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Monday, December 24, 2007

HIV/AIDS As a Non – Conventional Threat to Nation States

The African State and the AIDS Crisis

Edited by Amy S. Patterson, Aldershot: Ashgate Publishing Ltd., 2005, pp.240, $ 51.62

Infections and Inequalities: The Modern Plagues

Paul Farmer, London: University of California Press, 2001, pp. 375, $19.95

HIV/AIDS as a Security Threat to India

Happymon Jacob, New Delhi: Manohar Publishers, 2005, pp.97, $5.82

Reviewed By: Javed I. Naqi

“There are men who fight one day and they are good;

Others fight for a year and they are better;

There are men who fight many years and they are very good;

But there are those who fight all their lives:

These are the indispensable one!

Bertold Bretch, in Silvio Rodriquez’s song.

There is a vast literature on the subject of HIV/AIDS and its socio – economic and political implications. These three books under review are continued attempts on the topic by some eminent scholars. As their title indicates, the books share a common overarching theme, but they are complementary to one another in so far as they view the same subject matter through from alternate angles. While the first book throws light on African State HIV/AIDS crisis and States response to the epidemic, the second largely deals with social inequalities associated with infectious diseases and finally the last, examines the security implications of HIV/AIDS on India as a core.
“The African State and the AIDS Crisis” edited by Amy S. Patterson contains a collection of articles from a variety of world regions, which offers a thorough view of the socio – economic and political implications of HIV/AIDS epidemic in context of African States. This volume also examines the role of the African States in addressing the HIV/AIDS crisis. Through the chapters, the book questions how the African state, which is usually seen to be institutionally weak, limited in resources, and lacking in international power, has responded to HIV/AIDS. Though several of the themes are woven throughout the chapters, the book starts at the sub – national level with an examination of the effect of patriarchy, political culture and civil society on State actions to address HIV/AIDS.
Siplon in his individual piece argues that traditional institutions customary laws affects women vulnerability to HIV/AIDS, at the same time cause women to be underrepresented in AIDS policy making. In the subsequent chapter Farlong and Ball demonstrates that inefficiency on the part of civil societies resulted in ineffective AIDS policy making, thus increasing the vulnerability. Eboko in his write up moves beyond a narrow focus on civil society to illustrate how political cultures shape State actions on AIDS. He asserts that political cultures explain the variety of State responses to AIDS as in the cases of Cameroon and South Africa. These chapters set out continental macro causes for the HIV/AIDS epidemic, including, gender inequality, ineffective HIV/AIDS policies, ignorant political cultures and civil war. Next, the book investigates anti AIDS efforts at the national level. It questions the impact of economic and political transitions on the HIV/AIDS epidemic and the ability of states to address AIDS, using the case studies of Ghana, Swaziland, Senegal, Uganda and South Africa. Digging out varied response of African States to HIV/AIDS pandemic, Patterson and her co – authors observe;
“The role of the State in HIV/AIDS has varied dramatically. While the governments of Uganda and Senegal have been proactively engaged in combating the epidemic, other governments such as Ghana and South Africa have been less eager to address the problem. The effectiveness of the State is often limited by domestic considerations. In particular, the tenuous relationship between the government and civil society in many African States such as South Africa has resulted in ineffective responses to HIV/AIDS epidemic. In other areas, such as Ghana and Swaziland this terse relationship has resulted in the State using AIDS funding to garner political favor, further impeding effective HIV/AIDS policy.” (Patterson, 2006)
Further it situates a national level analysis of AIDS policies in Uganda in the larger context of national and international security concerns, particularly in light of the weakness of the African State. In contrast to Happymon’s(2005) approach of how the virus may threaten State security and contribute to State failure, the piece by Robert and Barul investigates an interesting facet that how security threats impact HIV/AIDS. Finally the book turns to the international level, illustrating the role of African states in the development of the Declaration of Commitment on HIV/AIDS and the Global Fund to fight HIV/AIDS, tuberculosis, and malaria. It demonstrates the impact of the TRIPS agreement on the ability of African states to fight AIDS, arguing that the African State has proved fairly impotent in the face on International trade regulations.
Amy S. Patterson in this volume makes use of a broad range of up – to – date literary, scholarly and journalistic, policy and popular sources. The book is of considerable value for its insights into HIV/AIDS pandemic in African States. But some of the concepts outlined in this volume do not always compliment each other. For example, the role of international aid and its effect on the State remain confused. While international aid has undermined the autonomy of the State in decision – making, it has also increased the power of the state versus civil society. Thus creating an overall confusion as to whether the state could be a potential actor for proactive policy making, or whether the State is part of the problem. The conclusion raises questions about the future role of the African States in combating AIDS.
