Today, India is facing 4 deadly pandemics. (i) Tuberculosis (TB) and especially multi-drug resistant variants (roughly 2 million Indians had active TB in 1998). (ii) Sexually Transmitted Diseases (STD) like syphilis and gonorrhea (70-100 million new occurrences per year). (iii) Hepatitis B and Hepatitis C (The long term effect of hepatitis infections is to cause cirrhosis of the liver. Hepatitis C has no vaccine or cure and is fatal in the long run, about 30 years). And (iv) HIV leading to AIDS, is the unforgiving killer. Conservative estimates are 5 million HIV infections by end 1998, and doubling every 2-3 years. Most people suspect that the numbers of HIV infections may already be much higher, closer to 20 million. Worse still, the rate of new infections is very large and also growing rapidly.
Each of these diseases are by themselves affecting millions of Indians and spreading very fast. Their combination is particularly disastrous as they each reinforce the spread of all others. For example, in someone co-infected with TB, the HIV infection is likely to proceed more rapidly to AIDS; and of those with HIV, 63% in India have died of TB. Similarly, a person with history of STD is far more vulnerable to HIV infection per sexual encounter due to lesions, sores, ulcers. Hepatitis is also spread through sex and blood, and is devastating on its own. Since the Hepatitis virus is far more virulent and able to survive outside bodily fluids than HIV, precautions by medical workers (using properly sterilized instruments) have to be very strict.
Even using the conservative estimate of infections, 5 million by end 1998, and doubling every 3 years, there will be 100 million Indians infected by year 2010 if not sooner. This is one in every ten. Thus, on average, one in every nuclear family of brothers and sisters and their children will be HIV positive. I don't anticipate anyone wants to witness such a situation. Unfortunately, the only way to avoid it requires that we act decisively and start in a very big way TODAY.
The two leading causes for the explosive spread are risky sex and contaminated blood supply and surgical instruments. It is in our hands to stop the spread provided we can change habits leading to these behaviors. During my recent visit to India (March 1 - 8, 1999) lecturing on AIDS awareness in Ludhiana and Delhi, I was heartened to find that the people are receptive to the message. The problem is in reaching one billion people and in MAINTAINING A CONTINUOUS REINFORCEMENT OF THE MESSAGE for years as is needed to change lifestyles. The current reality is that in spite of the efforts by the government (through NACO -- National Aids Control Organization) we are barely making a dent in curbing the spread.
At this point there is no cure and no vaccine for HIV. Given the past experiences with attempts to find a cure or vaccine for HIV, there is a strong suspicion that there is not much hope for a breakthrough leading to a cheaply available drug in the next five years or MAYBE EVER. Our only hope is to stop further spread by prevention through mass education and awareness. It is essential that even the die hard skeptics realize that there is no social/natural mechanism that will stop the spread in India. Hundreds of millions of Indians will perish unless there is a change in our life-style that eliminates risky sexual behavior; and collectively we all put a stop to cheating by providing sub-standard services and goods. It is unrealistic to expect the medical establishment only to adhere to very high moral standards when the rest of the society does not.
In India, the disease has already spread in all socio-economic groups and in all regions. There are no social or risk group barriers to contain further spread (like the well defined gay and IVD users communities in the US from which the leakage to the rest of the population has been slow). In this respect, the conditions in India are more similar to countries of sub-Saharan Africa where 12-26 percent of all adults between the ages of 15-49 are HIV+ (estimates by UNAIDS, 1998). What is really scary is that even with such high numbers, the rates of infection are still increasing in these countries. In India, even though people like to deny it, underground risky sexual behavior exists at all socio-economic levels. There is increasing evidence of a sexual revolution amongst school and college kids, similar to what happened in the US in the sixties. The timing for this sexual "liberation" could not have been worse. Lastly, the reality of using unsterilized instruments in the vast medical/semi-medical community, and the unethical practices in blood collection and transfusion, puts ALL PEOPLE AT VERY HIGH RISK.
