Issues of Women and AIDS in India

In India, AIDS control activity and the discourse generated by it reveal a number of power hierarchies between the countries of the North and South, between the sexes and between laypersons and medical/public health experts. The discourse has been North-centric and male-centred. Indian public health campaigns have tended to follow a decontextualised global framework set up by international experts. First, this article contends, that viewed against the health problems faced by the Indian people, AIDS is less frightening than has been projected by experts. Secondly, it points to the neglect of a segment of the population likely to be most affected in the coming years - the average middle and lower class women not belonging to the categories labeled 'high risk groups'. Finally, this paper raises the issue of AIDS education. In a society where social norms emphasize monogamy, sexual responsibility within such relationships needs to be promoted through the strengthening of mutually respectful and supportive gender relations. Instead, 'sexual freedom' is the message AIDS education appears to propagate in the name of "value free" messages. This resonates with the consumerist, ecologically destructive dream of an industrial society being 'sold' to Third World and can be viewed as a part of the larger 'cultural invasion' being forced through the neo-colonialism of 'globalization'.

AIDS and the Context of People's Lives

In India, as in many other developing countries, there is a very small elite section which wields tremendous power and is involved in the use of the dominant knowledge system to plan and implement development strategies and programs. Of these, the urban upper-middle class, who are also university educated, English-speaking and global in terms of their interactions and lifestyles, play a key role. This section stands in stark contrast to the much larger section of the lower middle class and the poor. While about three percent of the population may be said to constitute the elite section, by official estimates 40 percent are totally illiterate and live below the poverty line.

In all classes women have a lower social status and their primary role is perceived as within the family. However, they differ widely in lifestyles and experience the impact of development unevenly.

International and national AIDS experts are using statistical models to project the magnitude of the evolving AIDS epidemic in India. The data on which they are calculated are often questionable but this exaggerated portrayal has led to a panic-stricken response by dominant public health experts and has generated fear among others.

The response of the public health experts is epitomized in statements of the erstwhile Director, Indian Council of Medical Research. In 1990, he announced that "one-third of Bombay's housewives are going to be infected with HIV by 1995." In fact by 1992 only 0.5 percent of ante-natal women had been found positive. The action he vehemently advocated was to "ban all Indians from having sex with foreigners" - a prime example of responses arising out of panic.

The Indian public health establishment has unquestioningly accepted the industrialized countries perception of AIDS as THE major health problem requiring focused action on certain "high risk groups" comprised of socially marginalized people. The first action to be taken was of forced surveillance among commercial sex workers (CSWs) with the help of the police, despite lessons to the contrary from the experience of industrialized as well as Third World Latin American and African countries. Those found positive were then jailed because nobody knew what to do with them.

While AIDS is undeniably an important public health problem in India and needs special attention, there is need for preventive approaches that do not create fear and panic.

Comparing the high projections for AIDS with the data on other causes of disease and death, it is clear that the new disease will merely become "one more" in a whole complex. For instance the number of cases of malaria, filaria or STDs far outnumber those expected to arise from AIDS. Deaths due to tuberculosis in the 1990's will be eight times more than those expected from AIDS and deaths due to accidents and injuries are over three times those expected from AIDS.

Few AIDS experts ever place AIDS within this totality. They advocate dealing with it as THE major public health problem, pre-empting general health care services. One-fourth of the government's health budget is ear-marked for AIDS, in spite of other equally pressing needs. This is detrimental not only to other health services but to AIDS control as well.

The urgency expressed by the AIDS experts contrasts with the views of women living in poverty, powerlessness and poor health. An extreme expression of their perspective is the statement of a CSW in Bombay who said "I am not living even now. So how does it matter if I die!" It tells us that AIDS is not going to create the kind of panic, among a large section of Indian women, as it has created among AIDS experts. It also tells us that, for any effective AIDS control, the conditions giving rise to an attitude of fatalism must change. These views are not a denial of the AIDS threat by the individual, often described in the context of Third World countries. The lesson here is to prioritize AIDS as a problem within the lives of the majority.

From the Women's Perspective

An estimated 75 percent of HIV transmission in India is due to heterosexual contact and about one-third of those already infected are women. Nevertheless, AIDS discourse projects the epidemic as primarily a threat to young male citizens. AIDS is largely portrayed in association with the so-called "high risk groups" (a very biased and unsubstantiated picture) - the male homosexuals, the professional blood donors and intravenous drug users (who are overwhelmingly male) and male clients of the only female high risk group i.e., CSW While action targeted at the males is mainly preventative and protective of them, action targeted at the CSW is to prevent the spread of infection from them.

The female CSW is seen as the immoral spreader of infection to men, or in the more sympathetic view, as the spreader driven by compulsion of her socioeconomic circumstances. However, in the process of public health planning and programming even the latter view finds little expression and her social, economic and health needs continue to be largely neglected.

The "ordinary" women are seen as the spreaders of HIV to their new born babies. The official program considers them only for ante-natal HIV testing as easy sources of data for trends in the general population, while doctors go on refusing to help deliveries of HIV positive women. The official AIDS control program ignores these women who are expected to be the biggest group to be affected in the coming years. The women's perspective requires attention and the Indian public health establishment must reorient its approach to AIDS:

(a) It must look at AIDS within the whole gamut of health problems and services to ensure that women get access to health services and use them. Without general health services, STD and HIV/AIDS services too will remain out of reach.

