AIDS - When Silence Kills

[Guest guest]

This is not posted to show Bill Gates in a favorable light, to

promote AIDS drugs, or even show TIME as a reliable source of information. It is

posted to show how important information is to health and to show the size of

the problem and the degree of denial in India.

 

 

 

" Zeus " <info

Bill Gates AIDS/When Silence Kills

Wed, 29 Jun 2005 16:21:08 +0100

 

 

 

When Silence Kills

 

India's AIDS crisis is huge and growing, but both its government and

wider society have yet to acknowledge the scale of the problem. The

first step: get honest about sex

BY ALEX PERRY

 

When the richest man in the world announced 21/2 years ago that he

would give away $100 million to fight AIDS in India, he might have

expected thanks. Instead, Microsoft chairman Bill Gates was criticized

by the government then in power in India for " spreading panic " and

" completely inaccurate data " after he quoted much-cited predictions by

the U.S.'s Central Intelligence Agency that the number of Indians

infected with HIV and AIDS would top 20 million to 25 million by 2010.

That trajectory would double today's global HIV/AIDS population and

shift the epidemic's center from Africa to India. The Indian reaction

to his pledge back in December 2002 was decidedly " mixed, " Gates told

TIME earlier this year. " The Prime Minister met me [but] there were

other people trying to downplay the whole size of the problem. They

didn't like the figures. "

 

They still don't. India announced last week that it had cut the rate

of new HIV infections by 95% in one year. The reaction was one of

widespread disbelief. Granted, India's AIDS crisis is being taken more

seriously than it once was. Dr. Seth Berkley, head of the

International AIDS Vaccine Initiative (IAVI), says that when Sonia

Gandhi won India's general election last May, " real, accelerated

leadership on AIDS " arrived. In her only foreign trip as chairperson

of India's ruling coalition, to the U.N. World AIDS Conference in

Bangkok last year, Gandhi acknowledged that India had been ineffective

in an increasingly " daunting " fight, and she has pledged to turn that

record around. On a visit last week to India, Bill Clinton praised the

government of Manmohan Singh, Gandhi's ally, for its commitment to

" doing the right thing " on AIDS. But that would imply releasing

accurate statistics, and the ones just out are startling. Whereas 2003

had seen 520,000 new infections in India, the Health Ministry said

there were just 28,000 in 2004. Some states that had previously said

they were home to hundreds of thousands of people with HIV and AIDS

declared they were AIDS-free. Even government ministers had their

doubts. " Our numbers may not be exactly accurate, " said Science and

Technology Minister Kapil Sibal. According to the official count,

India has 5.13 million HIV/AIDS sufferers, while the U.N.'s estimate

is up to 8.5 million. The Naz Foundation, a New Delhi-based AIDS

charity, says the real figure may be closer to 15 million.

 

A problem that size demands resources to match. That's where Gates

comes in. In 2000 he set up the Bill & Melinda Gates Foundation with

his wife and father, William Gates Sr., who is co-chair. With an

endowment of $28.8 billion, it is the largest foundation in the world.

In visits to India, Gates saw that the nation's AIDS crisis could

reach a tipping point where it might turn into a pandemic. Yet this

also struck him as a war that could still be won, given enough money

and direct involvement. " We're much more on the ground [in India] than

in any other country, " said Gates. From $67.5 million set aside for a

campaign targeting the districts where AIDS is prevalent and the

highways by which it is carried, to $5 million for an Australian

project to fight HIV among heroin addicts who live on the edge of the

Golden Triangle area bordering Burma in northeastern India, Gates has

so far pledged a total of $200 million to AIDS projects in India.

" There was a need, a vacuum, an urgency. " Says S.Y. Quraishi, director

general of the country's National AIDS Control Organization (NACO):

" The world's battle against HIV and AIDS is going to be won or lost in

India. "

 

Yet in many ways the work of the Gates Foundation and its partners has

revealed just how tough that battle will be. India has still not

confronted its AIDS epidemic with the honesty that is essential to

success. Denial is still rife, and so is an uneasiness toward

outsiders. Ever since the Gates Foundation made its first grant five

years ago, its India campaign (called Avahan after the Sanskrit word

for " clarion call " ) has functioned under a cloud of suspicion. The

American's munificence is often dismissed as a cynical cover for his

corporate ambitions in the country. Says Purushothaman Mulloli, head

of the Joint Action Council Kannur, an Indian charity involved in

AIDS-related work: " Gates' interest in HIV projects in India is not

meant for charity but to protect his billions of dollars of

investments in pharmaceutical companies interested in conducting field

trials in India. " " Doing good in India, and getting away with it, can

be very, very difficult, " says Avahan's New Delhi-based head Ashok

Alexander. " Indians don't like to be in a begging-bowl position. And

everyone suspects ulterior motives. The question is always: 'Why are

you really here?' "