The social, economic, and medical cost are already prohibitive and will grow until there is a collapse in the economy. For example it takes one to four years to train a skilled worker in industry. Confederation of Indian Industries (CII) estimates that it will cost industry at least Rs. 1 lakh per worker per year after HIV infection due to absenteeism, reduction in productivity, and retraining of new workers. Considering that a significant fractions of the 5000-10000 NEW INFECTIONS PER DAY in India are now in industrial workers it is not hard to imagine the impact on industry. The medical costs are also prohibitive: on average a patient with AIDS will require 100 days of hospitalization per year. The daily expense, even in a general ward, will be at least Rs 1000-2000. This cost cannot be borne by the industrial and agricultural workers. So, even the most caring amongst us will will have to watch them die a horrible death without any medical help. Finally, The social cost in terms of millions of orphans, fear, and panic is hard to estimate.
A lay person might ask why he has not begun to see such industrial, medical, and social costs of the HIV pandemic. The reason is the long lead time before the AIDS stage during which a person may be unsymptomatic, or mildly so, but nevertheless infectious. Also, the early symptoms can be confused for many common ailments present in India, and a very specific blood test is required to detect infection. A tragedy of the Indian situation is the lack of free, reliable, confidential, and anonymous testing and diagnosis facilities. If a person does not know their status, and not counseled to change their life-style, they can continue to infect others through sex or blood transfusion (exchange of bodily fluids). If free testing is not available, then those who cannot afford medical treatment in general have no incentive to pay to get tested. Thus, we will be denied true knowledge of the pandemic until it is too late. I anticipate that we will start to see the first rush, greater than 250,000 AIDS cases per year seeking medical help nation wide around 2002-2003. One has to realize that this is only 3-4 years away. Starting to curb spread then will be too late as obvious from the experience of Sub-Saharan Africa where they are now spending up to 60 percent of the national budget on health and education and yet the rates of new infections are still increasing.
I feel that Government efforts can only start to have a major effect if the PM gets personally involved and declares a national emergency. He has to make awareness and education a priority. To make an organization like NACO really effective, he has to bring in a director who reports directly to him, and who makes the eradication of this scourge his/her mission, i.e. identifies with it and does not simply pass on the buck. The latter unfortunately is the usual mode of operation as no one wants to stick their neck out or does not have sufficient mandate/authority. The constant daily reinforcement of the message has to be maintained for years and via all possible means: television, newspapers, billboards, schools, seminars in work places, etc. It is not hard to understand why maintaining such repetitious program of a dull, "dirty", monotonous message is hard. Yet it must be done. It is our only hope.
I believe that even the best efforts of the government will not be enough. To be really effective we will ultimately have to bring about a social change which raises the standard of living and education for all. Only that will result in a stop in the spread of these disease and create a defense against any such further situation. In short, all of us have to understand the urgency of the situation and to educate all those we have contacts with. Our very survival is at stake. The accumulative cost of even today's rate of new infections, 5000-10000 per day, cannot be borne by India. In the next few years we shall start to see the effects in everyday life. Consequently, even today's living conditions, which test our resources and patience daily, will cease to exist. Therefore, I would like to urge all concerned individuals to join hands and contribute some part of their time and means to stopping this deadly combination of pandemics. We have no time to spare for we all are at very high risk for HIV infection already.
We have to always keep in mind that a single HIV positive person can restart the pandemic if we ever lower our guard. HIV has the potential to make the joy of sex and sexual freedom a forbidden fruit. Migrant workers and the poor, denied all dignity of a decent life and for whom sex is perhaps one of the few available pleasures, will still seek joy in a coital union with their apsara even though her desperate existence and frail body may warn them of the disease within.
The current health pandemic is doubly diabolic. It will wreck havoc amongst those that can least afford it. Third world countries will see all their gains in industrial production and standard of living reversed. My fear is that the ensuing social unrest, economic collapse, panic, and terror may eventually bring even the developed countries down. The safety net countering this reasoning is the possibility that the affected are so marginalized and helpless, as is the case of our brothers and sisters in Sub-Saharan Africa, that they, along with their centuries of history, folk songs, culture, and artistic traditions, vanish without a trace and in silence. In short, without an all out and concentrated effort to stop its spread, HIV may prove to be the Black Death of the new millennium.
Please feel free to get in touch with me if you wish to help or if you have questions.
Rajan Gupta Los Alamos National Lab e-mail: rajan@lanl.gov