| Looking for light
China and India evoke images of (i) the world’s two most populous countries; (ii) the world’s two fastest growing economies that would soon occupy second and third positions in world gross domestic product rankings; and (iii) the destination of the world’s blue collar and white collar jobs respectively. But the dynamic duo have also acquired a darker and more dubious reputation which they prefer not to talk about. The world health community sees China and India as potential HIV/ AIDS time bombs waiting to explode in the next two-three decades.
Bill Clinton’s recent sojourns brought the issue of HIV/AIDS in the two nations into global focus yet again. On November 10 at an AIDS summit in Beijing, he called for stronger leadership to combat the spread of HIV/ AIDS in China. On November 22 in Delhi, he secured the involvement of three Indian companies — Ranbaxy, Cipla and Matrix — to supply cheap drugs for antiretroviral combination therapy for HIV/AIDS patients in Africa and the Caribbean.
There is no shortage of doomsday scenarios. Last month, while on a visit to Beijing, the American health secretary, Tommy Thompson, said that the rapid spread of HIV/AIDS in India and China could destroy chances to contain or cure the disease. In November/ December last year, writing in the sober but prestigious American journal, Foreign Affairs, Nick Eberstadt provided new ammunition. In 2002, China is estimated to have had about 0.85-1 million HIV/AIDS cases. Eberstadt estimates that by 2025, this could rise to between 32 million (“mild epidemic”) and 100 million (“severe epidemic). The corresponding numbers for India range between 30 million and 140 million on a 2002 base of 3.8-4.6 million. By the end of 2000, Chinese government officials themselves now publicly talk of 10 million HIV/AIDS cases in the People’s Republic of China. Indian government officials are more cautious in public but privately concede that India could also have 8-10 million HIV/AIDS cases by 2010. China is reporting an annual growth rate of 30 per cent, while India’s reported annual growth rate of HIV/AIDS cases in 2002 was much lower, at around 15 per cent.
It is only in the past two years that the Chinese government has acknowledged HIV/AIDS to be a serious issue. In late 2001, the world media focussed attention on the very high rates of HIV/AIDS prevalence in the central province of Henan. Henan is China’s most populous province, apart from being the home of Mao. The severe AIDS outbreak here was apparently caused by blood-buying companies using unclean methods. These methods have continued. Blood donations have become a widespread source of supplementing incomes in many parts of rural China. The breakdown of the rural commune-based health system over the past decade and a half and massive urban migrations appear to be contributing to the crisis.
Not surprisingly, provinces adjoining Henan like Anhui, Heibei and Hubei are also suffering serious consequences. In other provinces like northwestern Xinjiang, HIV/AIDS has been spread on account of intravenous drug use. In provinces like Yunnan, Guangxi and Sichuan in the south and southeast, resurgence of prostitution is being seen as contributing significantly to the spread of HIV/AIDS. Yunnan is where the AIDS epidemic was first noticed and it is estimated that it accounts for almost half of all HIV/ AIDS cases, although this could also be the result of better epidemiological monitoring.
Just last month, Li Liming, director of the Chinese office of the United States Centre for Disease Prevention and Control, revealed that almost two-thirds of HIV/AIDS patients were infected through intravenous drug use and about one-tenth each through unsafe plasma sales and sexual transmission.
India too was in denial mode for long. But since the mid-Nineties, an active National AIDS Control Organization, with its counterparts in states, has come into being. Unlike the Chinese programme, India’s programme is better organized and better funded. NACO has been spending close to $ 50 million a year and this could increase to around $ 80 million a year during 2004-2010. This excludes whatever financial support organizations like the Gates Foundation are expected to provide to nongovernmental organizations directly. But even with the involvement of such organizations, NACO’s investments will drive the country’s programme.
India’s investment in AIDS control may appear impressive in relation to the numbers for China which vary currently between $ 15-25 million a year. But clearly NACO is substantially under-funded. One casualty of the under-funding is antiretroviral therapy which is not used by NACO since it costs around $ 1 per patient per year. Ironically, Indian companies are global leaders in anti-HIV/AIDS drugs. Other countries like Brazil, Botswana and now South Africa have made such therapy an integral element of their AIDS control efforts.
India’s HIV/AIDS incidence has distinct regional variations with Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu being the high-prevalent zone where epidemic levels may already have been reached, measured by HIV prevalence in antenatal women. Manipur and Nagaland suffer on account of intravenous drug use like in Xinjiang and Yunnan. That Manipur, Nagaland and Yunnan are close to Myanmar and Thailand has surely impacted on widespread drug use leading to high HIV/AIDS prevalence rates. India has also registered some successes. A very high rate of condom use in Sonagachhi, for instance, is widely heralded as a major breakthrough for NACO, as has been the significant improvements in the blood supply chain all over the country. Political leadership has provided momentum to AIDS communication and control, especially in Andhra Pradesh and Tamil Nadu. It has also helped that India’s most populous states are low HIV/AIDS prevalence zones, unlike the populous Chinese provinces. Whether this has to do with cultural practices or poor reporting or low urbanization or because of low in-migration is difficult to tell. That low-prevalence must remain so since these poor, populous states have appalling health infrastructure unlike the peninsular states with high HIV/AIDS prevalence rates.
What about vaccines' Presently, a number of vaccines developed by various companies like AlphaVax, Chiron, Aventis Pasteur, GlaxoSmithKline, Merck, Therion, VaxGen and Wyeth are under different stages of clinical trials. VaxGen’s human clinical trials in Thailand have just been announced to be a failure but hopes have not faded for making a safe and efficacious vaccine available in the market by the beginning or the middle of the next decade. Interestingly but not surprisingly, many of the top researchers in the United States of America are scientists of Indian or Chinese origin. David Ho, who discovered drug “cocktail” therapy, is Taiwan-born, and Emory University’s Vaccine Research Centre, whose vaccine is under trial, is headed by Hyderabad-born Rafi Ahmed. But neither India nor China can afford to sit back waiting for such a vaccine even while they participate in clinical trials themselves.
AIDS is no longer considered a health or a social or an economic issue. It is now being reckoned as a “security” issue. The United Nations security council and the UN general assembly have both debated HIV/AIDS. The possibility of HIV/AIDS being used to check labour flows into the West also cannot be ruled out. Both India and China face a stupendous challenge. They can and must cooperate in mounting an effective and credible response, learning from the success that one of their close partner countries — Thailand — has had in this area.