 

If it wasn't asked so often, that query would sound crazy. Says

another Gates Foundation executive: " If it were a p.r. thing, we'd do

something warm and fuzzy with kids. Can you think of anything you'd

less like associated with your brand than sex work, anal sex, drug use

and sexually transmitted diseases? " Yet it is precisely such matters

that India now needs to discuss. And the nation finds it incredibly

hard to do so. In India, people simply don't talk about sex. From the

West the subcontinent can seem like a land of sensual exoticism, home

to an erotic history stretching from the Kama Sutra to the epic

Tantric orgasms celebrated by today's more ostentatiously profound pop

stars. But India is more inclined to see itself as just the opposite—a

bastion of decency under attack by Western forces of lust and

pornography. While there are signs that India is loosening

up—Bollywood couples now kiss onscreen, India has its own sex-obsessed

edition of Cosmopolitan, and a lesbian couple recently married in New

Delhi—there are many more indications that conservative morals still

dominate. The Supreme Court effectively reaffirmed a ban on

homosexuality last year, and " respectable " Indian women still wouldn't

dream of owning a miniskirt or a bikini.

 

AIDS experts regard India's social constraints as a key reason the

country hasn't yet seen infections reach the rates witnessed in

Africa. But prudishness is also a liability. Two years ago, for

example, India's then Health Minister pulled condom ads from state TV

for indecency. While AIDS campaigners receive public money (albeit

tiny sums), they have also been attacked by mobs and arrested by

police. Half of India's parents marry off their daughters before they

are 18, but almost none will tell them the facts of life. Suniti

Solomon, a doctor who documented India's first case of HIV in Madras

in 1986, describes how, at sex-education talks in schools, " parents

have got up and screamed, 'Why are you spoiling our children? Our

children are angels!' " Even her cardiac-surgeon husband avoids the

subject. " If even I can't talk about it at home, " she says, " imagine

the distance the country still has to travel. " Gates said he is more

and more aware how big a task he has taken on: " AIDS relates to

sexuality, drug use, men having sex with men, and it's very much

[about] first owning up to the problem. "

 

India has a lot of owning up to do, as health workers at the Gates

Foundation know. As they fan out across India to study and quantify

the country's sex industry, they are discovering a sexuality far more

active and diverse than anyone suspected. A foundation executive in

southern India describes as a " total revelation " the large communities

of homosexuals, gay sex workers and transsexuals found in every major

town. In India's cities, millions of men have long secretly visited

brothels, and researchers in New Delhi have also discovered

wife-swapping rings and networks of high-class prostitutes who double

as executives and doctors by day, while in Bombay they found

middle-class housewives—or " aunties " —who entertain teenage boys. " HIV

brings your secrets out of the cupboard, " says Sanghamitra Iyengar,

director of Samuha Samraksha, which is a Bangalore AIDS NGO and a

Gates Foundation partner. " And what always comes through is a much

more colorful rainbow of sexuality than anyone expected. " Far from

exposing India to tawdry Western mores, says Arundhati Char, general

manager of DKT India, a charity that promotes and provides

contraceptives, those campaigning against AIDS are forcing the country

to confront its own sexuality: " It's coming out into the

open—boom!—and people are amazed. 'Is that right? Do these things

happen?' We've even had to hold history classes for our sales staff to

tell them about the Kama Sutra and show them it comes from our own

culture. "

 

Lifting the Covers

Neelu, 26, is an example of a culture many Indians would prefer to

forget. He is a eunuch, or hijra. Like witches in medieval Europe,

hijras make money blessing clients and cursing their enemies. But they

are also the dirty little secret of some rail commuters. Neelu speaks

of servicing 20 men a day for as little as 50¢ each while wandering

the platforms of Madras' rail stations. On the lowest rung of India's

social order, hijras have existed almost entirely outside mainstream

society. " No ration cards, no identity cards, no vote, " says Neelu.

