When Bill Gates arrived in India in November 2002 bearing $100 million that he was prepared to give to help combat the nation's AIDS crisis, he was met with less than universal adulation by some government officials. The source of their irritation was that Mr. Gates quoted estimates from a report issued by the U.S. National Intelligence Council in September 2002 which predicted that the number of persons in India infected with AIDS (currently about 4 million officially) would rise by the year 2010 to be between 20 and 25 million, the highest number of any nation on the planet. For citing this report as an impetus for his gift Gates was attacked by Health Minister Shatrughan Sinha for "spreading panic". Human Resources Development Minister Murli Manohar Joshi joined in: "In his enthusiasm to fight out a certain menace, Gates has overdone it." The Indian Government nevertheless indicated it would take Gates' check.
The effect of AIDS on U.S. national security is a growing area of study. Clearly the Indian government did not appreciate being the subject of any study by the U.S. National Intelligence Council, which reports directly to the Director of the CIA. The fact that Russia, China, Nigeria and Ethiopia were also the subject of the report did not mollify the Indian government. The NIC report was diplomatically critical of the Indian government's slow reaction to the AIDS crisis within its border.
The AIDS epidemic in India is fueled largely by heterosexual transmission, though in a few areas it is fueled by intravenous drug use. Public awareness of the disease is low, as is condom use. Other fatal diseases such as TB and malaria compete for government attention. The public health system is highly inefficient. All this indicated to the National Intelligence Council that India would soon have the largest number of people infected with AIDS on the planet, but that this would be camouflaged by India's huge billion plus population. Because young productive workers are the ones struck down, the AIDS epidemic would have a negative effect on India's economy, an effect which would be large but difficult to measure. The NIC report was cautious in predicting the effect of the AIDS epidemic on India's internal security, politics and foreign policy. The report did note in passing that the AIDS crisis will exacerbate India's gender imbalance problem caused by female infanticide and sex selection abortion, but did not predict what the effect of this worsening imbalance would be.
The gender imbalance in India begins before birth and is exacerbated by India's efforts to slow its population growth. India's population passed the one billion mark in 2001 and continues to grow at about 2% a year, a rate which the government hopes to cut almost in half by 2010. Less than half of couples use family planning. Infant and maternal mortality remain high. When all the problems of poverty and diseases like malaria and TB are added to the AIDS and family planning crisis, the challenge for India's public health system appears overwhelming.
India has moved away from its policy of quotas and targets for childbearing that had been a hallmark of its earlier population policies. India, in 1951, was the first country to have a national population policy. Throughout its history the Indian Government had on occasion resorted to bribes and coercion to force its population growth rate down. Now the government uses incentives rather than force. There is no "one-child policy" as in China, but nevertheless Indian couples are feeling economic, political and social pressures to have smaller families. Some Indian states have a two-child norm that they urge on the local population.
Some states give housing priority to smaller families, and some prevent parents of larger families from voting in local elections. There are cash incentives for delaying marriage until after age 19 and having children later still. Because Hinduism favors males (a son must light the funeral pyre) and because the sons traditionally care for the parents in old age, Indian parents try to ensure that their smaller families have at least one son. As a result parents resort to prenatal sex selection abortion or infanticide to improve their chances. Driving around Delhi, especially in the vicinity of the hospitals, one could see signs for diagnostic clinics which offered not only MRI and CT scans, mammography, and x-rays but also ultrasound examinations. The use of ultrasound for sex selection abortion has been outlawed in India, but the law has had little practical effect. In December 2002 the enforcement sections of the law were strengthened. The juvenile sex ratio in India has fallen so that currently for every 1000 boys there are only 927 girls. This skewing of the sex ratio has gotten more attention in China, but is approaching the same epidemic proportions in India.
If India is going to win the battles against AIDS and a skewed sex ratio, it must change the culture in every community and village in the country. It must win these battles using clinics like the New Delhi branch of the Family Planning Association of India which I visited recently.
Even with a local guide and a local driver it took us over half an hour to find the clinic. We wandered back and forth through Sector IV of New Delhi getting one set of imprecise directions after another. My guide only asked men for directions. If he had asked a woman, we would have found the clinic in no time flat. Upon my arrival the waiting room was filed with women and children. Many had traveled some distance to get there. Women knew where the clinic was.
The clinic was in a four story concrete building on a side street about one hundred yards off one of the main thoroughfares of New Delhi. There was no sign visible from the main thoroughfare, just three faded yellow signs out front on the side street listing a huge variety of services available inside: one sign listed family life and marriage counseling, maternal and child health services, old age care and comprehensive family planning, and so on. A second larger sign listed all the blood, urine and semen tests that were available and a smaller third sign said simply Old Age Health Care. On the day I visited in November 2002, most of the clients were women getting immunizations for their children. They lined up quietly on the second floor. The children, seemingly between the age of 1 and 2, sat quietly in their laps. The mothers smiled for a photographer, the children didn't. They seemed to know that they were about to get stuck with a needle.
