AIDS in India and its Potential Impact on the Tibetan Refugee Community

AIDS in India and its Potential Impact
on the Tibetan Refugee Community
by Spencer Seidman, L.C.S.W.

Part One: India in General

G.V. Satyavati, director-general of the Indian Council of Medical Research, writes:

"At end of the century, India will have the dubious distinction of being the country with the largest number of HIV infections."1

AIDS has arrived in India with a vengeance. In 1988-89 there was a 1.6-8.8 HIV seroprevalence rate among commercial sex workers in Bombay. In 1992 the rate of HIV infection increased 30.0-41.2 %. HIV, is not confined to sex workers, however; the illness is found in all levels of Indian society. Victims of HIV now include housewives, businessmen, soldiers and college students. HIV is prevalent in remote rural regions as well as in large metropolitan areas.

Since HIV takes from 5 to 8 years to manifest as full-blown AIDS, the final repercussions of the epidemic have yet to be realized in either the Indian or in the Tibetan refugee community. This can be contrasted, for example, with the situation in Africa, North and South America, and Europe, where the impact of AIDS was experienced in the mid-1980s. According to many health workers, social awareness of the reality of AIDS in India is a relatively recent phenomenon:

"Sunlit Solomon, director of the YRG Center for AIDS Research and Education, recently found that among truckers in Madras who requested testing because they have Sexually Transmitted Diseases (STDs) and are concerned about their high-risk behavior, HIV seroprevalence rates rose from nearly 60 percent in 1993 to 91 percent in 1995. Also at risk are those who are not part of the high risk groups -- people who need blood transfusions." A Bombay study found that "86 percent of the commercial blood donors screened in 1992 were seropositive. Some commercial blood donors engage in unprotected sex to earn income; others may have been infected through unsterile plasma-phersis equipment (blood transfusion equipment)."2

The transmission of HIV in India is also occurring in a country that has very high rates of other potentially-terminal infectious diseases. Tuberculosis, leprosy, malaria, hepatitis, hemorrhagic fever and encephalitis are common in India and command greater attention due to their long history in the sub-continent. There are some "20 lakh (200,000) deaths a year from TB alone."3 It is also estimated that "46% of those who are HIV positive and are in the South and Southeast Asia region also have TB."4 Unfortunately, HIV serves as a magnet for TB since the immune system is impaired once a patient is infected with HIV. This is causing additional problems in controlling the spread of TB in India. Furthermore, many in India do not even realize that they have AIDS because their symptoms are so similar to those of other infectious diseases.

On the positive side, the impact of AIDS is producing a kind of revolution in India. Open discussion about sexuality, which was previously considered taboo, is now a socially accepted form of discourse. Evidence of this is found in (Indian) English-language women's magazines. Indeed, AIDS is forcing women to reexamine their role in traditional Indian culture. To be an 'ideal wife' endowed with the attribute of unquestioning subservience is now a dangerous role to assume. Another example of change is found in Indian cinema: two films in the 1996 Montreal Film Festival were about subjects that were traditionally considered off-limits: lesbianism and transsexuality. But the long-ingrained traditional customs and mores will continue to exact a significant toll upon Indian society before they are abolished or altered through cultural reformation.

India is an ancient and multidimensional culture. Cultural values proscribe sexual relations. Given the close connection between religion and culture, it should come as no surprise that HIV is challenging traditional sexual customs. Though India has numerous tribal communities which also have their own specific practices, the following are some of the most common religio-cultural sexual practices in India:

The tradition of initiating “poor, low-caste girls into the devadasi sect. Dedicated to the goddess Yellamma when they are young, devadasis historically served priests, assisted in religious ceremonies, and cleaned temples. With the decline of temples as power structures, however, their role was stripped of much of its religious import and they found themselves selling sex to survive."5
Another cultural sexual phenomenon is that of the Hijras. "Hijras are eunuchs and transsexuals who sell sex for a living."6 Surveys done by Ram Pal Vasisht, director of New Dehli's AIDS Control Cell, suggest however that "one in three hijras there (Chitti-Pournami festival) is infected with HIV."7
Dangas: "Dangas are men who 'become' woman for the duration of the (Chittirai Pournami festival) festival ... they will don saris, elaborate wigs, and bright plastic jewelry. They also flirt, saunter, and sell sex to other men attending the festival."8
Matas: "A beautiful `harijan', or a low-caste child, who attracts the attention of the village landlords and is chosen to become a mata or `sacred mother'. She is then dedicated to a life meeting her patrons' sexual needs: she is bathed ceremoniously in the temple pond, paraded through the village, and then sent to a seasoned mata who tutors the girl in her new role."9

These practices will need to be reformed in light of the reality of AIDS; but, as evidenced in the rest of the world, it will take time, and much education, to change sexual behavior which has been considered normative for so long.

Part Two: The Tibetan Situation

Because the majority of the Tibetan community-in-exile live in India, one cannot analyze the effect of HIV on the Tibetan refugee community without reviewing how it has impacted India, its host culture.

The Tibetan community is tight-knit and consists of approximately 120,000 refugees settled in forty-eight settlements scattered across almost every state in India and Nepal. Some of these settlements are in exceptionally remote areas containing very few resources and limited means of communication with the outside world. In all areas the local traditional medical-model usurps the Western medical model. Consequently, many Tibetans believe that illness is caused by previous negative karma and bad spirits and is not related to other factors -- such as microbes. A volunteer physician working with the Tibetan community reported that approximately half her patients see a fortune teller before consulting a Western doctor because they distrust Western medicine. This distrust of allopathic medicine can lead to the worsening of a patient's medical condition when traditional Tibetan medicine is not successful. When they cannot address a problem, traditional physicians will refer their patients to allopathic physicians if they are available. Fear of allopathic medicine, however, is still prevalent.