" Not even clients talked to us. " Now, paradoxically, " AIDS has given

us respect and recognition. Health workers and government people come

to us, accept us, treat us as human beings. "

 

Across town, the Gates Foundation is funding Dr. R. Lakshmibai of the

Tamil Nadu AIDS Initiative to take the first comprehensive head count

of male sex workers in India. While the hijras were impossible to

miss, she says she was shocked at the far larger number of

conventionally dressed gay prostitutes; by her estimate, there may be

thousands of them in Madras alone. " I thought it would be a minority

thing, " she says. " I could hardly even conceive of a male sex worker. "

Partly that's because in India, " even homosexuals don't accept

homosexuals, " adds Lakshmibai. " [Male] clients who pay for sex with a

man don't consider it sex at all. " As a result, many homosexuals would

not even recognize their own relevance in condom or AIDS campaigns;

and Lakshmibai says a persistent Indian myth is that AIDS is a

" straight plague. "

 

Delusion is hardly limited to the gay world. In India's business

capital, Bombay, a surging economy has produced millions of young men

with money to burn and an industry of 80,000 women in thousands of

" dancing bars " keen to take it. Some clubs are simply brothels with a

bar. But in high-end establishments, patrons and managers join in an

elaborate pretense to mask the sex on sale. A typical bar will feature

30 or so girls in saris dancing coquettishly to Bollywood numbers as

customers look on from sofas like modern Mughal Emperors. There is no

touching or nudity, and devoted customers shower their favorite

dancers with hundreds of dollars in small notes. After hours, it's a

different story. " Definitely, some girls have sex with customers, "

says Manjit Singh, owner of the Karisma, a dance bar in downtown

Bombay, and head of the city's dance-bar association. " We keep it

decent in here, but how can we control that? " DKT India general

manager Char says even the women buy into the illusion. " Many of these

girls are married, " she says, " but they haven't told their husbands,

their friends or their neighbors. And they'd certainly never use a

term like 'sex worker.' " Char considers the dance bars an improvement

in Bombay's red-light areas. There is less sexual slavery, and bar

owners like Singh who preach safe sex have helped keep HIV prevalence

relatively low at 10%, according to surveys by various NGOs, compared

with 50% in the city's brothels. But she warns that Singh is an

exception and his competitors' pretense that they are not in the sex

industry means " this is an epidemic in waiting. " On April 12, R.R.

Patil, Deputy Chief Minister of the state of Maharashtra, which

includes Bombay, announced his intention to shut all 1,300 of the

city's dance bars, saying: " These bars are corrupting the moral fiber

of our youth and culture. " There was no announcement, however, about

the less visible, more infected red-light ghettos, where thousands of

former dance-bar girls may end up if Patil goes ahead with his plan.

 

A day's drive south of Bombay, in the district of Koppal amid the

rocky barrens of the northern Karnataka state, there's no pretending

anymore. Brought in by truckers and migrant workers returning from the

cities, AIDS is referred to in Karnataka as " Bombay Disease. " HIV was

first detected in the district 12 years ago, and health surveys show

the prevalence of AIDS in Koppal's million-plus population may already

have reached 5-8%. Dr. Satish Bhuthaieh of Samuha Samraksha holds a

weekly clinic in the village of Kustigi in a shack with two attached

dormitories—one for women, one for men—that are reserved for the

dying. That the disease has long crossed over into the general

population is apparent from the 300 people—truckers, migrants,

prostitutes, grandmothers, child brides and toddlers—outside his door.

Samuha director Iyengar says HIV was spread by more than the mere

mobility of truckers and migrants. " Most married men have multiple

partners, " she says. " And women quite often have a steady stand-in

partner, or more than one, for when their husband goes away. " Koppal

is a testament to the dangers of denial. " When the first cases started

appearing, the government said: 'AIDS is not an issue in India. This

is a foreign thing. Condoms only promote promiscuity.' Today, every

single village in Koppal knows it's an issue. There's not one

untouched by HIV. And that's because none of those cherished ideas

about sex and fidelity apply. " Asked how far ahead Koppal is of the

rest of India, Iyengar replies: " Five years. "

 

Giving Hope

Melinda Gates is sitting cross-legged on the bare floor of a Calcutta

slum, holding hands with some of the world's poorest and singing a

civil-rights anthem. " We shall overcome, " chant 14 AIDS-outreach

workers squatting around her. " We shall overcome, we shall overcome,

someday ... " The singing stops for a moment and Gates tries to stand,

but the singers have a firm grip on her and are determined to finish

the last four verses. " Oh, we are not alone, " they start again,

pulling a laughing Gates back down to the floor. " We are not alone,

today ... " Granted, a moment of connection cannot bridge the huge

divide between a multibillionaire and paupers with holes in their

shoes. But the Gateses are serious about tracking what happens to

their donations on the ground in India. Melinda Gates remarks: " One

thing you can say about Bill and I: when we decide to take something

on, we're very possessive about it. "

