Lessons from the AIDS epidemic to help India fight Covid-19 equitably
In a recent address at the international AIDS society to mark 40 years since HIV was first reported, Dr Anthony Fauci juxtaposed the chronic AIDS crisis with the contemporary Covid-19 pandemic. Fauci, who spearheaded global health interventions even during AIDS, noted that in the four decades, 76 million people had been infected by HIV in contrast to one year of Covid-19 which saw more than 91 million infections. In terms of fatalities, 2% of those with Covid-19 succumbed to the disease, whereas 43% of people died of AIDS and other HIV-related illnesses.
Reiterating the urgency of ending HIV, Fauci acknowledged the debt Covid-19 vaccinologists owed to decades of ongoing HIV research. Nearly 90% of Covid-19 vaccines developed at a record pace today used diagnostics, animal models and clinical trials networks from previously “unsuccessful” HIV vaccine trials. HIV genomic sequencing also inspired stabilising the Sars-CoV-2 “spike protein” resulting in “maximal immunogenicity”, crucial for efficacious vaccines today.
India, with the third-largest HIV epidemic in the world (2.1 million infected people), the second-highest Covid-19 infections and third-highest Covid-19 deaths, must heed important lessons from the global AIDS crisis while combating Covid-19.
First, AIDS established the epidemiological value of involving affected communities in the planning and implementation of research and care. Not only does emergency medicine require community trust to be effective but it also enhances public health based on a collaborative approach. India’s response to AIDS integrated the granular, social expertise of “target communities” (such as sex workers, and people from the transgender community) and their everyday assessments of risks. India’s Covid-19 responses must likewise engage vulnerable communities (for example, the rural poor) not only with the aim of securing medical compliance with vaccines but importantly building a bottom-up, community-based public health system. This includes incorporating the abilities of vulnerable groups to anticipate infections and fortify local care networks. In a health emergency, such a system can play a vital role in communicating risk and protective guidelines in terms people easily recognise and encouraging local forms of behavioural surveillance led by community leaders and grassroots health ambassadors.
Second, AIDS established the practice of “harm reduction”, which entails lowering risk behaviours in the absence of total risk elimination. Harm reduction is imperative because biomedical risks are always socially patterned and located within structures where inequalities and stigmas are rife. The mutating Sars-CoV-2 pandemic is ideal to harness harm reduction approaches especially for marginalised groups by building their structural capacities during health emergencies and in everyday life. Harm reduction propagates that disproportionate risk and suffering necessitates differentiated health interventions. Vulnerable groups in India facing challenges to physical distancing, overcrowding, nutritional deficits and infectious disease burdens must be aided by State interventions for income support, debt relief, cash-transfers, free food rations, internet data (for telemedicine) and door-to-door pharmacies throughout lockdowns. Despite structural constraints, vulnerable populations also create their own harm reduction strategies, which must be recognised without shame or blame. The same logic can also crucially help contain and address vaccine hesitancy in which hesitant communities are encouraged to see vaccination as a form of harm reduction rather than a threat or hazard.
Third, the AIDS experience morally compels India to nuance its health data. Metrics have the potential to allow vulnerable groups to make sovereign claims on public health. The moral and material force of “grassroots metrics” comes from evidence and risk assessments from vulnerable communities themselves. Indian public health data during Covid-19 insufficiently reflects binaries like urban/rural, young/old, compliant/hesitant, which while functional fail to ensure an intersectional approach to health justice or take into account the shifting nature of categories. Indian health data must also make space for vulnerabilities beyond just age and comorbidities, accounting for the socio-cultural and politico-legal textures of at-risk groups. Vulnerability metrics must reflect the intersections of caste, class, gender, ethnicity and religion and how they react with specific forms of labour, occupational exposures, residential segregation, welfare exclusions etc. To scale up socially viable primary healthcare, Indian data must first deepen our understanding of the social world.
Fourth, AIDS reinforced the need for evidence-based non-pharmacological interventions (NPIs). These are crucial for multiple reasons: To reduce the everyday burden on fractured medical systems including hospitals; to build public health infrastructure based on community health strategies even after vaccinations; to counteract catastrophic out-of-pocket expenditures caused by neoliberal pharmaceutical markets (including black markets for oxygen and life-saving drugs) on vulnerable people’s lives; to respect people’s refusals of biomedical care premised on personal histories of violence and harm by profit-oriented medical systems; to encourage ethical and effective home-based care; and to reduce post-treatment toxic infections and mental health withdrawals. NPIs in Covid-19 must complement biomedical and biosocial public health responses.
Fifth, AIDS put social justice at the heart of disease control. Globally, between 1996-2003, when anti-retroviral therapy (ART) was extensively promulgated most beneficiaries were in high-income countries while a majority of HIV patients were in low-income countries. Ironically, this was also the period of maximum AIDS deaths. India must negotiate neoliberal vaccine regimes by transforming its trounced vaccine nationalism to ensure that lack of Covid-19 vaccines doesn’t maim the marginalised at any cost. Social justice during infectious disease outbreaks involves recognising the nuances of where an individual is structurally placed and requires social epidemiological models to predict and propagate last-mile health services for communities which have barriers to health access and retention.
Learning from the injustices of AIDS, India’s Covid-19 response must frame its health and development agenda within concrete socio-cultural determinants of harm, healing and well-being. Critical inter-epidemic lessons must drive equitable global public health in India.
Nikhil Pandhi is a doctoral candidate in medical and cultural anthropology at Princeton University. A Rhodes Scholar, he ethnographically researches global health and the structural and social determinants of health in India.
The views expressed are personal
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