Public Health Nowhere to Run, Nowhere to Hide

By Kenneth M. Pierce

With her large, dark eyes and thick, waist-length hair, the 18-year-old was a favorite among the truck drivers who called at the squalid brothel on Highway 45 in Ulundurpet, a small town in southern India. When she was placed in a ) reformatory for convicted prostitutes in June, five men offered to bail her out. Today she is emaciated, weighing only 62 lbs., her hair is falling out, and she is showing unmistakable signs of mental derangement. The source of the woman's suffering: the acquired immunodeficiency syndrome, or AIDS, virus. Doctors at the home want to delay her release, fearing that if she returns to prostitution, she will transmit the AIDS virus to her clients.

Despite the rapid spread of AIDS throughout the developing world, its appearance in India came as a shock to the country. The case of the young woman, as well as those of 18 other Indians known to have been infected with the virus (two of whom have died), is thought to be just the beginning. Poverty and a burgeoning population of more than 750 million make it difficult for Indian doctors to cope with even familiar diseases, such as tuberculosis, malaria and cholera. Now that the first AIDS cases have been detected, says Dr. V. Ramalingaswami, former director general of the Indian Council of Medical Research, "we in India have been shaken and face a moment of truth."

Indian researchers have long been afraid that AIDS, which destroys the body's natural defenses against disease, would spread rapidly once it reached the subcontinent. Known as HIV, or human immunodeficiency virus, the AIDS microbe is transmitted by sexual intercourse, blood transfusions and contaminated needles, though not, say researchers, by casual contact with infected persons. During pregnancy, infected women can pass the virus on to their unborn children.

The first AIDS cases were identified five years ago in the U.S., leading many officials in developing countries to assume that it was solely a Western disease. Today the U.S. accounts for 80% of the 28,976 active cases reported to the Geneva-based World Health Organization. But it increasingly appears that the number of reported AIDS cases is far smaller than the true incidence of the disease. Halfdan Mahler, director general of WHO, estimates that there may be as many as 100,000 cases globally, plus up to 10 million carriers of the virus.

The disease is spreading fast in Africa, where it was first detected in 1982, but is believed by some medical researchers to have appeared decades earlier. In Kigali, the capital of Rwanda, one test discovered AIDS exposure in 18% of the city's inhabitants. In Uganda, a study of more than 1,000 pregnant women in the capital city of Kampala showed that 13.6% carried the virus. While male victims outnumber female victims by 13 to 1 in the U.S., in Africa the disease appears to strike women and men in roughly equal numbers. The same holds true in Haiti.

AIDS was initially called a gay disease because most U.S. victims are homosexual men. But, says Robert Gallo of the National Cancer Institute in Bethesda, Md., "AIDS was never a homosexual virus. It's just that the homosexual group was the first to be infected in the U.S., and they spread it among themselves." In some African countries, where homosexuality is uncommon, the virus has become so prevalent that doctors cannot single out risk groups, apart from prostitutes. In Kenya, 54% of the prostitutes from Nairobi slums carry AIDS virus antibodies.

Health professionals warn that mass education to combat AIDS is not easily carried out in the developing world, where poverty and illiteracy are rampant. Even so, public-education drives linking promiscuity to the spread of AIDS are under way in several countries, including Kenya, Ethiopia and Haiti.

In India, where less than 7,000 AIDS blood tests have been conducted, the obstacles are formidable. Rural clinics and small hospitals typically fail to sterilize needles before reusing them. The government hopes to increase the number of AIDS testing centers from twelve to 29. It has also ordered spot testing of all commercial blood donors and has announced that imported blood must be certified as AIDS free. But these precautions cannot ensure the containment of the virus. More than half of India's blood supply comes from local paid donors, whose blood is usually not screened. Some tests, moreover, can be prohibitively expensive.

Given such problems, some physicians in India and Africa believe resources devoted to fighting AIDS should be used instead to treat curable diseases. That view was recently echoed in the Deccan Herald, the leading daily in the state of Karnataka, which declared, "The question must be asked whether so much publicity, time, money and attention must be thrown behind a disease that is barely known to exist in India." Sadly, if the resources are not committed, AIDS may soon become an all-too-familiar household word on the subcontinent.

With reporting by Anita Pratap/Madras and Maryanne Vollers/Kampala, with other bureaus