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Most people in India have never heard of AIDS. Most of those who have
think only foreigners have it. Most of those who accept that Indians have
AIDS too, think only gay men, prostitutes and heroin mainliners are at risk.
Yet despite such misconceptions, education in India receives only 14 per
cent of funds earmarked for controlling AIDS and other sexually transmitted
diseases. Without it, AIDS will hit the poor of India hardest, just as it
has in other developing countries.

AIDS kills people at their most productive age, which is bad for any
country but much more so for developing countries. At this year’s international
AIDS conference, James Chin, of the WHO’s Global Programme on AIDS, predicted
that more than 2.5 million people in South and Southeast Asia are likely
to be infected with HIV within the next four years. Chin estimates that
by the year 2000, well over a million people will have developed AIDS worldwide,
more than one-quarter of them Asian. Finding out how many are likely to
be Indian is a priority of India’s National AIDS Control Programme.

By June, India had screened 901 468 people for HIV, of whom 5131 were
confirmed to be infected. Within the country, only 55 Indians and 13 foreigners
have so far been diagnosed as having AIDS. Taken alone, the figures are
not so worrying. What alarms Indian health workers is the potential danger
of AIDS in a country where more than a third of the population lives in
poverty, and where many more people are ignorant of the disease, its cause
and how to protect themselves. Commitment to education varies from state
to state.

The one region that looked as if it would break the usual link between
poverty and AIDS, at least at the outset, was the northeast frontier states
that sit between Myanmar (Burma) and Bangladesh. In 1984 in Imphal, the
capital of Manipur state which borders Myanmar, it was fashionable among
middle-class kids to inject ‘white powder’. The white powder, heroin of
more than 90 per cent purity, still comes from Southeast Asia’s Golden Triangle
but former users say it now costs up to Rs1800 ( £51) per gram instead
of the Rs80 it used to cost. The states of Mizoram, Nagaland and Manipur
have since experienced what researchers at Calcutta’s National Institute
of Cholera and Enteric Diseases (NICED) have called an ‘explosive’ HIV epidemic.

This spring, NICED researchers found HIV antibodies in 80 per cent of
the 273 intravenous drug users they screened in Churachandpur, a border
town in Manipur. A more recent study by epidemiologist Swarup Sarkar and
colleagues at NICED shows that, although intravenous drug users in the same
town know of HIV and how it can be acquired, 436 of the 450 interviewed
continued to put themselves at risk by sharing needles. About a third of
the interviewees were students, almost all between 15 and 35 years old.
Only 13 were illiterate. Groups often injected together. All bar 14 used
improvised syringes made by taping a needle to a plastic ink dropper. Nobody
bothered to sterilise needles, and as many as 280 interviewees said they
never washed them.

Several factors lie behind this apparent recklessness, says Sarkar.
The high cost of drugs means most users, even those from rich families,
try to spend as little as possible on clean needles. Few Indian drug users
have friends with AIDS or have any experience of discrimination against
people with HIV, of the kind common in the West. Moreover, it takes time
for people to adjust their behaviour to a newly-exposed threat, says Sarkar,
citing cigarette smoking as a prime example.

Manipur is culturally unique. Compared to the rest of India, people
are more accepting of sex outside marriage and of the recreational use of
drugs, especially alcohol. People are influenced by the Western culture
they buy, prepacked, in music cassettes and videos. It’s hip to speak American
English, wear leather jackets, listen to heavy metal music and get stoned
on heroin. There is more money around. The central government in Delhi has
been generous with development aid to the northeast, not least because it
is a politically volatile region. In the early 1980s, when heroin first
began to appear on Imphal’s streets, there was no stigma attached to using
it and people would talk freely about their habit.

But things are changing now. Increasingly, drug users are found in all
income groups, and attitudes towards them are hardening – not because of
HIV, but because people are experiencing the social impact of drugs. Parents
who find a son or daughter injecting drugs now call the police to put them
in prison. Dinesh, a former heroin user who is training to be a drug counsellor,
spent 15 days in Imphal jail. ‘There’s no law for drug addicts. You’re simply
beaten up.’ Dinesh was wealthy enough to pay his way out. But for the poor,
or those neglected by their parents, jail is longer term. Dinesh said there
are now about 350 intravenous drug users in Imphal jail.

