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Aids and maternity in India

 | 
Patrice Cohen
, 
Suniti Solomon

Part 1. HIV/AIDS epidemic in India

2. Critical Analysis of HIV/Aids Epidemic Prevention Policy In India

Frédéric Bourdier

Texte intégral

1In 1985, the government of India was still convinced that the HIV/AIDS epidemic would eventually be confined to the Western countries. The cultural and social patterns of Indian civilization were supposed to act as a natural protection against a virus mostly transmitted through sexual intercourse. The dream of such a cultural immunity rapidly proved to be overestimated when the first cases appeared and the epidemic became rampant all over the country. In a sense, the government reacted promptly by creating various national bodies in order to tackle the diffusion of the dreadful virus. With the help of the WHO, an impressive administrative network of institutions was implemented in various places in the country. A number of scientists and public health doctors began to devote their activities to research and policy planning and tried to combine their efforts against the new disease. The challenge was formidable, perhaps more so than in other countries due to the difficulty in approaching the sensitive but essential question of the sexual behaviour of the Indian population. Furthermore, the stigma attached to a disease assimilated to death and strongly connoting moral values (sex outside marriage) renders the situation more difficult for the decision makers.

HIV/ AIDS Control, Policies and Stigmatization

2R.N. Gupta (Infra, chapter 1) said that one of the first decisions of the central government was to establish a system of sentinel surveillance throughout the states. Nobody can deny the right of any government to act in such a manner. It is absolutely needed, justified and legitimated. But contrary to what happened in other countries, the national surveillance campaign has been used as a pretext to accentuate discrimination and stigmatization. The first Elisa tests turned out to be repressive tests: the so-called high-risk groups, which were socially and arbitrarily constructed (prostitutes, injection drug users, blood donors, etc.), were quickly targeted for discriminated testing without proper counselling. In Manipur, contaminated drug users were put in jail and in other states the professional sex workers were ostracized by the society and put in closed re-education houses (remand homes) that are in fact similar to prisons. The first infected persons who dared to claim their HIV status and tried to mobilize the positive people in associations were also arrested and their activities prohibited, as was the case in Goa with Dominique De Souza.

3Homosexuality, still considered as a crime according to Indian law, has been denied and action directed at men who have sex with men has never been encouraged, in spite of the widespread existence of homosexuality throughout the country. On the contrary, it has been silenced. What is more, the gay community was debarred from starting any specifically oriented participation for prevention and those who had the intrepidity to put forward their sexual behaviour as a social identity were sentenced as dangerous activists. In short, the first eight years of the struggle against the epidemic have mostly consisted in a struggle against the infected people. Under the “law and order” banner, both the government and the medical system tried desperately to confine the HIV/AIDS epidemic to certain particular categories of the society considered as marginal, if not abnormal.

Orthodoxy and Socio-cultural Dynamics Prevailing in Indian Society

4At the same time, the orthodox way of thinking and acting has been chosen as a reference model and as the strategy most adapted to reach the targets and achievements foreseen by the government. Abstinence, chastity and fidelity were the only ways to avoid divine retribution. Everybody agreed that information, awareness and prevention should be included in the agenda of any national policy against AIDS, but the sensitive questions about the content and about the various tactics to reach people’s minds have not been sufficiently discussed. The decisions were taken from top to bottom, sometimes influenced by international donor agencies that did not have any proper knowledge of the socio-cultural dynamics prevailing in Indian society (who is doing what? who is who?).

Adequate Prevention Programmes?

5After years of denial and lack of effective action at the grassroots levels, the national government still remained hesitant when it came to the question of starting adequate prevention programmes.

6But what do we mean by adequate prevention? Two main conditions should be fulfilled: first, it is the duty of the state to clearly inform the whole society about the existence of the epidemic, its epidemiology and the ways to be protected. Second the population may have particular doubts and questions to ask and, according to the local contexts, the citizens may have specific preoccupations and needs.

7Before implementing a nation-wide prevention policy, one has to identify such needs, preoccupations, constraints, pressures, doubts and questions emanating from each segment of the population in order to adjust progressively the communication strategies and the ways of implementing real long-term prevention. Lamentably, nothing has been done in that direction.

8The metaphoric directive was to go more quickly than the epidemic, without taking into consideration people’s perceptions, preoccupations and life conditions. Worse, decision makers had to face the reluctance of local administrators, doctors, teachers, trainers, as well as a good part of the orthodox society who did not want, or thought it would be degrading for them, to speak openly about sex. Innumerable debates, which are still going on nearly twenty years later, have questioned the relevance in Hindu culture of accentuating the need of using condoms and of exposing in detail the risks due to various sexual practices. The fallacious idea is that the more we speak about sex, the more it will encourage the population to have sex, specifically the youngsters. As a result, in 2000, many young men from Tamil Nadu, a state that is supposed to have received a great deal of attention, still remain in doubt as to whether masturbation or kissing can transmit the virus. The ignorance of the people is the responsibility of the state, not of the people, as is often said.

Consequences

9The consequences of such a strong and mis-informative policy have caused drastic damage. Even if most of the actors involved in the struggle against AIDS do recognize the inadequacy of the first eight/ten years of the health policy, time has played in favour of the diffusion of the epidemic in all the strata of the society. The new trend is its pauperization, with more and more women infected, as shown by recent data. Definitely, the face of AIDS in India reflects the face of India itself. More than ever, the government must refrain from restricting its activities to the strengthening of its institutions and to decentralization, as has been planned by phase II of the prevention programme launched under the auspices of the World Bank.

10When it comes to the care dimension, India is still far behind many countries, including other Southern countries (in Africa, in South America). Community responses to HIV/AIDS and coping patterns, information about socio-cultural mechanisms that could be used to help design household- and community-level control and prevention interventions have not only to be encouraged on paper: they should receive material and human resources to be better implemented in a sustainable way.

11So far, the country refuses to have a national ARV drugs policy, while other countries like Brazil have proved it is possible, in spite of having a majority of poor people and an immense territory. Of course, one can argue that the Indian population is five times greater than Brazil’s, but independent scientific studies have demonstrated that prevention cannot be effective without care. The more the drugs are available, the more the people have the desire to be tested. A progressive health delivery system cum drugs provision could improve prevention, strengthen the communities, attenuate the discrimination (specifically the stigma of death), encourage the pharmaceutical companies to produce more drugs and subsequently to reduce their prices. India has already shown in its history its capacity to deal with many health issues and epidemics and to organize a free health access service throughout the country.

12To deal with AIDS remains first of all a question of political will. India has no choice but to have the courage to counteract a globalization process that is regularly endangering its organizational ability to tackle health issues.

© Institut Français de Pondichéry, 2004

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