“Infection and Inequalities: The Modern Plagues” edited by Paul Farmer deals with Farmer’s medical experience in Haiti to provide a trenchant analysis of the biologic and social realities of chronic infectious diseases. An interesting facet that the work throws is the assertion that the cause of tuberculosis and AIDS, the two epidemics this book addresses, has as much to do with social inequality as they do with microorganisms. Using data mostly from Haiti, in addition to the data from the United States and Peru, Farmer argues that social and economic inequalities have powerfully sculpted not only the distribution of infectious diseases but also the course of health outcomes among the afflicted. The pathogenic agency of inequality is so great, Farmer maintains, that “inequality itself constitutes our modern plague”, a statement he seeks to demonstrate in the balance of the book. In doing so, he repeatedly acknowledges the work of his mentor Arthus Kleinman, economist Amartya Sen, epidemiologist Richard Wilkinson, and others whose work in a variety of disciplines over the past two decades has focused attention on inequality and lack of social cohesion and their adverse effects on हैल्थ.
Farmer argues that anthropological analysis falls short in explaining the causation of disease. He takes aim at anthropologists who explain the failure of tuberculosis – control programme among poor Haitians as the result of either an inadequate understanding of the local culture on the part of the practitioners or the supernatural beliefs of the local, or both. Farmer writes that it is not that cultural analysis is unimportant but rather that it misses the point when it does not place cultural perspectives in a socio – economic context. Farmer also derides the anthropological studies of the 1980’s that explained the emergence of AIDS in Haiti as the consequence of ‘exotic’ indigenous practices. Instead, Farmer argues, these researchers should have emphasized local and regional socio – economic conditions that impeded effective care and promoted dissemination of the HIV. Farmer is right in his illustration that the understanding of local and regional socio – economic conditions and political cultures are more important in order to produce an effective response against an epidemic in addition to the necessary biological causal agents. Looking back, Eboko (Patterson 2005)in his individual piece in the edited book on ‘African State and the AIDS Crisis’ makes the similar argument in context of Uganda where he draws correlation between HIV/AIDS epidemic and political cultures. He sketches the picture of very different official responses in different settings in the following lines;
“Infections and inequalities: in a wealthy country, the specter of biological warfare, for which there is exceedingly slender evidence, triggers a sort of officially blesses paranoia. In a poor country tightly bound to rich one, real infections continue to kill off the poor, and we are told sternly to look harder for cheaper, more “cost - effective” interventions. At best, those of us working in places like Haiti can hope for trickle – down funds if the plagues of poor are classed as “U.S. security interests.” (Farmer, 2001)
Farmer highlights a “critical epistemology” of emerging infectious diseases that explores in detail how poverty and inequality cause infectious diseases to emerge in specific local context. Aiming to explain why infectious diseases such as TB and AIDS targets the poor, he fill his new work with harrowing public health case studies of the pathogenic effects of poverty and other grim social conditions. Farmer provides a well referenced analysis of everything from cell – mediated immunity to health care access issues. The studies outlined show that extreme poverty, filth and malnutrition are associated with infectious disease and what attitudes and behaviors contribute to the lack of understanding about disease. This connection finds amplification in the work of Happymon Jacob on ‘The Dangerous Factors: Poverty, Ignorance and Stigma’ (Jacob 2005), but I return to the specific empirical illustration in greater detail later.
In “HIV/AIDS as a Security Threat to India” Happymon Jacob, addresses India’s HIV/AIDS epidemic and seeks to build up the argument that the epidemic is a security threat to India. The book attempts to bridge the gap that exists between non – traditional security theories and issues. It argues that HIV/AIDS is rapidly becoming a security threat to India as the disease is affecting the traditional, economic, human and societal security of the country. It says that moreover, in India’s case it is necessary to highlight the dangers of HIV/AIDS in the country’s public as well as political leadership imagination as a security issue.
An interesting parallel that may be drawn between Farmer’s work and Happymon’s study is the desire to capture the often neglected aspect of HIV/AIDS pandemic. For instance Farmer’s close examination of poverty and social inequalities and Happymon’s stress on security implications of HIV/AIDS are never studied in greater depth as these authors did, thus raising questions for future research.