Care for drug users is sparse in the northeastern states. Manipur has
one million people but only four psychiatrists and one government centre
for detoxification. Nongovernmental organisations such as the Samaritans
and KRIPA, which specialises in drug counselling, are now setting up rehabilitation
centres in the northeast.

NICED estimates that there are as many as 20 000 intravenous drug users
in Manipur alone, half of whom could be infected with HIV. Sarkar and the
handful of other Indian scientists following the progress of drug use and
AIDS in their country are understandably alarmed. Sarkar spends a lot of
his time travelling the railway and major roads that link the northeastern
states to Myanmar, Bangladesh, China, Calcutta and the rest of India. He
suspects that heroin smuggled into India from Myanmar travels the same routes.
Wherever it goes it ‘leaks’ and spawns a drug-using culture close by.

Sarkar believes that the response to the ‘explosive’ epidemic in the
northeast has been slow. How much worse could it be in West Bengal, where
the gap between rich and poor is much wider and where the population density
is 20 times that of Manipur, Mizoram and Nagaland put together?

Sujit Ghosh, one of the few psychiatrists in India specialising in drug
counselling, is convinced that injecting is still rare among users in Calcutta.
‘White’ is expensive and hard to find, so most users take ‘brown sugar’,
a less pure but much cheaper form of heroin. It is popular with all social
classes and drug counsellors say there may be 100 000 users in Calcutta.
Despite the unpopularity of injecting, Ghosh and other doctors in Calcutta
fear the influence that northeastern users might have on those users in
Calcutta who do not inject.

A cheap fix that won’t end addiction

Anecdotal evidence confirms these fears. For example, northeastern intravenous
drug users discovered that they could avoid withdrawal symptoms when heroin
was unavailable, when they could not afford to buy it or when they wished
to quit, by injecting buprenorphine (Tedegesic). Buprenorphine is an opiate
analgesic usually prescribed in hospital for people undergoing minor operations.
But in India, it is available at chemists’ shops at Rs3 an ampoule to buyers
of any age.

This practice has now spread to Calcutta. Shirley, an Anglo-Indian prostitute
in Calcutta, took buprenorphine to get off ‘brown’. She says two shots a
day keep the jitters away but after a week you’re injecting three times
daily or more because you’re hooked on ‘Tedi’. Shirley said she couldn’t
bear to inject herself and always got a ‘compounder’ to do it for her. Compounders
make up medicines for doctors or pharmacies and, according to Ghosh, will
inject drug users for a small fee. Shirley said she always took her own
needle with her because she knew that compounders often inject groups of
five or six people with the same needle.

‘Chasing brown’ is popular among Calcutta’s Anglo-Indian community although
it is not confined to them. ‘Anglos’ are the descendants of children born
to British colonials and Indians and, in Calcutta, they have retained a
cultural identity and are treated as a separate caste. Like the northeasterners,
Anglos are mostly Christian, speak good English and have fewer taboos than
other Indians.

Eileen and Mary, two Anglo women who sold sex for the money to buy brown,
said they knew many people who inject brown, buprenorphine or both, although
both claimed never to have injected themselves. Their reasons for not injecting
were more a mixture of fear and moral disgust than a conscious effort to
avoid infection. Eileen and Mary had both heard of AIDS and knew it was
in some way linked to drug taking, but they thought that taking any drug
would put them at risk.

Mary said she always insisted her clients used condoms, but her only
reason was that she did not love the men. Eileen used condoms because they
were supplied by her ‘aunt’ (the woman who arranged clients). Neither knew
that condoms could protect against sexually transmitted diseases.

