Among all the activities taking place to mark World AIDS Day today, one has assumed the character of a silly ritual. It is the annual dispute between the Joint United Nations Programme on HIV and AIDS (UNAIDS) and India’s National AIDS Control Organisation (NACO) over the figures for AIDS prevalence in India.
Are there, as UNAIDS would have it, 5.7 million HIV-positive people in India, so confirming the country’s unenviable status as having the biggest epidemic in the world? Or are there, as NACO assures us, just 5.2 million HIV-positive people, thus putting India’s epidemic a few hundred thousand cases below South Africa’s in these wretched world stakes? The truth, of course, is that no one knows the true figure, and even United Nations epidemiologists allow for an astonishingly wide range of possibilities from 3.4 million to 9.4 million.
Besides, there is no comparison between the AIDS catastrophe that has unfolded in sub-Saharan Africa and the challenges that India faces. It is ridiculous even to roll out a league table that puts India ahead of South Africa with a population 25 times the size. India has also been subjected to much ill-informed speculation in the past over its AIDS figures. Four years ago, the American intelligence community formally declared that India would have 25 million HIV-positive people by 2010. Top AIDS bureaucrats have asserted that the Indian epidemic is on an “African trajectory”, but just a few years behind. They are wrong. Armageddon will not happen.
One key reason is that international experts have failed to pay proper attention to India’s social and sexual norms. They have ignored the strong family ties and conservative social structures that have had the effect of containing the spread of this sexually-transmitted infection in much of India. It is where those social circumstances do not apply that AIDS has attacked most wantonly: among women driven into the sex trade by economic desperation; among migrant workers driven to the booming cities by the crisis in the countryside; and among sexual minorities driven to the margins of society by intolerance and discrimination.
The annual numbers game between NACO and UNAIDS has the further distracting effect of masking both the tragedy of AIDS in India and, by way of paradox, the opportunity that this crisis represents in broader development terms. Since it is on the poor and the marginalised that the epidemic impacts most severely, the political attention and the vast sums of money that AIDS receives should be used more creatively to tackle some of the underlying problems at their source.
For several years I ran a BBC World Service Trust project in India that partnered NACO and Prasar Bharati in the cause of AIDS awareness and prevention. This was during the BJP coalition when Sushma Swaraj was first Information Minister and then Health Minister. In her determination to reinforce those Indian moral values — rather than protect public health — Swaraj banned a number of our TV public service advertisements because they promoted condoms as a defence against HIV. Many never saw the light of day. It was that experience that led me to investigate the role of ‘moralism’ and religiosity in fuelling the global AIDS epidemic over the past 25 years.
Returning to India after three years, I find that much has changed for the better. Condom promotion is no longer a contentious issue, and the Health Ministry makes a virtue of their distribution. To its credit, NACO has taken on other parts of government in demanding the striking down of Section 377, that disgraceful piece of colonial law-mongering which criminalises homosexuality. Even in the area of treatment for HIV-positive people, where the government faces sharp criticism from activists, the policy commitments are at least in place. Four years ago, the last government declared that India could not afford to provide AIDS treatment for poor people, and that was the end of the matter.
Despite this, there is still something profoundly disturbing about the state of the Indian epidemic, and the treatment figures begin to tell the story. Of those estimated five million HIV-positive people in India, some 500,000 are in urgent need of the anti-retroviral drugs that have been saving lives in the West for the past decade and are now saving lives in great numbers in Africa and Latin America. But only 45,000 Indians are receiving the drugs on government programmes, and NACO’s initial 100,000 target keeps getting postponed.
Clues to explain this poor state of affairs can be picked up almost daily in the Indian press. They are those terrifying stories of prejudice and discrimination that occasionally invite political comment and action, but more often remain tragic tales of a paragraph or two. These are the children banned from school because of an unreasoning response to HIV infection, the husbands and wives rejected by their families, the babies ejected from orphanages, and most shocking of all, the countless incidents of HIV-positive patients being refused hospital attention by supposedly qualified and humane medical personnel. These acts of discrimination represent the biggest barriers to a proper treatment programme.
In all this darkness and suffering, it may be fool-hardy to suggest that anything good can come from the deadliest epidemic the world has ever known. But as I travelled the world to research my book, I was struck by how the disease had both adjusted and underlined the essential development priorities. In the field of drugs for poor people, for instance, there would have been no major advance if AIDS activists had not taken on the major pharmaceutical companies (and the Western governments which back them) and forced them into retreat on this vital principle. In the pugnacious form of Cipla’s Dr Yusuf Hamied, India’s generic drugs industry played an immensely important role in providing affordable AIDS drugs to Africa, although it now looks as though such initiatives will be throttled in future by the combined forces of Big Pharma, the US Trade Establishment and the World Trade Organisation.
What the AIDS lobby gained in the field of medicines needs urgently to be extended to other development areas. How, for example, can the world expend vast resources on AIDS prevention without providing the basic education for people to assimilate such campaigns? How can treatment be delivered to people with HIV if, along with fearful prejudice, they also have to deal with a barely functional health system? Most emphatically of all, AIDS underlines the developing world’s yawning gender disparities, and AIDS will not be effectively countered until they are addressed.
As the first disease of globalisation, AIDS has united the world in what in many ways is a remarkable collective effort. This is a disease that first assumed epidemic proportions in the US and then spread via other rich countries to the developing world. But now, 25 years into the epidemic, we know it for something else — for disfiguring the lives of the poorest and most marginalised people on Earth. That is the challenge for the world in the second quarter century of the epidemic — tackling poverty at its root and by extension making AIDS history as well.
Peter Gill is the author of The Politics of AIDS: How They Turned a Disease into a Disaster (Viva Books).