By Mihir Gupta
Published November 2008
In the summer of 2008, I traveled to northeastern India to study the impact of HIV/AIDS in rural and urban areas. With a team of social workers from the Indian government and several collaborating NGOs, I journeyed from inner-city alleyways to lush rural villages, on a variety of HIV/AIDS public health interventions. This series chronicles my encounters with several groups of people. Their narratives coalesce in a mosaic of experiences, each a function of time and place, but not far outside the definite contours of socio-cultural influence. The result is a snapshot of the impact of a devastating disease on a society and its core institutions; of chaos and uncertainty, but also of profound unity and hope.
Our crowded sedan comes to a sudden halt along a nondescript side street. “We’ll walk the rest of the way,” says Rakesh, our team leader for the day. We have spent the past hour traversing the city of Allahabad, in northeastern India, en route to the southern sector of the city. We are visiting an HIV/AIDS outreach clinic that serves injecting drug users, many of who live in underserved areas such as the neighborhood where we have now arrived.
“Leave your camera in the car,” Rakesh tells me, “so that they don’t get suspicious.” I hide the camera behind a seat cover and catch up with the rest of the team as they enter a web of alleyways between slum dwellings. The tropical heat is merciless, and droplets of sweat form along my brow by the time we stop walking. “Come in and cool off!” calls a voice that seems to come from inside a brick wall to my right. Upon closer inspection, I see a narrow entrance to what appears to be a pharmaceutical dispensary, where a man in a white laboratory coat is seated below a ceiling fan. “I’m Dr. Chatterjee!” he says, though I can barely hear him over the loud grating of an electrical generator — electricity is a rare commodity during the tail end of the monsoon season, and gas-fueled generators power the fans that provide respite from the extreme heat.
I enter the drug dispensary, which is actually a government-run charity clinic that serves drug users in the area. Dr. Chatterjee is the clinic’s physician, pharmacist and administrator. He shows me a thick ledger of patients who visit the clinic and their ailments; although he is assigned to serve drug users, his patients include many of the destitute residents of the surrounding slums. “The government hospitals,” he explains, “are too far away. Also we have a rapport with the people here.”
While I talk to Dr. Chatterjee, our team members restock the clinic. The most vital supplies they bring are sterile syringes, for the clinic’s needle exchange program. The premise of needle exchange is to enable drug users to avoid reusing or sharing their syringes. By exchanging their used syringes for sterile ones, injecting drug users (“IDUs”) can greatly curb the spread of blood-borne infections. Our team also delivers condoms and informational pamphlets for the condom dispensary attached to the clinic, which aims to control the spread of sexually transmitted infections. Both the needle exchange and condom distribution programs are vital to fight the spread of HIV, which is transmitted both sexually and through blood.
I ask Dr. Chatterjee what motivated the clinic staff to leave their posts in large government hospitals for this isolated part of the city in an almost-invisible alleyway clinic. “This,” he replies, “is where the battle needs to be fought.” Drug users, he argues, rarely desire to visit large hospitals. The locally situated ‘micro-clinics’ staffed by individuals like Dr. Chatterjee are often the only ones to have contact with these individuals. Coincidentally, one of Dr. Chatterjee’s longtime patients visits while our team is at the clinic.
At first glance, one would not guess he regularly uses injectable drugs. His arms are clean of the abscesses that usually mark drug users; his body is thin but strong. He drives a bicycle-powered rikshaw, which is decorated with bright paint and professions of his Hindu faith. Even driving a rikshaw in this heat does not make him sweat. He introduces himself as Surojeet; he is in his mid-forties, married and has five children. He has visited the clinic for several years, though he never confessed to using drugs until Dr. Chatterjee gained his trust by obtaining tuberculosis treatment for his daughter.
Two years ago, after Surojeet suffered precipitous weight loss, fever and nausea, Dr. Chatterjee had him tested for HIV. The test returned positive. Luckily for Surojeet, Dr. Chatterjee started him on antiretroviral therapy immediately, which he continues to this day; without the therapy, Surojeet may have lost his life. After receiving a checkup from Dr. Chatterjee, Surojeet exchanges several used syringes for fresh ones from the dispensary. After a brief conversation (over a requisite cup of chai), Surojeet pedals his rikshaw into gear and takes his leave.
Having delivered the supplies and taken inventory, our team prepares to leave as well. On our way out, I notice a man crouching in a corner of the clinic, rocking back and forth on his heels. Before I can approach him to ask if he is alright, Rakesh stops me. “Don’t disturb him. You could get hurt.” In fact, the clinic also serves as a safe place for IDUs to take their daily injection. “He won’t be able to understand you,” Rakesh explains, because of the narcotic effects of his drugs. “Let’s keep moving,” he continues, “the team is waiting for us.”