Eileen’s and Mary’s ignorance is typical of most of the poor women.
Their clients – truck drivers, rickshaw pullers and other manual labourers
– may be no more knowledgeable, according to Vineeta Chitale, a lecturer
at the Tata Institute of Social Sciences in Bombay, who has worked for 27
years in a hospital for industrial workers. She added: ‘Condoms are seen
as a birth control device, because that is how we have portrayed them. They
are not seen as a barrier to disease and the concept of safer sex is totally
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There was little research on prostitution in India until last year when
the health ministry commissioned studies from major cities including Bombay,
Delhi, Madras and Calcutta. There have been no studies of the men who visit
prostitutes, and no education about the risks of disease. The Calcutta study
was carried out by Development Dialogue, an agency concerned with the factors
that marginalise women in India, one of which is sexual exploitation.

Development Dialogue’s survey of the eight red-light areas of Calcutta
makes clear the link between poverty and prostitution. According to Avijit
Dasgupta, who runs the agency, a quarter of the women working there came
from a cluster of villages in one particular area of West Bengal, well known
for its scarcity of subsoil water. More than half, he said, belonged to
the lower castes. In one of the villages, 150 of the 200 families had sent
their daughters to Calcutta to work in the brothels and send money home.

Dasgupta sees a direct link between prostitution and the demise of feudalism
and, therefore, of the caste occupations. Many castes were hit by industrial
development. Textile mills and power looms, for example, left the weaver
caste with no livelihood. Many other prostitutes come from lower castes
who are landless labourers. Fifty years ago rural landlords owned not just
land but women, too. Some kept town-based mistresses in Calcutta. Some of
those houses became brothels after 1954 when the zamindari, or landlord,
system was abolished. Development Dialogue offers women in villages training
in new skills in the hope they can avoid being pushed into prostitution.

Tarun Roy, studying the potential impact of HIV infection and AIDS in
West Bengal for Oxfam (India), is alarmed at the lack of awareness, even
among professionals. Roy believes that straight, unprotected sex may be
the major route of transmission of HIV, especially among migrant workers,
who are among the poorest of Indian society. ‘Between sowing and harvest,
thousands of men leave their villages to find work as manual labourers in
the cities,’ he said. ‘There they may sell their blood to blood banks, visit
prostitutes, perhaps even inject themselves before returning to their villages.’

But not all medical officials share Roy’s anxiety. Manish Chakraborty,
for example, heads West Bengal’s AIDS control programme; his concern is
tempered by the belief that ‘we don’t have these gay boys here’. Shankar
Chowdhury, a medical anthropologist at the Centre for Community Medicine,
in Delhi, would probably disagree. In Bombay, there are brothels run by
Hijras, male prostitutes who have been castrated and dress as women. This
may be the traditional way of dealing with male homosexuality in India,
but Chowdhury has discovered a more Western male gay scene, which is flourishing.
As news of his studies spreads, he finds himself spending more and more
time offering confidential counselling on AIDS and psychosexual problems
to men.

To date, West Bengal’s screening centres have tested 550 prostitutes
and 50 pimps, and found one person to be infected with HIV. In January,
the centres also began screening people believed to be at very low risk
of contracting HIV. None of the 5000 people tested so far is positive.

‘It proves the rate of infection is slow up to now but we apprehend
that AIDS transmission is a potential threat in Calcutta because of the
large numbers of prostitutes, and foreigners who come by sea and air,’ Chakraborty
said. Reinforcing his view that AIDS is a problem only for gay men, prostitutes,
foreigners, drug users and people who live in northeast India, he said:
‘Calcutta is a gateway to the northeastern states and many come here for
treatment. Many stay with prostitutes. They are mostly students or young
people who come for moneymaking purposes.’

Chakraborty is a senior virologist who has been catapulted into tackling
an issue that makes many people uncomfortable. He is forced to try to understand
a sector of society that he has rarely encountered face to face. In India,
where caste and tradition can be more isolating than social class in Britain,
and where talk of sex is strictly taboo, his views on Indian sexual mores
are commonplace.

Sarkar, whose job as an epidemiologist brings him into more direct contact
with the people he studies, recognises a sort of national self-delusion:
‘People still feel that we are more monogamous, more pure. But there have
been no studies of prostitution. We know nothing about homosexuality in
this country.’ For Roy, West Bengal’s strategy is ostrich-like. ‘The government
is not really ready to accept that AIDS is a major public health problem
in West Bengal.’

