection to

their wives and future children. The wives of many migrants in India

suffer the same fate as Vimala — becoming crippled with HIV and

becoming the sole caregivers to their children, either because their

husbands are dead, or because they are too ill to help raise the

children. Shanti Prajapati is one such tragic case. A resident of

Shri Matur village outside Jaipur, Shanti is 33, pretty, barely a

literate and very docile.

She's married to Suresh, a former tile-cutter. The couple lives in a

shabby brick-and-cement home owned by his father. Early in their

marriage, Suresh picked up and relocated to distant Surat in

Gujarat, where he found work as a tile-cutter that paid him three

times what he had made in Shri Matur. The trouble was he also found

himself at least one girl friend there.

" It was my kharab (Hindi word for bad) behavior that got me

infected " 10 years ago, he said in Marwari through an interpreter,

while sitting with his wife in the verandah of their home. Suresh,

37, passed on the virus to Shanti, who tested positive five years

ago.

" She gets angry with me now and then about what I did, but what can

we do now? " he said, wiping his moist forehead with the back of his

hand. Suresh has the telltale signs of the dreaded disease. His ribs

poke through his torn undershirt, his eyes are rheumy and he has a

persistent cough. His salt-and-pepper hair is disheveled, making him

look deathly ill. So bad was his condition that two-and-a-half years

ago, doctors at a hospital in the Sikar district gave him no more

than three days to live, he told India-West.

In the Sikar district, at least one man in every household is a

tilecutter, said Anila, a family planning worker from the village of

Shri Madhupur in that district. A ceiling fan in the verandah of

Suresh's home produces more noise than breeze. Suresh is frank about

his own health condition, but not his wife's. Even though his

neighbors know that they are both infected, and even though they

don't shun the couple or their children, he is still embarrassed to

tell them how exactly she contracted the virus, Suresh said.

" We have told them that it rained one day, my wife got a fever and

ended up with HIV, " he said, looking sheepish. He has sold his

wife's jewelry and used the Rs. 35,000 (about $780) to buy some

medicines for himself and his wife. He used the rest to feed his

family for a time. The couple has a son, now 15, and a daughter, now

17. Suresh said he needs to get the girl married, but doesn't know

where to get the money to do that. For a girl to be 17 and single is

uncommon in his village.

The family is dependent on his father and brothers, who don't make

much themselves. The couple's only source of income is from the

sequin work Shanti does on saris for her neighbors. They pay her Rs.

15 per sari.

For the same amount of work, a store would charge at least Rs. 200.

But Shanti and Suresh are in no position to bargain. Shanti, clad in

a colorful sari, has her pallav pulled over her face as she works on

a chiffon sari. Only occasionally does she push the pallav back a

little to help her see better, revealing attractive features.

The disease hasn't ravaged her to the extent it has her husband,

possibly because she has had it for a shorter time, or maybe because

she has more resistance.

Some 5.134 million people in India are HIV-positive, according to

the government. According to many AIDS workers, the figure is closer

to 10 million. Each day, 10,000 new patients are diagnosed with the

disease, according to the National AIDS Control Organization chief,

S.Y. Quraishi. Sex workers, migrant laborers and intravenous drug

users form the greater part of the HIV-positive pool in India. Where

once the disease flourished mostly in the urban areas, the high

mobility of the male population has brought the virus to rural areas.

Intra-state migration adds to the problem. For example, in Andhra

Pradesh, in Nizamabad, Karimnagar and Prakasam, all frequently

plagued by drought, men migrate to coastal areas within the state

for seasonal work, augmenting the client base of commercial sex

workers, Ashok of the New Dehi-based Gates Foundation's

India campaign, Avahan, told India-West. In Rajasthan, where 70

percent of the 56 million population lives in rural areas, 20

percent is migrant workers. One-fifth of the HIV cases treated at

the SMS Hospital in Jaipur, one of the biggest teaching hospitals in

the city of palaces, forts and havelis, is migrant workers, noted

Dr. Dinesh Mathur, professor of skin and sexually transmitted

diseases at the hospital. Mathur is also the project director of the

Rajasthan AIDS Control Society.

Mathur seemed not to think that AIDS was a major problem in his

state since the rate of infection had not crossed " the dreadful

limit of one percent in the general population, " but when told about

the concerns of NGOs there, he acknowledged that there was " no room

for complacency in Rajasthan. "

Surat, the high-prevalence city to which Suresh migrated, is the

heart of the diamond, tile and textile industries. Men who migrate

there looking for jobs live in subhuman conditions in little lodges,

noted Delhi-based AIDS activist Anjali Gopalan, who founded The Naz

Foundation, a non-governmental organization. The same is true of

those who migrate to Mumbai and other megacities.

" They live 10 men to a room, with no running water and no toilets, "

Gopalan told India-West.

" Lot of sexual activities take place in those dwellings — men having

sex with men and with women.

" They don't seek treatment because that would mean spending a whole

day in hospital and depriving them of a day's wages. " And, she

observed: " What's the use of telling this guy about HIV

when his other conditions are so sub-human. "

In India, targeted intervention is generally not aimed at migrant

workers, but more at truckers because it is easier to design a

program for them, noted . One reason for this is migrants are

difficult to identify from the rest of the working population.