The book opens with an overview of India’s HIV/AIDS epidemic. Its history and current status and also takes a brief look at the future of AIDS in India. He argues that there has been a steady increase in the rate of HIV/AIDS infection in India and has now changed its ‘focus groups’ and is increasingly concentrating on the general population and both the rural and the general areas. The author also throws light on the fact that how the disease is a traditional, human, economic and societal security issue. Various levels at which HIV/AIDS acts as a security threat are identified and there is an analysis of its impact on each of these levels. The author finds the future scenario of HIV/AIDS in India highly disturbing because of increased mobility in a highly competitive globalized economy and also the nature of the population that is most vulnerable to this threat. He adds that extensive spread of HIV/AIDS can shaken the pace of economic growth by slowing down the flow of foreign direct investment into India. The author argues that personnel of the armed forces and the state security agencies are highly vulnerable to the risk of contracting HIV/AIDS. Thus the threat of HIV/AIDS is also linked by the author to the traditional military security arena, he records;
India has about 1.3 million military personnel. Since India has a large pool of potential recruits, the disease is unlikely to create a military security problem. However, the lack of recruits is not the only way a nation’s military can be threatened by HIV/AIDS. There are many more ways a country’s military can derail national security which it is supposed to safeguard. As mentioned earlier in a country like India, military personnel who are infected by HIV/AIDS and who would not divulge it due to the fear of losing their job and the social stigma attached to it could jeopardize military prowess and preparedness.” (Happymon, 2005)
Next he analyzes how poverty, ignorance and the social stigma attached to the disease can prove to be accelerators of the epidemic in the country. He writes that ignorance, poverty and social stigma are catalysts in spreading the disease and act as major roadblocks in combating the threat. He argues that wide spread poverty in India, can increase HIV/AIDS through malnutrition, sex for survival and due to the lack of access to health care. Further he makes the point that ignorance and widespread stigma about HIV/AIDS can make it very dangerous as it contributes to the suffering of those infected and their relatives.
Finally the author attempts to briefly describe the HIV/AIDS situation in Africa and compares the experience of African countries in combating the threat of HIV/AIDS to that of India. It highlights the fact that the Indian government must accord HIV/AIDS a special stature of security concern; otherwise India will overtake African States in HIV/AIDS epidemic and India’s situation would be where South Africa is today. He adds up Thai experience in combating the epidemic as a success model which India could emulate in order to reduce the epedimicity of the chronic disease.
The authors endeavor to relate HIV/AIDS epidemic to security threat is praiseworthy. I find Happymon’s study and style of presentation commendable, thus making the text highly accessible even to a general reading public. Several relevant statistics and a treasure of sources have been added. This further enhances the value of the book. However, the book is weak in its analysis and does not address issues that would help us to develop our understanding of the long term solution to this crisis. Nor does it addresses the State and non – state responses to the HIV/AIDS epidemics. More important than minor criticism, this piece represents a stellar contribution in the best tradition of applied social science while providing a bridge heal into the world AIDS pandemic. An interesting and though – provoking book, the piece by Happymon raises questions for further research.
In the final analysis, authors of the three books reviewed herein have tried their best to critically examine and analyze the global HIV/AIDS pandemic. We argue that, in the case of the books reviewed herein, HIV/AIDS pandemic is not only causing a devasting socio – economic and political impact on the nation – states but is also posing a great threat to the security of the nation – states. The books highlight the fact that HIV/AIDS poses new challenges to the existence of humanity. The studies try to show that the epidemic can be catastrophic depending how the states respond. The books therefore, make a valuable contribution to our understanding of the HIV/AIDS crisis and the issues to be addressed. It deals with new initiatives and global priorities and their relevance and implications for developing world in general and India and African states in particular. The winners over the pandemic in today’s world are those who gives top priority to HIV/AIDS crisis as given to other threats like war and terrorism and dealing the situation with well – planned and mass – based programmes, can only reverse the pace and the spread of the disease. That is the illumination brought to fore by these literatures.
Overall the authors of the three books are commended for accomplishing a great task that is to put forth a well argued, well organized and useful contribution on such a sensitive issue.

