AIDS thrives on people’s poverty and ignorance, and as the pandemic prepares to spread, it threatens to sap the health of nations as well.
Bombay has the largest sex bazaar in Asia. There are almost 100,000 prostitutes working in the city´s red light districts, half of them infected with HIV. The prostitutes average 600,000 sexual contacts per day. The chance of HIV transmission during a sexual encounter is 0.1 percent, which means there are potentially 10,000 infections every month from the Bombay brothels. Most of the sex workers come from Nepal, and the poorer parts of India and Bangladesh, and they take the virus back with them to the remotest corners of the Subcontinent.
The threat is not confined to red light districts. Urban-rural cross-migration into the city from all over the region, especially movement of high-risk groups (soldiers or sex workers in India, Nepal or Sri Lanka) is contributing to the spread of the virus in rural areas. Truck-stops along India´s highway network, where unprotected sex is the norm, is another conduit for the spread of HIV to the hinterland. Given the minimal awareness and poor health care in the region, South Asia´s AIDS fuse is getting shorter.
Statistics forecast doom, but there is still time to avert a catastrophe. The epidemic is still in its infancy in the worst-affected countries of Asia: Burma, India and Thailand, and there is still time to ward off the impending epidemic. For now, government complacency on AIDS is based primarily on the inability to appreciate the magnitude of the danger because of the false sense of security provided by official data.
Going by official figures, there isn´t much cause for alarm. The number of reported HIV cases in India till January this year was 2312. Sri Lanka had only 173 HIV-positives till March this year. Nepal´s National Institute for STDs and HIV reports only 349 cases of HIV infection. Since AIDS was first detected in Pakistan nine years ago, the National Institute of Health had identified about 1,000 cases up to December 31,1995. Bangladeshi official sources claim that only 49 people have been infected by the virus. Bhutan has tally of zero.
But officially reported cases represent only a fraction of actual incidence, and may have no bearing on reality. On a worldwide basis, only about one out of ten AIDS cases in both adults and children is reported to the World Health Organisation (WHO). In India, up to five million people may actually be infected. Projections show more than 6000 in Sri Lanka and 20,000 in Bangladesh to be infected with HIV. Up to 30,000 Nepalis and anywhere between 30,000 and 50,000 Pakistanis may already be HIV positive, while independent estimates put the number of carriers in Burma to be 500,000. Even Bhutan, which reports no HIV cases, is suspected of having at least 75 HIV-positives.
Even more frightening is that HIV has the potential to spread exponentially through the population if preventive measures are not taken. “Although it came to Asia after Africa, AIDS is beginning to show some real fury here,” says David Bloom of Columbia University, who specialises on the economic impact of AIDS in Asia´s developing countries. “There is very little question that the centre of gravity of aids is moving to Asia, and moving rapidly.” With South Asia as the seat of Asian AIDS.
Epicentre of the Epidemic
The World Bank says that the region´s share of the global total of people with AIDS (pwa) rose from one percent in mid-1993 to six percent in 1994. At this rate, the majority of new infections in the world is expected to occur in South Asia by 2000, and India will be at the epicentre of this epidemic. The current pwa population in India is doubling every year, and if HIV continues to spread at the present pace, some studies indicate that by the end of the decade, 160 million Indians—one in every six—will be HIV positive. To put the figure in perspective, in Bombay alone, 10,000 people will succumb to AIDS every month by the turn of the century.
If there is no medical breakthrough in the search for an AIDS vaccine, and if proper medical care is not provided to those already infected, the cost of an HIV epidemic could cripple South Asia´s fragile economies. “The best time to spend a dollar on HIV control is when you´ve got no HIV in your country, the cost-effectiveness of control declines markedly as prevalence rises, countries as yet little affected should be investing heavily,” says Dr Richard Feachem of the World Bank.
Some experts even forecast a collapse of the region´s economies if present infection rates continue. “AIDS is a costly disease but the medical costs are minor compared to the loss of income from morbidity and mortality among the afflicted,” warns Dr Bloom. He and his colleagues at Columbia University have calculated the indirect costs of AIDS to be at least ten times the direct costs of medical care for each patient.
For the moment, working out the cost of AIDS to the social economy is being perceived as a futile exercise for, as Dr A.K. Mukherjee, India´s Director General for Health Services puts it, “The numbers are too small to show any visible effect on the economy at present.” But, when HIV infection rates soar, and the financial effect of the disease on national economies begin to be felt, it could be too late.
The economic costs of a disease include direct expenses, the hospital costs of doctors, nurses, drugs, equipment, administration, as well as the costs of out-of-hospital care, such as hospices, health visitors and counselling and the indirect costs of labour— and, therefore, of potential income—lost because of illness and death of patients and the task of caring for patients.