A middle aged man sitting outside the clinic manager's office explained that the manager wasn't in yet. He introduced himself as the resident yoga consultant. When I asked what a yoga instructor could offer the patients at a family planning clinic, he pointed out that the clinic dealt also with couples who were experiencing marital problems. "Men in India are stressed", said the yoga consultant, "and often have problems having sex. I help them learn how to release the stress so that they can have a good sex life and get their wives pregnant."
The yoga instructor led me to the office of the medical director, Dr. J.B. Babbar, a burly, middle-aged man of kindly disposition. Dr. Babbar and his wife, Dr. Raknee Babbar, have been the medical staff of the clinic for the past 20 years, assisted a few days a week by another part-time physician. The small office was filled with two or three patients at a time seeking advice on marital matters, sexual diseases, infertility and family planning. Dr. J.B. clearly has the respect and trust of his patients. Sitting in his office was a woman who with her husband underwent fertility treatments for five years until finally two years ago they succeeded in having a baby girl. She had just come in to chat with the doctor, who had become a trusted advisor on all family matters. Another man sat quietly in the office. He too was just there to chat but his topic was HIV. The man also had had a bad burn on his foot which Dr. J.B. had treated. All the while a steady stream of patients came in getting prescriptions for various medicines and getting their charts updated.
Dr. J.B. could teach a course in multi-tasking. While seated at his desk he was simultaneously talking to us, talking on the phone, advising patients and writing in charts. While in the United States we are used to having private conversations with our doctors, there appeared to be less of a notion of privacy in India. Patient conversations took place in the hearing of other patients and visitors. There were some gender boundaries though. Most of the men saw Dr. J.B. while most of the women saw Dr. Raknee. Many women, but not all, would not feel comfortable being examined by a male doctor, Dr. J.B. explained.
On the wall in front of his desk, Dr. J.B. had posted a wall chart which listed totals for various clinic services since 1993. Totals were posted for infertility, HIV, STD's, sterilization, oral contraceptives, other contraceptives, abortions, male services, prenatal care and old age services. Half the chart was taken up with immunization records---BCG, polio, DPT, measles, DT and vitamin A. Some 70,000 polio vaccinations a year were given, as were 60,000 DPT and 15,000 measles vaccinations. These services were outnumbered only by the number of new contraceptive cases a year, over 80,000, and male involvement cases of about the same number. In India most women opt for the IUD over the pill. The clinic performed about 180 vasectomies a year and about 3000 tubal ligations. The wall chart revealed a declining number of HIV positive cases being detected, about 300 a year. Dr. J.B. explained that this was due to other testing sites opening in Delhi as part of the government's efforts to deal with the burgeoning HIV crisis.
Bill Gates' $100 million gift to combat AIDS will be targeted at truckers, prostitutes and other migrant workers. The gift will support prevention efforts that will include public education projects (a difficult problem in a country where 44% are illiterate), programs for treatment of other sexually transmitted diseases in order to try to also catch HIV, and condom distribution programs. It was not clear from driving around Delhi that the Indian government was fully engaged in prevention efforts around AIDS. Many signs were visible along the road for leprosy cures and for typhoid and hepatitis B vaccinations. There was but one visible sign put up by the Delhi city government urging HIV testing.
I asked Dr. J.B. his reaction to the Gates fuss. He claimed that knowledge of AIDS and HIV transmission was low but increasing in India, but in his opinion the AIDS problem was not caused by professional prostitutes having sex with truckers. It was the amateur prostitutes that were the problem. The pros use condoms and protect themselves. The amateurs don't. These amateurs are students, housewives or low income workers who need extra money to get by and who turn to prostitution as a source of extra cash. Perhaps they don't know about AIDS or they can't or don't want to pay for condoms. Dr. J.B. pointed out that condoms were handed out free at the clinic to all comers, and I witnesses men and women leaving the clinic with bunches in their hands. The New Delhi newspapers reported two days later that an illegal condom manufacturing establishment had been raided by the police and closed down. The unlicensed establishment appeared from news sources to have highly automated machinery, and about 150,000 condoms of undetermined quality were seized on the premises. Despite condoms being available for free, at least until the clinic supplies from the government ran out, it seems that there is a thriving black market in and big demand for, condoms in India.
A recent report from Population Action International, "Condoms Count", highlighted the need for increased funding for condom distribution in India and other nations. In India just 3.1% of couples use condoms for family planning. In India as elsewhere it is the wives at home who are the fastest growing group of those contracting HIV, through having unprotected sex with their husbands, who have contracted it from prostitutes. PAI estimated that outside donors provided India 120 million condoms annually or a grand total of 0.4 condoms annually for each male aged 15-59 in India. Clearly a commercial sector, legal and illegal, was necessary to meet the demand.
Dr. J.B. announced it was time for his vasectomy clinic. We walked upstairs to the male operating suite at the opposite end of the hall from the female operating suite where his wife was performing tubal ligations. About a half-dozen women had come in that day for tubals, and three men, all brought by a friend or relative, came for vasectomies. The men had two or three children already. One worked as a security guard, the others were in the military. They had traveled a long distance to get the operation; one traveled 200 kilometers. They chose to travel mainly because their relative or friend who brought them had had their operations done by Dr. J.B.