Monday, December 3, 2007

Home page > 2007 > December 1, 2007 > NACO and HIV/AIDS in India
Mainstream, Vol XLV, No 50

NACO and HIV/AIDS in India

Monday 3 December 2007, by Javed M Iqbal
The human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS), is the leading infectious cause of adult deaths in the world। Given the scale of the epidemic, HIV/AIDS is now considered not only a health problem, but also a developmental and security threat. Even if a cure is found tomorrow, the toll of death and suffering by 2010 will far exceed any other recorded human catastrophe, any other previous epidemic, natural disaster, war, or incident of genocidal violence.
India is experiencing rapid and extensive spread of HIV. This is particularly worrisome since India is home to a population of over one billion. As a single nation it has more people than the continents of Africa, Australia and Latin America combined. The situation is graver in States like Tamil Nadu, Maharashtra, Andhra Pradesh and Karnataka. A report by the World Bank released at the 16th International AIDS Conference says that India is home to 60 per cent of South Asia’s HIV patients. The NACO and UNAIDS paint a contrasting pictures of HIV/AIDS estimates in India. According to the UNAIDS 2006 report, out of an estimated 46 million people living with HIV worldwide, 5.7 million people are living with the virus in India, more than any other country in the world. On the other hand, NACO’s projections shows that by the end of 2005 there were 2.5 million people were infected by HIV. The UNAIDS statistics reveals that India is the most infected country surpassing South Africa. On the other hand the Union Health Minister renounces the UNAIDS claims and asserts that India stands next to South Africa in terms of number of people living with HIV/AIDS. These figures make it very difficult to ascertain the exact status of AIDS cases in India. It is unfortunate that even after more than a decade of existence of the National AIDS Control Organisation (NACO), the nation is still debating the accuracy of the HIV/AIDS statistics. It seems that instead of addressing the issues of primary concerns, NACO is involving itself more in trivial cases of data projections and collections. The much-needed treatment, healthcare and infrastructural development has taken a back seat in the current strategies and policies of NACO. As Peter Piot, the Director of UNAIDS, in an interview with Associated Press rightly said, “At the recent meetings in India, I heard great speeches, but as for action, zero.”