Roy is particularly concerned about blood banks and, it seems, justifiably
so. According to Vishwanath Sardana, who is in charge of the national blood
banking system, 30 per cent of the blood required in India comes from private,
profit-making banks whose practices are difficult to regulate. The remaining
70 per cent comes from government banks and voluntary agencies such as the
Indian Red Cross.

In West Bengal the contribution of private banks may be still greater.
The state needs 180 000 bottles of blood per year, but the 54 government
banks can supply only 80 000 bottles. Nobody knows how many unregistered
blood banks there are in the state. Since 1989 the government has been licensing
profit-making banks, and since last year, inspectors are required to visit
each licensed bank twice a year. But progress is slow. So far, only six
banks have been licensed and the central blood bank was licensed only in
June. The deputy director was optimistic that the remainder would be licensed
by the end of the year, but could not say how much time there would be for
monitoring them.

The blood bank business is certainly open to abuse. Because people are
so reluctant to donate, there is a great shortfall of blood. Many would
rather buy than give blood, even for their relatives. The result is that
selling blood is a profession in India. The price the consumer pays includes
rake-offs for the professional donor, the blood ‘shop’, the agent, the hospital
and the surgeon: not surprisingly, many people have an interest in using
blood. Roy says that many of the blood transfusions recommended by hospital
doctors are unnecessary.

Professional donors are typically very poor. They travel around the
country selling blood in different states. Mike Bailey, HIV/AIDS advisor
to the British charity Save the Children Fund, learned from Indian nongovernmental
agencies that some donors also give blood to manufacturers of blood products.
They told him of one city where 15 to 20 commercial blood houses are served
by a population of 7000 to 10 000 professional blood donors. Bailey reported
after his visit to India earlier this year: ‘Where only the plasma is needed
the donors may receive injections of pooled, packed red blood cells in order
to boost their recovery and increase the number of donations that they can
make. If this is the case then HIV infection will be efficiently transmitted
. . .’

Those fears are justified by the results of screening. After the 2531
seropositive people defined as ‘heterosexually promiscuous’ and the 1188
infected intravenous drug users, the next largest seropositive group are
786 blood donors. (These groupings conceal the fact that some of the donors
may also be infected prostitutes or drug users.) One 33-year-old man, undergoing
detoxification from heroin for the 19th time, said he had managed to sell
his blood six times within 17 days. Sardana admits the problem: ‘We have
no control over donors. They may donate in one hospital today and in another
blood bank in another state tomorrow under two different names.’

India’s AIDS control plan for 1990 to 1992 focuses on the northeastern
states, Calcutta, Bombay, Madras and Delhi. The bulk of the budget, 86 per
cent, is spent on blood testing and building infrastructure to cope with
AIDS patients once they begin to appear. Of all preventive measures, blood
testing is the easiest to carry out so the policy makes good sense. But
Roy and other health workers criticise the lack of pre-test counselling
or aftercare for those found to be HIV positive.

So far, West Bengal has done little to educate people whose behaviour
puts them at risk of acquiring HIV. Papiya Sen of the Women’s Coordinating
Council has been working with prostitutes so far for two to three months.
Sen visits brothels in Calcutta about twice a week, usually in the late
morning for about four hours. She has two aims. The first is to introduce
condoms. Although the women want to use them, she said, their clients seldom
agree. Her second aim is to help in screening, although she finds it hard
to explain the need for this to the women. Chakraborty has provided organisations
such as Sen’s with kits for obtaining blood samples from prostitutes. He
says he has yet to receive a single sample.

Because Sen does not work after 5 pm, she sees only a fraction of Calcutta’s
prostitutes. A more ambitious, and perhaps realistic, programme is under
way at the Institute for Psychological and Educational Research in Calcutta,
which has three social workers who visit the red-light areas at all hours.
The institute also began a centre for women drug users and discovered that
many were also prostitutes. Bijli Mallick, the programme coordinator, said
the women laugh at AIDS. ‘They do not think of AIDS as a problem. They think
it’s a problem only for Westerners. There is a lot of misinformation coming
from their ‘aunts’.’ They come for treatment and say they feel trapped by
the web of ‘aunts’, pimps and pushers. Some tell her: ‘I want to change
but I can’t. I can’t be different, I must do as others do. I don’t have
an opinion.’