Clinics like this one, as Dr. Chatterjee put it, are at the frontlines of the fight against AIDS in India’s urban areas. They represent a departure from previous efforts, which were focused on containing the sexual transmission of the disease. The change in approach has largely occurred in the past six years, due to the implementation of the Indian government’s National AIDS Control Programme (NACP). Under NACP, government, private sector and NGO efforts have combined to create the current model of fighting the spread of AIDS: an integrated, multifaceted approach with infrastructure at all levels, from national programs to grassroots efforts like Dr. Chatterjee’s clinic. Government efforts now target multiple groups of individuals, including IDUs, who were previously ignored.
Given that injection drug use accounts for an estimated ten percent of HIV infections across the globe, and a comparable amount in India, the decision to target IDUs has proven vital. The presence of HIV infection among IDUs in India was first documented in the early 1990s. However, since the percentage of HIV-positive IDUs paled in comparison to HIV-positive commercial sex workers, prevention efforts were targeted towards the latter. Meanwhile, the Indian government responded to injection drug use with impunity, launching a police crackdown on drug suppliers. Popular illicit drugs such as heroin soon became very difficult to obtain. However, this did not result in decreased drug abuse; on the contrary, drug users found ways to circumvent law enforcement efforts. They resorted to injecting cocktails of prescription and over-the-counter drugs. One of these drugs was Buprenorphin, an injectable prescription drug normally given to ex-heroin addicts to treat withdrawal symptoms.
Injection of these prescription drug cocktails continues today. There has been no systematic documenting of the ingredients most commonly used, other than Buprenorphin and its paralogs. The prevalence of injection drug use, however, has soared. There are an estimated 2,000 IDUs in Allahabad alone, only 500 of who are linked into the network of government healthcare services. More importantly, IDUs are contracting HIV at a rate several times as high as that of the general population. The rapid spread of HIV among IDUs is due almost exclusively to the sharing and reuse of syringes. IDUs are also more likely than other individuals to visit commercial sex workers and engage in unprotected sex. Preliminary studies in Allahabad estimate that one in every fifty IDU has HIV, and this figure could grow exponentially if interventions are not made immediately.
Luckily, the government response has been quick and decisive. More importantly, however, the response has been based on a forward-thinking, progressive and humanitarian approach to drug usage. The approach is known as ‘harm reduction.’ The goals of harm reduction, broadly speaking, are to limit the harm that drug usage does to the drug users and to society at large. In practice, this has meant mobilizing resources to reduce IDUs’ risk of contracting diseases such as AIDS, increasing access to treatment and rehabilitation services, and empowering IDUs to re-enter mainstream society.
The harm reduction approach stands in direct to the ‘prohibition’ drug policy adopted by many industrialized countries including the United States. The prohibition method aims mainly to limit drug supply by punishing drug suppliers and incarcerating drug users. Had India chosen to take the prohibition route, its problems would likely have multiplied. Several studies have revealed that prohibition marginalizes drug users; the fear of prosecution dissuades them from seeking treatment for diseases like AIDS and rehabilitation services to quit using drugs. Aggressive law enforcement efforts also scares drug users away from needle exchange and outreach programs, which fuels risky practices such as sharing syringes. In India and elsewhere, law enforcement efforts have been ineffective in reducing the prevalence of drug usage; ultimately, they siphon precious resources from harm reduction-oriented programs that can contain the damage done by drug use.
Indeed, the harm reduction paradigm holds the most promise for India’s efforts to combat the spread of HIV among drug users. Fundamentally, it shares the same premise as programs that combat the spread of sexually transmitted HIV by distributing condoms and empowering women instead of preaching abstinence: namely, that making individual behavior safer will achieve more than punishing or trying to eliminate that behavior. The harm reduction approach to IDUs and HIV takes several forms. Clinics such as Dr. Chatterjee’s give IDUs access to healthcare and rehabilitation; support groups provide economic empowerment; and needle exchange programs enable safe injection of drugs. The common element in all of these activities is that government institutions reach out to IDUs instead of punishing them indiscriminately. This outreach is based at the grassroots level, and is sensitive to community and individual needs. This approach is likely to bring IDUs and other marginalized populations into the healthcare network and to build a constructive relationship between them and government institutions that will be vital to combating HIV/AIDS in the upcoming years.