SOON after reporting of the first HIV/AIDS cases in the country in 1986, the government launched a National AIDS Control Programme in 1987. The programme stressed on surveillance, screening of blood and blood products, and health education. By this time, the HIV/AIDS had already attained an epidemic status in the African region and was rapidly spreading in other parts of the world. Realising the intensity of the epidemic, the Government of India, with the support of the World Bank, established the National AIDS Control Organisation in 1992 to enhance the ongoing programmes. The same year that NACO was established the government launched the National AIDS Control Project under which State AIDS Control Societies were set up. The purpose of the setting up of State AIDS bodies was to carry out NACO’s AIDS control programmes. NACO’s initial efforts were to control sexually transmitted diseases, to promote condom use, to provide testing, counselling, care and support for people with HIV/AIDS, to conduct surveillance, and minimising harm for injecting drug users, to provide blood safety and blood products and supporting research and product development. Unfortunately, these efforts remain a dead letter as no serious steps were taken for effective implementation. Even the prime HIV/AIDS control measure, like making HIV screening mandatory in all blood banks, was initiated only due to the landmark Supreme Court directive in 1996.
Still after more than two decades of HIV/AIDS in India, the issues and concerns remain unaddressed. NACO’s initiatives were inadequate in combating the new millennium pandemic and are focused mainly on urban populations rather than rural. Its reluctance to intervene in prevention efforts in rural areas has in a way increased the epidemicity as the rural populations are more vulnerable and a large proportion of the Indian population resides in these areas. The epidemic is gradually getting concentrated in rural areas with 58 per cent infections being reported from villages. According to Dr Meenakshi Datta Ghosh, HIV/AIDS is no longer affecting only high-risk groups or urban populations, but is gradually spreading into rural areas and the general population. One can also find an interesting dichotomy in State response in terms of HIV/AIDS awareness programmes. The government- run awareness programmes are more concentrated in urban areas as compared to rural areas. Thus the increasing susceptibility and lack of community participation in HIV/AIDS prevention programmes. NACO’s commitment in dealing with children and women living with HIV/AIDS is quite dismal as there are no specific guidelines for the treatment, care, and support of HIV positive children and women. As per UNAIDS 2006 report, approximately 700,000 children became infected with HIV and 95 per cent of children got the infection from their mothers. The report also reveals an alarming increase in the number of women with HIV/AIDS, reflecting the greater vulnerability of women to HIV/AIDS, especially in the rural areas. There are about 16 lakh women, aged 15 and above, living with HIV. Despite these burgeoning statistics, NACO’s responses are far short of meeting the demands and in their policies, women and children with HIV remain a neglected face.
The AIDS control mechanisms are not well integrated with the basic public health care infrastructural facilities. Surveillance of HIV/AIDS is the weakest link in the health infrastructure and preventive strategy. HIV/AIDS surveillance has been always accorded low priority in national planning and resource allocation causing discrepancies in surveillance mechanisms. This resulted in inappropriate epidemiological data causing confusions in policy-planning vis-à-vis policy failure. Epidemiological data remains a major weakness affecting policy planning and even today tell us virtually nothing about what is happening in the rural areas. At the same time, there are discrepancies in the surveillance facilities between the more urbanised and less urbanised States. The more urbanised States like Maharashtra, Tamil Nadu and Karnataka have greater concentration of facilities and technical skills helping them to determine the number of cases while in the case of less urbanised States like Bihar, UP and Rajasthan these testing facilities are lacking. Thereby HIV/AIDS cases in these States always go unnoticed. In 2003 both Dr R. Feachem, the then Executive Director of the Global Fund to Fight AIDS, and Dr Meenakshi Datta Ghosh as a Project Director of NACO, in separate interviews stated that the epidemic is moving into the general population. Even many surveillance data suggested the same but unfortunately found no takers. Making the situation worse NACO in their prevention policies completely neglected the general population and clinged on to the approach that the epidemic is limited to high-risk groups such as sex workers, drug users and truck drivers and targeting them is the best strategy.
The low status accorded to both prevention and facilities for diagnosis and treatment in rural India is also one of the major reasons for where we are today on the AIDS epidemic map. The supply of anti-retroviral drugs in villages is erratic. Unfortunately, these issues and voices remain relatively unheard. So even 20 years after the entry of AIDS, the issues here remain just as they were. Public health systems are virtually ineffective and therefore seeking treatment is difficult and most villages have no access to these treatment facilities. In general, India’s ART treatment rate at the present stage is also dismal. The UNAIDS 2006 report says that only seven per cent of Indians who needed antiretroviral drug therapy actually received it and a meagre number of 1.6 per cent of pregnant women, who needed treatment to prevent mother-to-child HIV transmission, are receiving it. Even as per some official estimates of the 5.5 million people living with HIV, only 60,000 are on these drugs. Of these, only 30,000 are being supplied through the public health system. Further NACO’s claims on treatment measures fell flat in Supreme Court, when hearing a bunch of PILs, the Court found that against the target of giving ART to one lakh people by 2005 only 33,000 have got the medication by the same year. Later the policy-makers in NACO in a more unfortunate way shifted the target year to 2007. The simplest and most effective preventive measure like condom promotion was not taken on a massive scale; sidelining this intrinsic care, NACO invested time, resource and energy in organising conferences, seminars, which are unreachable to the majority of the HIV/AIDS patients. A case in point is India’s anxiousness to host the International AIDS Conference in 2012, for which the preliminary preparatory work has commenced on a war-footing. This gives an impression that the government is more serious in flourishing the tourism industry rather than spending a few bucks on most affordable prevention measures like condom promotion.
Last but not the least, insufficient budgetary allocation and HIV discrimination strains many preventive efforts. This is evident from the previous experiences where NACO was allotted a meagre $ 38 million of the government’s own funds over the 1999-2004 period. Social reaction to people with HIV/AIDS in India further fuels up the crisis. The negative attitudes from health care professionals and responsible institutions have further worsened the situation. For instance, in Orissa a young HIV+ couple committed suicide after being ostracised by their locality and surprisingly the State AIDS Cell’s anti- discrimina-tion unit claims ignorance about the episode. Similarly in another instance the Orissa State AIDS Cell was completely unaware of the killing of a youth by his community members in Puri as he was HIV+. Such cases are alarmingly proliferating in various parts of the country. To check this injustice NACO is yet to come up with a concrete legislation. The proposed draft bill against HIV/AIDS discrimination, which was initiated in 2002, is still under consideration of our lawmakers. The lack of such legislation till date raises questions on the seriousness of the government’s commitment and strategies.

