An anthropological study of HIV/AIDS


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"An anthropological study of HIV/AIDS among the tribal people of Chandel".

Introduction: HIV/AIDS, though a couple of decades old since its first discovery in 1981 among a group of los angeles gays, has taken millions of lives across the world and more so in the third world or developing countries. It has threatened not just the physical health of an individual but makes his existence in the society miserable by affecting his life in all aspects and at all levels such as in family, community, society, health care setting, work places, socio-religious institutions, etc. Person living with HIV/AIDS(PLHA) have to go through a whole lot of mental and emotional turmoil as in most societies, HIV/AIDS is seen as an outcome of failure to respect religious codes and social norms and as such, are stigmatised and discriminated despite the fact that the disease is fatal per se.

The advent of anti-retroviral therapy (art) has been one of the greatest achievement in the field of hiv/aids so far albeit it can only control further multiplication of the virus and prolong the plhas' longevity of life.

Manipur: Manipur is one of the six states in india that has high hiv prevalence rate. The state of manipur can be broadly divided into two regions- the valley and hill. There are altogether nine(9) districts of which five(5) are in the hill and the other four(4) in the valley. The five districts in the hill are predominant by the tribal people while the latter by the non-tribal population. Manipur shares 358km long international border with myanmar running from south through north.

The district of chandel is one of the five hill districts of manipur populated by different tribal groups and is situated on the southern part sharing an international border with myanmar along its entire eastern border. The National Highway(NH) 39 runs along the state and terminates in the border and commercial town of moreh in chandel district bordering myanmar whereby trades between the two countries are carried out. The state is also connected directly to the "Golden Triangle" in myanmar via moreh town where an estimated 20% of the global opium and the purest form of heroin is manufactured. Heroin in its purest form of injectable white powder is smuggled from myanmar via moreh to rest of manipur, other neighbouring states and to international market. In fact, it is not surprising that manipur is an alternative route for drug traffickers and peddlers and subsequently drug user state.

The first case of hiv/aids in the state was detected in 1990 from the blood samples collected in 1989 from a group of IDUs. Given its geographical closeness to the golden triangle, the maximum number of hiv/aids case in the state is found among IDUs'and is spilled to the general population through their sexual partners and children. However, this is not to say that hiv/aids is spread only through IDUs'.

The district of chandel is divided into four sub-divisions viz- chandel, chakpikarong, machi and tengnoupal. The district has a total population of 1,18,327 distributed in its four sub-divisions, out which, chandel alone accounted for 26,276 (statistical abstract, manipur, 2007). The people of chandel comprises of seven naga tribes residing in close proximity.

The present study was carried out in chandel where seven naga tribes namely anal, lamkang, monsang, moyon, maring, chothe and tarao are preponderant with negligible number of non-tribal population. The tribes mention above all follow christianity and their social organisations are of patriarchal type. Besides relying on government job for employment, agriculture is the main occupation of these tribes as has been from time immemorial. There are neither industries nor multi-national company to employ the youths although the literacy rate in chandel is quite high i.e ..%. Many youngsters migrate to other cities of india in search of greener pasture as getting govt. job in the state has become almost impossible for vast common people due to upheaval bribery system that is so prevalent these days. Those who are unable to migrate are left with the obtion to either joint the indian military force or the insurgent group; become drug peddler for easy and fast money or drug users; become agricultural labourer or small time business, etc.

Conclusion: Factors like unemployment, poverty, drug, insurgency, migration, poor infrastructure of transport and communication, poor access to health care and information, political instability, geographical landscape and social relation and cultural setting all contribute to the spread of hiv/aids in the area.

Methodology: An extensive fieldwork was carried out in the study area in 2008 whereby, participant observation, indepth interview with both PLHAs and the general population[1] and also with some stake holders, etc was taken. This was supplemented by secondary sources in the form of booklets, articles, books, etc collected from both government and NGO offices and health care setting in the study area and literature review on the subject matter.