AIDS, a disease characterised by intermittent bouts of illness, places considerable demands on health spending. Experts put the present value of income losses due to the death of skilled adults at approximately INR 353,000 each in India. In macro-economic terms, medical care and income losses due to AIDS are projected to cost India an annual INR 352 billion before the next century. That represents a full five percent of the Gross Domestic Project.
The main channel through which AIDS will affect economic performance will be in the change in the size of households and decreased productivity levels. Because AIDS tends to selectively affect young adults in their most productive age, an epidemic will be an uncalled-for burden for South Asian countries already struggling with heavy debt loads, fragile economies, high levels of poverty, limited resources, inadequate human capital and an unsure food situation.
Teetering on the Fringe
The region´s rural areas will bear the brunt of an AIDS epidemic. As much as 60 percent of South Asia´s population depends on subsistence farming, a highly labour-intensive endeavour. Shortage of able-bodied adults will lower overall agricultural yield. Illness before death and the time other members spend caring for those infected will also reduce productivity, as will medical costs taken out of household resources, otherwise used to purchase agricultural inputs such as labour or fertiliser.
Equally devastating would be the effect of an HIV/aids epidemic on the service and industrial sectors. Losses due to absenteeism, followed by eventual death of workers, and replacement costs will prove significant. Expenditures on medical care, pensions, insurance, housing and death benefits will also be considerable. Foreign investors are lured to South Asia by its large supply of inexpensive labour. If present forecasts come true, the reduction in the supply of healthy labour would increase both wages and production cost.
Remittance from overseas labour is crucial to South Asian economies. With the increasing prevalence of HIV among migrant workers from the Subcontinent, this source of income is sure to be hit hard as labour-importing countries establish elaborate screening procedures. As a taste of things to come, in 1993, 353 Pakistanis were deported from the United Arab Emirates for testing HIV positive.
Meanwhile, increased economic inequality has been predicted for a future South Asia as the region´s poor try to grapple with AIDS. Economic regression has always had a disproportionate effect on the poor but that effect is multiplied manifold when a worsening financial situation is coupled with AIDS.
Economic liberalisation, large-scale migration to cities, and urbanisation, all are contributing to a rapidly evolving industrial labour force that teeters at the fringe of sustenance, in a setting far removed from the relative security of village life. Such low-income urban groups have been identified as being most vulnerable to AIDS, both the virus and the attendant economic loss—to the extent that it has become common to call HIV the “poverty virus”.
As Dr Bloom points out, “Since public and private institutions, such as health, life, disability and social welfare insurance, will be beyond the reach of the majority of the working class, AIDS will force secondary workers to look after family members who are sick— another productivity loss.” The indirect effects of AIDS within households are numerous, aids threatens more than the capability of a household to function as an economic unit, the entire social fabric of the family is potentially disrupted or destroyed.
As AIDS claims more and more victims, there will be a growing number of AIDS orphans. In absolute terms, the loss of a parent is an incalculable tragedy for children. When a mother dies, it doubles the death rate of her surviving sons and quadruples that of her daughters. When both parents are gone, the situation is worse still. Left on their own, children who are not fortunate enough to be absorbed into the family circle of relatives are rudderless and often turn to prostitution or petty crime to survive. They are often pushed to the edges of organised society, have few allies and have negligible access to information and services, and thus are highly susceptible to being infected or themselves spreading infection.
Women will once again find themselves disadvantaged in the world of AIDS. More and more girls are likely to be taken out of school to nurse siblings or to substitute for the reduced productivity of other family members. They may be encouraged to marry early as growing numbers of men seek younger, and presumably, uninfected wives. For AIDS widows, loss of land, shelter and inheritance will force them to migrate to cities where there is a great possibility they will join the urban underclass as domestic help, in underpaid sweatshops, as prostitutes, and so on.
AIDS will also bring about drastic changes in the dependency ratios—the number of children and elderly people dependent on working adults. Most diseases strike the weakest first, the very young and the very old. HIV/AIDS primarily targets adults, leaving children and the elderly without those on whom they traditionally depend. Because of this, and because most nations in South Asia have smaller proportions of their populations in the 15 to 60 age group, the number of dependents will rise.
In sub-Saharan Africa, aids deaths and illnesses in the 1980s increased the number of dependents per 1000 working adults to 1024. In South Asia, the epidemic is growing at a pace reminiscent of sub-Saharan Africa in the early 1980s, but, with a difference. There is greater potential for spread, given South Asian adult population of nearly 500 million as opposed to just 25 million in sub-Saharan Africa.
No Breathing Space
The biggest impact, however, will be felt by the health sector. AIDS comes to South Asia at a time when easily preventable diseases are still killing children by the thousands. Lack of basic health care means that people die of simple infections. As it is, the sum allocated by South Asian governments for health care is hardly enough even for preventive immunisation programmes, says Dr. Arole Aurore of the UNICEF Regional Office for South Asia. With the increasing number of people with AIDS, medical costs will rise further due to the association of aids with other diseases, particularly, tuberculosis (TB).