Additionally, " migrants stay in one place for a short period, and

then move on, " he said. Hoping to reach out to as many Rajasthani

migrants as possible, AFXB has launched three programs – vatan

uddharak (advocacy for prominent Rajasthanis), upahar grih

(intervention at lodges) and vapsi (awareness for returning

migrants),

AFXB founder and president Countess Albina du Boisrouvray told India-

West via e-mail from Chennai, where she recently attended the 5th

International Conference on AIDS India. In the 14 years it has been

in

India, AFXB has spent around $6 million on its AIDS programs. It has

an ambitious budget of Rs.2.50 crore ($500,000) for next year,

according to the countess.

Rajasthan, which has one of the highest maternity and infant

mortality rates, also has a threadbare public health care system.

None of the primary health care centers there is capable of

identifying an HIV-related illness, asserted . And there are

not enough surveillance centers to gather information

on how many are infected. Because Rajasthan is not considered a high-

prevalence state, it is not included in the central government's

free anti-retroviral therapy rollout program. But some hospitals buy

the drugs with money from the state, said , and give it to

their patients.

" We have high levels of illiteracy, commercial sex work and

migration in our state, but it is still called a low-prevalence

state, " observed Brijesh Dubey, founder-president of the four-year-

old Rajasthan Network for People Living with HIV/ AIDS,

angrily. " This is why we are not getting included in the central

government's ARV rollout program. "

High prevalence states are given high priority in programs and

policies. India's Health Minister Anbumani Ramadoss told India-

West last June that Rajasthan has recently been categorized as " a

highly vulnerable state, " and as such would get more attention from

the central government from now on.

According to the International AIDS Economic Network, far more of

India's resources are concentrated in its vast cities, leaving rural

areas with low literacy rates, less money and fewer NGOs.

Dr. Piot, director of UNAIDS, pointed out in a

teleconferencing session with the U.S. media last July, that " it was

clear not much was being done (to fight AIDS) in most states in

India, and data coming out of northern states are not enough. "

Dubey, the father of three children and once a pastor in a local

church, as well as a primary school teacher, is HIV-positive

himself. He told India-West that government apathy both at the state

and central level has made it a struggle for people like him to

survive. He said that people like Vimala would have been teetering

on the brink of destitution had his organization not stepped in. She

now makes enough money as an RNPL counselor to feed and clothe her

children and herself.

" Rajasthan has displayed indifference, " acknowledged Quraishi to

India-West, declining to elaborate. India currently spends on AIDS

around $0.29 cents per person. By comparison, Thailand spends

$0.55 cents per person and Uganda $1.85. Last year, the Indian

government promised free anti-retroviral drugs to 100,000 patients

by April of this year. But only about 8,000 currently receive it,

said Gopalan.

The government recently repeated its 100,000 pledge, this time

giving itself a deadline of 2007.

Anti-retrovirals cannot cure the disease, but can slow its

progression. But once patients are started on the drugs, they must

continue taking them all their lives. " The drug is inaccessible to

most people, " lamented Gopalan.

Suresh's strategy is for him and his wife to take medicine whenever

there is money to be spared. They sometimes spend Rs.2,000 a month

on special foods and medicines, which includes some native healing,

he said.

Such a strategy is not uncommon among poor patients. Frequently,

said Dr. P. Vidya of the Chennai-based YRG Research Care Center, if

patients are buying their own medicines, a crimp in the family

budget can force them to go off the drugs, or to skip a dose or two

to stretch out the prescription.

" Most (poor) patients who buy their own medicine discontinue ART

because of the (prohibitive) cost, " she told India-West.

said that in Rajasthan it is not uncommon for some physicians

to tell their patients to " take a break " from their ARV therapy when

their immune cell count goes back up, causing great harm to the

patients. " Treatment education for physicians as well as patients

is almost nil, " he said.

Given the high cost of the antiretroviral drugs and without the

assurance of treatment, there is no motivation for people to seek

the specific blood test, worsening the spread of the disease.

Thirty-two-year-old Om Prakash, HIV-positive and a resident of

Kanchanpore village, quit his job as a tile-cutter in Surat last

year, after he began falling ill frequently. A few months later, his

29-yearold wife, Premdevi, died of an AIDS-related illness, leaving

her husband to take care of their two young children.

Om Prakash lives with his widowed mother, grandmother and married

siblings. He said he rarely gets his immune cell count checked. And

he has no immediate plans to get his children tested for HIV.

" What's the use of testing them, when I can't get medicine for

myself? " he told India- West bitterly.

Dubey worries about Vimala's oldest daughter, who got recently

married to a tile-cutter who has migrated to Mumbai, leaving his 16-

year-old bride behind in the village.

" We have explained to her what precautions she should take when he

comes to visit, " Dubey said. " But God only knows whether she will

follow our advice. "

(This is the fifth and final report in the series on " Women and

AIDS " by India-West staff reporter Viji Sundaram, who was in India

earlier this year on a fellowship from the Henry J.Kaiser Family

Foundation in Menlo Park, Calif.)