There are several major risk factors for the Tibetan community concerning HIV. They are:

Receiving HIV-infected blood at non-Tibetan hospitals;
Lack of access to HIV barrier-contraceptives in remote communities;
Migrant work which takes men and women away from their homes for more than six months at a time, placing them at a higher risk-level for engaging in unsafe sexual practices;
Stress caused by immigration and by having international "stateless status," where general uncertainty over the future leads to employment limitations, which may, in turn, lead to drug and alcohol use.

The Tibetan Department of Health is responsible for seven hospitals and sixty-six public health centers. It has taken a proactive stance towards the prevention of HIV transmission by printing and distributing a wide variety of literature geared to different levels of literacy in the Tibetan community. This literature discusses all the typical ways that infections occur and corrects erroneous information about the disease. The Department of Health has also conducted numerous workshops, which health workers from regional centers have attended. Delek Hospital, in conjunction with the Tibetan Department of Health, sponsored an HIV workshop in Dharamsala for physicians and health workers; it has also distributed literature to the Dharamsala community, through restaurants and social agencies.

But even with this proactive approach, there are community issues which must be addressed on an on-going basis. Problems associated with condom use, for example, illustrate certain societal issues and biases:

Condom use has never been a traditional form of contraception.
There is a prevalent feeling in the Indian host community that access to condom use would lead to higher levels of premarital sex.
Many Tibetans don't know how to use a condom properly and also find it difficult to acquire them.
Indian condoms are expensive and are of very poor quality -- additional factors that deter their use.

Tibetan Health workers therefore need to reeducate the Tibetan community in regard to the many prejudices and problems associated with condom use.

Other problems that lead to unsafe sex and intravenous drug use include the high level of unemployment among Tibetan youth and the general sense of insecurity that people feel concerning the future. Due to the uncertainty of the Tibetan community's legal status in India and to the high value they traditionally place upon self-sufficiency, a feeling of despair grips Tibetan youth who have difficulty finding employment within their own communities. This is a greater problem for new refugees. The legal status of most Tibetans is that of being stateless. Consequently, Tibetan refugees are unable to compete for Indian civil service positions -- a serious problem, since the Indian civil service is the largest employer of white-collar workers in India. Because this route of employment is closed to them, Tibetans become very dependent on the Tibetan civil service, which is a very small organization and which offers only limited employment. Compounding the problem is the fact that the Tibetan government-in-exile is not recognized as a world government; it is therefore unable to receive assistance from the International Monetary Fund (IMF) -- assistance which could help expand the economy and create more jobs. This situation forces Tibetans to leave their communities. In seeking employment, they move either to large urban Indian cities, which may have only a very small Tibetan community (or even none at all); or they attempt to emigrate (which is almost impossible); or they stay in their own communities and are underutilized. This is problematic from a public health point-of-view, because it can lead to severe depression among the youth, which, in turn, can lead to drug and alcohol abuse and to the practice of unsafe sex.

An additional issue is that of HIV in Chinese-controlled Tibet. Because of limited reliable data, it is difficult to comment with any degree of certainty on the HIV situation in Tibet. Dechen Tsering reports that

"China is potentially a major focus of the epidemic in the world. Tibet's minority Tibetans are particularly at a disadvantage fueled by widespread prostitution forced by the social system, frequent sexual torture and rape of Tibetan woman prisoners, severe unemployment problems among Tibetan youth accompanied by massive introduction of cheap alcohol, tobacco and karoke bars selling songs and sex."10

It is difficult to obtain statistics on HIV in Chinese-controlled Tibet, but it must be assumed that an HIV population is developing there. This is another concern for the Tibetan community and especially for the (in-exile) Tibetan Department of Health, because they have no way of addressing the issue in Tibet.

With the AIDS epidemic accelerating in India and posing a vast potential threat to the Tibetan community-in-exile, Western NGO's can be very helpful, especially in assisting in the Tibetan Health Department's proactive stance against HIV transmission. Free donations of Western-made condoms distributed through hospitals, public health centers and local tea shops, and continued support for the Department of Health's education programs would be most useful. The creation of employment training programs for Tibetan youth would also be very beneficial and would result in an increase self-esteem and a decrease in behaviors which lead to HIV infection.

Given the meager resources available and the wide array of medical issues that must be addressed, the Tibetan Department of Health has done a commendable job, especially in assuming a proactive stance against the HIV problem in a country which is undergoing a pan-epidemic. But the Department of Health's work will be hampered if it does not continue to receive outside support in its struggle against the illness. The HIV epidemic not only affects the present generation: it will affect all future generations of Tibetans.

Acknowledgements:

Thanks to Mr. Sonam Paljor, of the Department of Health Media Unit, for his assistance; and Ms. Dechen Tesering, of Delek Hospital, in Dharamsala, for her insightful comments.

HIV and AIDS in India
Reference Information

1 Sheedhar, Jaya, "AIDS in India," Harvard AIDS Review, Fall, 1995, p. 2

2 Shreedhar, Jaya, "AIDS in India," p. 7

3 Menon, Subhadra, India Today, vol. XXI, No.20, 1996, p. 5

4 Shafer, RW Edlin,"Tuberculosis in Patients Infected with HIV: Perspectives on the Past Decade," Clin Infect Dis, 22: 683, 1996.

5 Shreedhar, Jaya, "HIV Thrives in Ancient Traditions," Harvard AIDS Review, Fall, 1995, p. 10.

6 Ibid.

7 Ibid.

8 Ibid.

9 Ibid., p. 11.

10 Tsering, Dechen, "HIV/AIDS: A Vague Threat or Reality?" 25 Years of Community Health Service, Tibetan Delek Hospital, Dharamsala, October 1996.