With Robert Cornellier — friend, teacher and co-director — in a village in Rajasthan’s Shekhavati region. It was Robert who encouraged me to think audio-visually and look beyond the cliches. If I ever make a great film, I will look back at moments like these which helped me understand colour, sound and so much else.
INDIA: Poverty, Gender Imbalances A Lethal Mix for HIV/AIDS
Inter Press Service – July 5, 2004
HASAMPUR, India, Jul 5 (IPS) – In this village in India’s north-western state of Rajasthan, Kamla, a woman in a long and flowing sequined skirt and a bright pink headscarf speaks of the hurdles in spreading awareness HIV/AIDS among other village women.
It is not an easy task. Most women in Hasampur are illiterate. In a milieu that is unashamedly patriarchal, sex remains a taboo subject that cannot be discussed openly even though it is unsafe sex that drives India’s HIV/AIDS epidemic.
“We try our best, with what we know and the weapons we have — a smile, jokes. I have never brought up the subject directly — I point to my four children, look at him lovingly, and ask him (husband) to be careful when he is away from the family.” says 30-year-old Kamla, whose husband, a poor farmer, left the village to work as a loader in one of Delhi’s prosperous satellite towns.
The challenge of disseminating information that can shape sexual behaviour is compounded by the difficulty of sounding the alarm in a place like Rajasthan, a desert state officially classified as one with low HIV prevalence in this country of one billion-plus people. Some 5.1 million people are living with HIV in India, according to 2003 figures released this week.
Indeed, as the pandemic continues to spread from the cities to villages and beyond groups with typically high-risk behaviour to the general population in India — including monogamous married women — the real test in India’s battle against HIV/AIDS lies in what happens in villages like Hasampur, in the vast countryside where 70 percent of the population lives.
The number of sentinel surveillance sites – areas that are monitored by the government and are the source of official data on HIV/AIDS — has increased from 184 in 1998 to 455 in 2003. But government-run clinics on sexually transmitted diseases and antenatal centres do not always pick up information about the vulnerable.
“We do not really have data on HIV/AIDS in rural India, except what we get from sentinel surveys,” says Dr S N Mishra, an Indian public health analyst specialising in HIV/AIDS.
“There is better representation of such sites in rural areas today compared to the past. But a lot of patients (of sexually transmitted infections) go to private doctors and quacks and most village women deliver at home, sidestepping the antenatal centres,” Mishra adds. “The prevalence of HIV/AIDS is good for epidemiological purposes. But vulnerability and risk should form the basis of planning for prevention and care and support programmes.”
Migration, a traditional survival mechanism in much of rural India, is a crucial factor in understanding the unfolding epidemics in the country. Unable to eke out a living in the villages, more and more farmers with small landholdings are leaving the countryside and heading for the big cities.
A significant percentage of migrants come from Rajasthan, Uttar Pradesh, Bihar and Orissa — states where HIV/AIDS is not perceived as a major problem. Many of them head for megacities like Mumbai, located in what India’s National AIDS Control Organisation (NACO) terms “states with high HIV prevalence”.
The Indian states classified as having high HIV prevalence – Tamil Nadu, Andhra Pradesh, Karnataka, Maharashtra, Manipur and Nagaland — are given high priority in programmes and policies. They get the chunk of donor attention because they have prevalence rates exceeding five percent among groups with high-risk behaviour and one percent among women attending antenatal clinics in public hospitals. In states perceived to have moderate or low HIV prevalence, the general perception is that there is ‘no problem’ there.
Here in parched Rajasthan, a severe drought in the last four years has given new urgency to HIV/AIDS prevention measures. The village of Hasampur falls in Sikar district, which does not have a single sentinel surveillance site.
Hasampur’s health problems are not captured in official surveys. But the sleepy village encapsulates much of what makes India so vulnerable to HIV/AIDS. Like many villages in India, Hasampur is at high risk due to its lethal mix of glaring disparities between men and women, untreated sexually transmitted infections and low literacy, poverty and increasing migration.
In such a situation, outreach workers and peer educators like Kamla have to constantly innovate to convey the high risks villagers face in this desert state famed for forts, frescoes and magnificent mansions called ‘havelis’.
“It is not easy discussing diseases which cannot be talked about in our society. It is not easy being a migrant’s wife,” she tells IPS. “And it is certainly not easy asking your husband about other women when he comes home just for a few days every three to four months.”
Meetings among village women are held at homes when the men are away, at odd hours, and messages conveyed through brochures with graphic visuals of symptoms of sexually transmitted diseases.
But Kamla is optimistic. As a peer educator for the demonstration HIV/AIDS and Migrants of Rajasthan Project (HAMARA), an Indo-Canadian initiative, she is part of the change underway in Hasampur.
Jugnaswamy, an HAMARA outreach worker, says the project in partnership with the Rajasthan government has stepped up awareness about sexually transmitted diseases and HIV/AIDS among migrants, their spouses, and “potential migrants” in 133 villages in three districts of Rajasthan. When discussing sex-related topics in a conservative milieu, Jugnaswamy says, “The starting point has to be through conversations about general health. I began by going from door to door, meeting the village women and asking them about their day-to-day problems.”
“Then, we got to discussing the common ailments — common cold, tuberculosis. Initially, they were very shy. It was embarrassing to raise the issue of sexually transmitted diseases. But today, many of our peer workers can demonstrate the correct way of using the condom,” the outreach worker adds.
There are monthly meetings and health camps for migrants, potential migrants, and their spouses. Those who get converted to the mantra of condoms and caring can depend on the village barber or vegetable vendors for contraceptives, such as condoms, that they give free of charge.
Still, there are the hurdles. For Dr Ram Niwas Yadav, who manages the primary health centre in Hasampur, the biggest is the general reluctance, especially among women diagnosed with sexually transmitted diseases, to complete their treatment because they have more faith in traditional healers. Many are afraid to discuss sexually transmitted diseases with their husbands, so their wives have untreated infections.
NACO project director Meenakshi Datta Ghosh has herself said recently: “There is at least one STI (sexually transmitted infection) clinic in each district in the country, fewer than 20 percent of STI cases report to these clinics set up within government institutions. Most people seek treatment from private practitioners and private hospitals.”
The number of Indians living with HIV is .9 percent of India’s billion-plus population, making its prevalence rate less than sub-Saharan Africa’s and Asian countries like Thailand, Cambodia and Burma. But because of the size of India’s population, it constitutes almost 10 percent of the 40 million people living with HIV/AIDS globally and over 60 percent of the 7.4 million living with HIV/AIDS in the Asia-Pacific.
Rajasthan, Bihar, Uttar Pradesh and other states are not considered AIDS hotspots today, but it is the success of experiments like HAMARA that will show if the message of condoms and caring does get across to rural India.