Hiv/aids scenario in chandel: hiv/aids in the district of chandel is spreading rapidly at an alarming pace. The epidemic has now reached even the remotest and far flung areas geographically considered isolated from the local town. According to the latest epidemiological report, the district accounts for 5.05% of the total hiv/aids in the state. However, the sero-positivity rate of the district is quite alarming as it stood at 23.30% which is the highest in the state followed by Ukhrul at 19.80% (MACS[2], april 2008). Besides these reported cases, there also exist an umpteen number of cases that goes unreported as well. The threat to the spread of the epidemic is also compounded by a large number of hidden population in the district as was discovered during the course of my fieldwork. These hidden populations are mostly the umarried young people who for fear of being stigmatised and rejected in the social circuit have kept their status hidden while continuing to lead and enjoy a normal sexual life forgetting the fact that by doing so, they are endangering the lives of those people who may not have been otherwise infected.

HIV/AIDS scenario in Chandel: HIV/AIDS in Chandel district is spreading rapidly at an alarming pace. ...when and where the 1st case.............The epidemic has now reached even the remotest and far flung villages geographically considered isolated from the local town. The people in this remote areas are illeterate, poor and isolated from the mainland. Transport and communication system connecting them to the local town i.e. chandel is extremely bad if not almost non-existent. They have to walk 2-3 hours or more so on foot to get to chandel for basic health check up and sometimes would prefer to opt for the traditional healer as the latter charge less money and are easily accessible as compare to the medical doctor.

The general population tend to be misguided as far as hiv/aids is concerned by constructing all sorts of sayings such as the virus was originally from monkey but due to a group of weird foreigners experimenting sex with the monkeys, the infection have come from them. And to quote them, "hiv/aids get transmitted when one is sexually promiscuous or when a person started taking heroin (no.4). Here, it may be noted that sexual promiscuity, IDUs and hiv/aids are synonymous...............

According to the latest epidemiological report, the district accounts for 5.05% of the total HIV/AIDS in the state. However, the sero-positivity rate of the  district is quite alarming as it stood at 23.30% which is the highest in the state followed by Ukhrul at 19.80% (MACS[3], april 2008). Besides these reported cases, there also exist an umpteen number of cases that goes unreported as well. The spread of the epidemic is also compounded by a large number of hidden population in the district as was discovered during the course of my fieldwork. These hidden populations are mostly the umarried young people who for fear of being stigmatised and rejected in the social circuit have kept their status hidden while continuing to lead and enjoy a normal sexual life forgetting the fact that by doing so, they are endangering the lives of those people who may not have been otherwise infected.

Mode of transmission: The main route of transmission in Chandel is through heterosexual and IDUs'. There are different factors that led to the rapid expansion of HIV infection through heterosexual mode. As has been stated earlier, unemployment among the youths have made them vulnerable to drugs and subsequently sharing of needles. These infected IDUs further infect their sexual partners who may again transmit the virus to others through sexual route as an infected person is likely to have more than one sexual partner. HIV infection is also spread by those who joint the indian army to their spouse and children and other sexual partners. This was evident from the case history of a large number of widows who were infected by their spouse from military background. These widows were not aware of their husbands' status and since the latter would come home once or twice in a year only, sex would be usually consumed without precaution. The women who were interviewed were not in favour of condom as they regard it as meant for morally loose and dirty people. They also expressed their apprehension about the possibility of condom getting stuck in the female genital part, the consequence of which will bring great shame to the entire family. Moreover, they feel that it was unnecessary for married couple to be using that as the purpose of marriage will not be serve with the use of it. However, the opinion regarding the use of condom tend to differ slightly with the younger and educated ones. Credit

Social structure: The cultural values of patriarchy is seen to be working against women in the society in many ways. Sexual laxity of male is somewhat tolerable while that of the women is not despite the fact that the tribal people under study are strictly monogamous. Women cannot question the sexual behavior of her husband and submits herself to him passively as this is considered ideal for a women to do so. Many people who know about the danger of sexual transmission, especially many girls and women, cannot avoid becoming infected because they cannot control the relations of power that put their lives at risk. Domestic violence.............There was a widow whom I interacted personally regarding her infection and according to her, she got the infection from her husband who was in the indian army. She got to know her husband's status only when he was dying as her husband never reveal his status to her eventhough he had been previously diagnosed in the military. There were similar cases whereby innocent wives became a victim of HIV infection from their husbands' whose backgrounds are either IDUs or military and also whose husband indulged in sex outside of marriage.