Perhaps nothing demonstrated the potency of outreach efforts better than our team’s visit to the Allahabad railway station, where we sought out homeless IDUs who live along the train tracks at the station. Our efforts at the railway station were led by social workers from the NGO ‘Lok Smriti Seva Sansthan,’ which receives government funding to reach out to IDUs in Allahabad. They have long been visiting the station, and, like Dr. Chatterjee in his clinic, have developed a rapport with the individuals who live there. Indeed, several individuals recognized our team members and approached us; others appeared momentarily: rikshaw drivers, railway employees, and many others. Most of these individuals, like Surojeet, did not fit the stereotypes of drug users. One was a ten-year-old boy who ran away from his home and ended up in Allahabad by sneaking onto a train. We learned that his peers have encouraged him to take inhalants ranging from rubber cement to cheaply available drugs; from there, he will progress to using injectable drugs and become one of their customers. The boy’s companion, a young man in his mid-twenties, reported that he has been injecting drugs for several years. Two years ago, while under the influence of drugs, he injured one of his legs and must now use crutches permanently. He and the young boy make money by picking pockets, collecting recyclable waste, and refilling empty water bottles and reselling them.
It is natural to wonder what any social worker can do in the face of such jarring social circumstances. But it is important to remember that the individuals at the railway station felt comfortable approaching our team, exchanging their needles and sharing their stories with us. This alone is a huge advancement from even a few years ago: while we may not be able to solve all the problems that give rise to drug use and destitution, the outreach approach to the drug problem has at least prompted individuals to seek out help and cooperate with social workers to minimize the damage their circumstances could potentially do. Indeed, several of the individuals we met presented their general healthcare concerns, and our team referred them to clinics for free treatment. Social workers were dispatched later to accompany the individuals to the clinics. The fact that people at the bottom of the social ladder trust government workers, and that the government can help them, means that India’s policies are likely the right ones.
Our team’s final stop is at a mobile health clinic, set up every month in a different sector of the city by NGOs with government funding. A physician, pharmacist and several social workers staff the clinic; all consultation and treatment is free. The goal of the mobile clinic is to reach areas of the city where individuals at risk for contracting HIV (such as IDUs) are highly concentrated, and to identify them among the myriad people who pass through. Mobile clinics with physicians trained to spot symptoms of AIDS or high-risk behavior are vital ways of finding new cases and individuals who have not yet been linked into the healthcare network.
Today’s clinic has been set up in the western sector of Allahabad, in a neighborhood suggested by three young men (themselves IDUs) who have been working with NGOs as peer educators. All three of them have been using injectable drugs since grade school, and were kicked out of their family homes because of their addiction. They now live together in makeshift housing in a nearby slum. Before the arrival of the outreach workers, they resorted to theft in order to pay for their drugs; they also shared and reused syringes to save money. Outreach workers found them through a mobile clinic like this one, and they have since been linked into support groups, healthcare services and stable employment. Their work as peer educators involves educating other young men about HIV/AIDS and recruiting more IDUs to the network. One way they do so is by helping to organize mobile clinics; in fact, several of their friends who also take injectable drugs live in this neighborhood, and some of them visited the mobile clinic.
The encounters our team had in just one day are powerful testaments to the success of India’s forward-thinking approach to the problem of drug use. It would have been easy for the country’s politicians to do what many other nations have done, and steer the government’s efforts towards punishing drug users. Such an attitude would have destroyed any possibility of working with the IDU community to curb the spread of diseases like AIDS. India chose instead to take the more difficult path, but ultimately one based on sound judgment that will pay long-term dividends. These dividends have already started to emerge, and are evident in every positive interaction between government employees and drug users — from Dr. Chatterjee and Surojeet in an obscure alleyway to the social workers and the young men at the bustling railway station.
This is not to suggest that the efforts thus far have been problem-free, or that the way forward will be easy. Several issues remain to be resolved; for example, IDUs frequently lose or sell the sterile needles they receive instead of using and returning them in needle exchange programs. The proportion of IDUs who contract HIV is still much higher than the proportion in the general population. And efforts will have to be scaled up to reach the increasingly large IDU population and find new cases. Nonetheless, it is safe to say that India has made the right choice in grounding their responses to these problems in compassion and sensitivity to local and individual concerns. As such, India’s officials have a deep understanding of the social conditions that create the diverse IDU population, and are well prepared to meet the challenges that lie ahead.
Please note that all names and personal references have been modified out of respect for subjects’ privacy. The final installment of this series will be published in the December issue of PERSPECTIVE.