THUS far India has struggled to curb the AIDS epidemic and it is high time that we should initiate measures to overcome the weaknesses and drawing appropriate lessons from other successful countries like Brazil, Thailand, Combodia, Uganda and Senegal. Here Brazil’s case is important and unique because of the similar socio-economic and political set-up it shares with India and India can emulate the Brazilian model. First, Brazil has enacted a law which ensures HIV+ people and others having opportunistic infections the right to free access to treatment. Secondly, a strong relationship between the government and civil society groups, including the Catholic Church, has reduced the stigma and discrimination associated with the virus thereby allowing the government to work swiftly. Thirdly, an innovative and mass campaign on condom promotion resulted in incredible increase in condom use among the general population. This strategy is believed to be one of the most important factors in bringing down the AIDS cases. Fourthly, greater emphasis on treatment and care further proved effective in preventing the spread of the virus. As a result, the AIDS cases in Brazil dropped to 620,000 cases, which is far less than previous records.
It seems that our policy-makers perceive the new millennium pandemic just as a health problem rather than a politico-economic threat or national problem. However, Brazil and other successful countries conceive HIV/AIDS as a national malady. It is true to some extent that there is simply no substitute for state action but at the same time it would be unfair to shift the burden of action or inaction on the state. We should also recognise the importance of collective commitment between individual and the state as a factor for an effective fight against AIDS as reflected in Brazil’s case. Finally, we should be less defensive about the issues and statistics, rather more offensive in actions and interventions. We should recognise that there is a global commitment in combating HIV/AIDS and it is time to act and deliver to all.

The author is a Research Scholar, CIPOD, School of International Studies, Jawaharlal Nehru University, New Delhi। He can be contacted at