The patients hopped up on the table, and Dr. J.B. injected a small amount of local anesthetic directly into the scrotum near the vas deferens. From the faces of the men, they felt the needle, but nothing more. Dr. J.B. said that each procedure would take 3 minutes. I got out my watch. The method was the "no scalpel" method. He punctured the skin near the vas deferens using a sharp pair of scissors, pulled out the vas, clamped it, cut it, tied it off, and pushed it back in. He put a clamp over the incision and turned to the other side and repeated the process. I looked at my watch. It took just over three minutes start to finish. He advised the patient not to have sex for 2 weeks and thereafter to have frequent sex (he recommended 30 ejaculations), use condoms, which he would provide downstairs, and return in three months for a semen test. The men got up off the table feeling no worse for wear, dressed and walked down to the doctor's office to pick up their condoms. They were paid 160 rupees for the operation under India's National Population Policy, which has incentives to encourage late marriage, late childbearing and sterilization after two children. Women are paid 200 rupees, or 40 rupees more than the men, because, as Dr. J.B. explained, they get more anesthetic and thus needed more recovery time and more help in getting home from a companion and thus need extra bus fare. The average annual income in India has been estimated to be between $350 and $460. At an exchange rate of 50 rupees to the dollar, the incentive amounts to $3 or $4 dollars, or 1% of the average annual wage.
The worst sterilization offences occurred during the administration of Indira Gandhi, which coerced or bribed the populace to have the operation. So it was interesting to find a quote from the former Prime Minister on the wall of the clinic:
"Family Planning in our country is an essential part of our whole strategy of enlarging welfare. Greater Welfare is, in fact, the only reason for Family Planning. And we need it not because we are against more children but because we want every child to have the best opportunity possible in life. We want our children to inherit a better world than our own. This is the aim of every father and mother, and this is the objective of planned development."
Family planning, as envisioned by Gandhi in the 1970's, is woefully inadequate for the problems facing India, as are the public health clinics as they currently exist. Family planning has now become reproductive health care and even family health care in India. The clinics, too few and too far apart, deal with every problem the family members have, as they should. And they do it well. The problem is that they reach too few on India's one billion people, 44% of whom are illiterate. A massive change of Indian culture is needed in order to counter the onslaught of AIDS and to ameliorate the effects of the imbalance of men and women in Indian society.
As the imbalanced age cohorts grow to adulthood, men will compete for brides and the poor and uneducated men will be the ones left out. Men will try to marry younger and younger women and girls to compensate. Arranged marriages at earlier and earlier ages will increase and perhaps dowry will flow the other way to the bride's family. We don't know if this will lead to a lessening of the problem or even to an increase in the number of girls born as they become more valuable economically.
Other social consequences of the sex imbalance are more dire. The prospects for a stable democracy in India become more uncertain. Societies don't worry about excess females. They do worry, or should, about excess males. Young unmarried males are a destabilizing force. Experts have observed that violent crime is rampant in the Indian states with the highest sex ratios-Uttar Pradesh and Bihar. Criminal gangs operate with impunity and often control numerous members of the state legislatures. The murder rate rises as the number of unattached males rises. Stable families make for a stable society. India will see less and less of this.
The solution to the gender dynamic in India is not simple. The cultural underpinnings of the anti-female bias have been present in India for thousands of years. Education, poverty reduction and change of culture are all required. In the short term, the Indian government is faced with what to do with its excess males. As one analyst put it, the only solution is to reduce their numbers--- "fight them, encourage their self-destruction, or export them". One cynical view of the Indian government's less than robust attack on AIDS is that the disease serves to kill off the nation's excess men. India may now be realizing that this is not only inhumane but also doesn't work since the disease will kill off as many or more women than men.
Another solution is for the Indian government to add more unattached, reckless males to its military forces. This gives some military observers pause. India is a nuclear power with a long standing dispute with its neighbor Pakistan, and not entirely placid relations with another neighbor, China. India may view that it can readily sacrifice a few million men in a war with Pakistan, also a nuclear power with excess males of its own. The U.S. National Intelligence Council may want to do its next report on gender imbalance.
Longer term, India must take steps to reduce the imbalance in its sex ratio. This means reducing the discrimination against girls so imbedded in its society. Some of the steps it can take are the same ones it must take to reduce the toll of AIDS: education and poverty reduction. It must enable women to fully participate in the economic life of the nation. It must eliminate incentives and quotas for small families. The Indian population growth will slow down on its own when women and girls are educated and can get jobs and decide their own futures. A social security system that would provide support for old age would lessen the reliance on sons. Inheritance laws must be revised to treat women equally.
All these steps were set forth in the UN Conference on Population and Development in Cairo in 1994. India signed on to the agreement, but the United States has indicated that it now does not support the Cairo language, saying that language requiring access to reproductive health care services encourages abortion. Since abortion is legal in India, one wonders whether the U.S. will use this excuse to reduce its foreign aid to India and whether it will be left to Mr. Gates to help India fight its battles against AIDS and anti-female sex selection. That would give the ministers in the Indian government cause to complain.