(b) It must drastically change the negative attitudes of health care providers towards AIDS to increase the confidence of people in the health services. Informed consent before testing, sensitive counseling, and confidentiality are necessary steps for building a relationship of trust between the service providers and lay public.

(c) Finally, it must inhibit the transmission of AIDS through medical interventions by improving the infrastructure and service delivery to ensure safe blood banking, proper sterilization of equipment, and adequate control of drug quality.

Portrayal of AIDS Primarily as an STD

There is heavy emphasis on the sexual route of transmission which is widely publicised to the exclusion of the role played by a negligent medical system. This approach has a number of negative effects. First, it does not allow for forceful action to change the health care provider's behaviour related to safety procedures. Second, it emphasizes AIDS as an STD only and thereby increases the stigmatization of HIV positive women. Media reports document the rejection of many HIV positive women by their families, leading to their destitution. Third, it makes promotion of condom use the primary AIDS control activity where the onus will be on women because of unequal gender relations.

Most of the resources are being used to change individual behaviour while nothing is being done to improve access to health services or to change the health care providers' attitude and behaviour. The distortion of priorities for the allocation of funds to AIDS education arises from an uncritical adoption of the Northern agenda for AIDS control. The North-centric perspective must be replaced by a public health plan that is derived from the Indian context.

AIDS Communication and Social Responsibility

AIDS communication directly involves issues of sexual behaviour. It is generally accepted that messages should not moralise to avoid alienating those who most need help. This situation could have been an opportunity to initiate a significant public discussion of gender relations, their emotional and physical aspects as well as the power equation. However, the dominant AIDS-related communication has largely been of two types. It has either been too bland, thus failing to register in people's minds, or it is cast within the frame of commercial advertising - promoting gender, class, and sexual stereotypes, using the physical female form to attract attention and promote the commodification of sex. A television AIDS education spot, for example, goes even further when it shows an uncle explicitly telling his young nephew that there is nothing wrong in going to a prostitute, "all you must do is ensure 'safe sex', i.e. use a condom". In a society where prostitution is not acceptable, an elder giving it sanction is not just 'non-moralising', it is promotion of a culture counter-productive for AIDS control and to women's social empowerment. Such AIDS communication is getting support from corporations which have been provided one more legitimate reason to promote the consumerist culture.

This kind of culture change can only increase the sexual exploitation of women. A stark illustration is provided by the spate of new magazines that came into the market invoking the purpose of 'AIDS awareness' and 'Health education.' They publish sexually titillating material including photographs of nude women in a vulgar manner. While some may justify this as satisfying a certain human need, it is certainly criminal when it is done under false pretences and by blackmailing/forcing young girls into being photographed in the nude. Several such instances became public in 1994 and public protest and court cases ensued. These young girls, from lower middle class homes, ill-equipped to deal with the viles of the world but egged on by the desire for a high class life-style, went in for small modeling assignments and were then forced into nude modeling.

A number of groups in India are opposed to the cultural changes coming in the wake of globalisation. Among the groups ranged against the World Bank and International Monetary Fund's structural adjustment package are the Azadi Bachao Andolan (Save our Sovereignty Campaign) the Narmada Bachao Andolan (Save the Narmada Campaign), the Jan Vikas Andolan (People's Development Campaign), etc. They view this manner of mass communication not only as economic aggression but also as cultural aggression on the majority of Indians. They are supportive of the human rights of all marginal groups including homosexuals. They provide an egalitarian and ecological, counter-position to consumerism by advocating values of self-restraint (by redefining physical and material needs), thereby limiting ecological and social disruption and promoting a just distribution of resources within society and between societies.

The rightist political fundamentalists raise issues of 'morality' in a narrow sense and are ready to use force to ensure compliance with behavioural norms set by them. They gain popular support on this, at least partly due to the negative consequences of advocacy of sexual freedom. Further, linking this issue with the struggle for other rights of women, they make these rights appear socially 'irresponsible'.

From the perspective of the majority of women, strengthening the existing value of monogamy through representation of positive gender relations which are mutually satisfying and mutually empowering would mean much more for women's well-being and AIDS control.

Therefore, we need to be very careful in how we communicate AIDS and sexual behaviour related information without moralizing, without detracting from an individual's sexual rights and yet without promoting irresponsible sexual behaviour or contributing to the expansion of fundamentalism.

Dr. Ritu Priya, Assistant Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University. (An earlier draft of this article was presented at the ICPD, Cairo in 1994).

Press Trust of India (report): Bombay Warned of AIDS. National Herald, 9th September, 1990.
National AIDS Control Organisation: National AIDS ControI Program in India - Country Scenario, An Update. Ministry of Health and Family Welfare. Government of India, New Delhi, April 1993.
Priya, Ritu. AIDS, Public Health and the Panic Reaction. National Medical Journal of India, Part 1 Vol.7 No.5 pp 235-40 Sept.-Oct.'94. Part II Vol.7 No.6 pp 288-91 Nov.-Dec.'94.
Bhandari, A. and Dalip, D. et al.: Women and AIDS -Denial and Blame -A Citizen's Report. AWS Bhedbhav Virodhi Andolan. NewDeIhi, 1990.