The Maharashtran government is much more serious about tackling AIDS,
perhaps because of Bombay’s larger social problems. It is India’s most cosmopolitan
and commercial city. It has the largest red-light area, housing an estimated
100 000 prostitutes, the largest slum and a well-established population
of intravenous drug users. According to Sriram Tripathy of the Indian Council
for Medical Research in Delhi, up to a third of prostitutes in Bombay may
have HIV.

Bombay is to embark this year on a major public health education campaign.
The government has commissioned Lintas, an international advertising company,
to design an education package suitable for all classes. Pathfinders, a
market research company, is carrying out a KAP survey (knowledge/attitudes/practice)
in Bombay city, suburbs, and an industrial area called Sholapur as well
as the tribal area of Gadchiroli. Lintas will base its designs on the results.

The preliminary boards for newspaper adverts pull no punches. One shows
how to use condoms in explicit line drawings. Tara Sabavala, one of the
Lintas team, said: ‘We discussed the adverts with a group of housewives.
We asked them whether their husbands ever used condoms. We expected them
to be shocked and said they could write their answers if they wished. But
they said no, why should we write?’ The first, six-month phase of the programme
aims at raising awareness. The second looks for changes in behaviour. Sabavala
said: ‘We are learning from the mistakes of the West, although it’s a much
more complex task here in Maharashtra. For a start we have to communicate
in four languagues.’

Shilpa Patil and Ranjani Bangera of the Indian Health Organisation’s
AIDS programme often work 12 hours a days, six days a week, counselling
women in the red-light areas and offering their children who have dropped
out of school informal education. Patil and Bangera work in Kamathipura,
Bombay’s largest red light area, and in three other areas. Kamathipura is
a maze of 14 narrow lanes, three of which are packed with brothels in which
the women earn Rs10 to Rs15 per client. The prostitutes, many of them girls
of 12 to 16 years old, embrace them when they turn up with boxes of condoms
under their arms.

One of their colleagues, Chitra Subramanian, has just started to counsel
people with HIV. She says that a lot of people who have been tested are
simply told they have ‘bad blood’. ‘They think that all they need is a blood
transfusion.’ Many are shocked and feel helpless when she explains what
HIV is. But they come back for more information. Their health consciousness
goes up. They cut back on cigarettes and alcohol and practise safer sex.

Each of the major hospitals in Bombay, Calcutta and Madras, the three
cities identified by the Indian Council for Medical Research as hot spots
for AIDS, has set aside a couple of beds for AIDS patients in a special
‘isolation facility’. Amar Nath Safaya, a hospital administrator in Bombay’s
JJ Hospital, knows that it is unnecessary to isolate AIDS patients but predicts
chaos in the wards if they are not isolated. ‘It is just like it was in
the West in the early days,’ Safaya said. ‘We are still at the stage of
fighting fear.’

Those who are following the progress of AIDS in India are convinced
that education and prevention are the only hopes the country has to avoid
widespread suffering. As it is, the health service must cope with the needs
of one-sixth of humanity in a country whose breadth spans the distance between
Gibraltar and Stockholm and whose cultural diversity is richer than Western
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On the face of it, India’s health infrastructure appears impressive.
A network of district hospitals, more than 7000 primary health centres and
85 000 subcentres, offers free health care to 844 million people. There
is one doctor for every 2520 people and another 12 000 doctors graduate
every year. Private health care is a boom industry. But the figures conceal
the fact that only a small fraction of villagers visit primary health centres;
transport is a luxury and time away from the fields means loss of income.

The lesson from Africa is that AIDS and poverty are inextricably linked
(see 91av, This Week, 22 June). This link may soon become painfully
apparent in India too. AIDS is forcing Indians to confront myths about their
sexual habits. It is forcing India to see the economic reasons that push
women into prostitution, manual workers into drug addiction, and others
to sell their blood for food. Many Indians feel that addressing those economic
factors is the strongest weapon against AIDS.