There are no known commercial sex workers and MSM[4] in the study area although the hidden existence of it is not totally ruled out. Most people who indulged in sexual relation tend to be doing it out of some affection for each other or for the pleasure of it in the case of unmarried people. However, society strongly opposes premarital sex and extra-marital affair on the basis that it is against christian tenets and so those people who indulged in these activities are looked down upon and would lost their socio-religious standing in the society. As a result such activities are carried out behind the back of society.

There is one district hospital(DH) in Chandel with a couple of doctors and nurses who cater to the needs of the people. The DH is poorly maintained with just....number of beds and inadequate equipments for emergencies. To put mildly in the words of a respondent, DH is a first aid health centre only and if it had been in Imphal, nobody would have dare to risk coming here. However, given the social reality of poverty added by transport and communication problem, and other such inconveniences pertaining to financial problem, agricultural work, etc. the nearest medical help the tribal people can get is the DH as they are left with no other option. The incompetency of the hospital is such that there were a couple of PLHASs' who revealed to have got the infection from the hospital equipments. There were many others from the general population who expressed their fear of getting medical treatment from the hospital as the chance of getting infected was there.

Recently, an ART centre was opened in the DH under the scheme..... whereby PLHASs are now able to avail ART free of cost without having to travel 65km or more so every month in Imphal as was the case earlier. A CD4 count machine has also been install but it is yet to be functional. So, CD4 count test is still taken to Imphal. At present, there are ....number of registered PLHASs in the DH ART centre. There is also PPTCT[5] program in the hospital whereby all pregnant women who came for medical check-up have to go through mandatory HIV test which is available in the hospital. It is through this program that many women PLHASs are identified and informed of their status who would otherwise have remain ignorant. As one woman relates, "I went for HIV test during my second pregnancy as it was mandatory and just to be on the safe side. So, I was quite stunned and shocked to learnt that I had tested HIV positive. It was hard for me to believe it as I have never indulged in any risky behavior and never once consider myself to be at risk for the infection. Later on, I realised that my husband who was often out of station for official work had been involved with some women and the infection was from him. If it was not for the mandatory test, I would have not known my status". There was another woman who recounted her memory of having done HIV test during her pregnancy a couple of months back. According to her, there were ten of them (all pregnant) on that particular day who had undergone for the test and it seems, only three of them were non-reactive while seven of them were reactive to the virus. She recoil at the thought of it and expressed fear for the future of her children. She felt that this might be just one incident among many others and there could have been more such cases.

In the case of voluntary HIV testing, the response is not good given the cultural complexity and psychological meaning attached to the spread of hiv/aids. As a result, any lay person would tend to shy away from getting the test unless he/she is compel by certain health or physical circumstances. For example: ...............This was evident from the response of many such common people who regard HIV/AIDS as the disease of the fallen people and do not consider themselves to be at risk for undergoing the test. Without denying the existence of it, sexual promiscuity and drug users are seen as the propagators of HIV virus in the society and as such they donot have any empathy on such PLHASs. Many people were of the viewed that since there isn't any medical cure for HIV/AIDS, it was better for PLHASs to die sooner than later as prolonging their life will only put the non-affected people at risk.

During the course of my fieldwork, I came across many cases whereby there were more than three PLHAs in one family who were mostly IDUs and sexually promiscuous. An hiv infected person getting married to non-reactive person without the latter's knowledge of the former's status was also not uncommon. Such is the gravity of the HIV epidemic that Chandel now seems to have become the potboiler of the disease. Biological and social conditions also propel spread of the virus; the disease becomes evident long after the infection takes place and manifest itself in the form of "opportunistic infection". So, it becomes very difficult for any lay person to understand the disease in its early stages. Due to poverty, unemployment and engaging in agricultural work, the tribal people of this area hardly have time for medical check-up. They seek medical help only when they are really seriously sick and are incapacitated otherwise they tend to compromise their health by engaging in works.

Government response:

Role of NGOs: There are .......NGOs and FBOs working for he welfare of PLHASs in the study area. According to a particular NGO, the challenges facing them in the area was mainly of identitifying PLHASs and convincing them to be open about their status at least to their immediate family if not to all.

[1] Non HIV/AIDS affected people

[2] Manipur state AIDS control society

[3] Manipur State AIDS Control Society

[4] Men having Sex with Men

[5] Prevention of Parent to Child Transmission

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