The strong link between HIV and TB is complicating the management of both the diseases. TB is the most important single cause of infectious-disease mortality in the world and responsible for one quarter of avoidable deaths given that one out of every three persons in the world is infected with the TB bacillus. The relationship between the AIDS and TB is synergistic and so the combined effect is much worse than their separate effects.
A few years ago, TB was considered a stable, endemic health problem. Now, thanks to antibiotics-resistant strains and HIV, TB is resurgent. Compared to people without HIV, HIV-infected people have upto 30 times greater chance of developing TB as they are already prone to infection simply by sharing breathing space with TB patients.
There is also a great danger of AIDS spreading through sexually transmitted diseases (STDs). Where STDs are common, AIDS flourishes, since high prevalence of STDs indicates a certain degree of high-risk sex behaviour among the populace. Moreover, STD sores and lesions act as an easy way in for the AIDS virus as does STD-related genital ulcer which is found widely in Asia and Africa. Studies have shown that the chance of getting AIDS, no doubt another STD, increases fourfold for someone with an STD.
Unprotected sex increases the possibility of getting aids—some are lucky, some are not. That is not the case with HIV-infected blood transfusions; the question of luck does not arise. In India and Pakistan, more than a tenth of HIV infections has been due to HIV tainted blood. Testing does not prevent HIV infected blood from circulating despite the development of various blood screening methods. There is a chance of getting AIDS even from ´HIV free´ blood since most of the blood that is collected is tested before the six-week “window-period” for the AIDS virus to be detected.
The sizeable amount of blood collected from “professional donors” has been identified as being primarily responsible for HIV infection through blood transfusion. India collects almost half of its annual blood need from such donors. Most of these donors are not screened. Neither are their counterparts in Bangladesh, where one study found 21 percent to be suffering from syphilis. Similar is the case in Pakistan, where a large proportion of the professional blood donors come from among the country´s 3.1 million drug abusers, whose addiction itself exposes them to considerable risk of getting AIDS.
When Squeamishness Kills
Most of the work being done to prevent AIDS in the regional countries is being carried out by voluntary groups. State spending on health as yet does not reflect the urgency that is needed to stem the epidemic. That trend, of course, is seen worldwide among developing countries. The turn of the century is expected to have more than 95 percent of PWAS living in the Third World, but current expenditure, on AIDS prevention is skewed in the opposite direction. Of the total amount spent globally on AIDS prevention, the developing world accounts for less than 5 percent. India spends a mere two cents per person.
For the moment, anti-AIDS programmes have not proved very effective. Propagation of incomplete information abounds. A Pakistani TV advertisement lists one of the ways of getting AIDS as “from a woman to a man and vice versa” (without specifying how, and without indicating the greater danger for women). Similarly, despite the existence of South Asian homosexuality, the possibility of man-to-man transmission is not advertised in any of the countries. This squeamishness about discussing sex publicly is a major reason why AIDS education programmes have not been effective.
Both religion and the so-called “Asian values” also have much to do with the slow spread of AIDS awareness. Indian Prime Minister P.V. Narasimha Rao admitted as much when, at the International Conference on AIDS, Law and Humanity in New Delhi in December 1995, he stressed the need for a practical approach and “not take refuge in morality and cultural heritage which has misled many countries to an AIDS catastrophe”.
Other awareness campaigns are just too difficult to understand. The main thrust of Bangladesh´s anti-AlDS drive has been to place hoardings at busy intersections, some crammed with written information and others depicting skeletons lying in the foreground of what appears to be ravaged villages, with the acronym “aids” written in a highly stylised script in one comer.
Even if it were noticed, the hoarding would be lost on 75 percent of Bangladesh´s population, which can´t read. When AIDS awareness goes on radio, things aren´t much different: several of Bangladesh´s top performers came together and produced a song for radio and television audiences about a “deadly scourge” that people should try and protect themselves against. One unfortunate flaw in this otherwise noble exercise: not once was it mentioned what this “scourge” is and how it is transmitted.
The AIDS scare has remained just that—a scare—in South Asia, and complacency defines the attitude of those with the responsibility of preparing the people and the economy for the devastating invasion to come. Just because you do not see it coming—because there has been no sustained surveillance campaign in any of the regional countries—does not mean that it is not approaching. The threat of the pandemic is also disregarded because it is difficult to correlate a future threat with future economic ruin.
The common South Asian citizen still does not understand AIDS. The average South Asian government is not doing much better. Without data, burdened with unresponsive public health structures, confronted by myriads of other public health problems, and in full denial of the facts of sexuality, South Asians are, basically, sitting back while they wait for HIV to spread. The disease is yet to strike hard, but it will.