 

That degree of engagement is almost unheard-of among India's own

financial élite. In a nation divided by caste and wealth, rich Indians

in their Bombay mansions and Bangalore estates exist in a world apart

from the poor. A constant complaint of Indian charities is that the

well-developed Indian sense of duty to family and religion extends no

wider. " Where is philanthropy, where is civil society? Why is Big

Business doing nothing about AIDS? " asks Avahan's Alexander. NACO

director general Quraishi agrees: " I had one CEO tell me that millions

dying in Africa was very sad, but why should he worry about 10 or 20

deaths in India? Frankly, the corporate sector doesn't understand. "

 

There are exceptions. Parmeshwar Godrej, whose husband Adi Godrej runs

a billion-dollar manufacturing empire called the Godrej Group, is

setting up a national AIDS-awareness campaign with actor Richard Gere.

She bridles at the idea that her activism is atypical and that the

indifference of rich Indians to AIDS has obliged a foreigner like Bill

Gates to intervene. Yet while the Godrejs have provided office space

for this campaign, their funding—as with so many other AIDS projects

in India—comes entirely from Gates. India's AIDS pioneer Dr. Solomon

says that while Godrej has signed up two big Indian names—cricketer

Rahul Dravid and Bollywood superstar Amitabh Bachchan—to help

publicize the AIDS issue, it's proved impossible to persuade prominent

Indians with the disease to speak out as, say, basketball star Magic

Johnson did in the U.S. " I treat film stars, " she says. " I try to

persuade them to [speak] out. But nobody will. "

 

Silence about AIDS is standard in India—and not just among celebrities

with the disease. NACO says that of the 5.13 million Indians

officially estimated to have HIV and AIDS, only about 100,000 have

braved the stigma to come forward for treatment. Such secretiveness

makes it all the more difficult to get any accurate sense of how

widespread the disease has become. Nowhere is this lack of information

more unsettling than in the adjoining central and eastern states of

Uttar Pradesh (U.P.) and Bihar, the hindu heartland along the Ganges.

Research has shown that AIDS tracks the poor in India: poverty turns

fathers into migrants, mothers into sex workers, and leaves health

care out of reach for most. And these two states, home to 250 million

people, are marked by an enduring destitution that keeps average

annual wages as low as $166 in U.P. and $105 in Bihar. That would

suggest AIDS would be especially prevalent there. Yet NACO's

statistics claim U.P. had only 1,383 AIDS cases by April this year,

and Bihar a mere 155. The experts are incredulous. Says Solomon: " U.P.

and Bihar must be hot spots. They have all the ingredients. But the

state governments still deny the disease is there at all. "

 

While that denial persists, India has much to fear. Yet there are

seeds of hope in its growing scientific prowess. India is the world's

leading producer of generic drugs for the treatment of AIDS. It is

also one of eight countries currently conducting human trials of an

AIDS vaccine: the Indian Council of Medical Research announced last

month that the first round of IAVI's tests had been successful, and

predicted a marketable vaccine within five years. Yet neither drugs

nor vaccines will help without government funding for distribution and

subsidies to make them affordable. The bulk of India's treatment

medicines, for instance, is currently exported to Africa.

 

Manmohan Singh's government is now readying a bill outlawing

discrimination against people with HIV and AIDS, and Berkley of IAVI

says the support New Delhi has given IAVI is " unique. " Enlightened

self-interest underlies the government's concern, said Gates: " India

is really on the rise and, other than a war, this is the only thing

that could stand in the way. " But there is an enormous amount still to

do. The Gates Foundation says India currently spends just $7 million a

year on HIV/AIDS. Even including money from donors like Gates, India's

average expenditure on the disease is just 29¢ per head, compared with

55¢ in Thailand and $1.85 in Uganda. As Richard Feachem, head of the

Global Fund to Fight AIDS, Tuberculosis and Malaria said last month,

unless " something big or serious " happens to transform and accelerate

India's war on AIDS, " millions and millions and millions of Indians

are going to die. " It's not hard to figure out one big, serious thing

that India needs to do: recognize and admit to the scale, complexity

and hidden social underpinnings of a crisis that could yet wreck its

golden prospects.

 

From TIME Asia Magazine, issue dated June 6, 2005 Vol. 165, No. 22

 

 

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