July 11, 2003
Sushma Fiat — No Condoms, Use Abstinence’’. Unprecedented front-page headline in a leading newspaper (while NACO claims ‘‘holistic paradigm shift’’ in AIDS prevention approach). ‘‘Condom Condemned’’ profiles yet another influential magazine, railing against ‘‘Sushma Swaraj’s experiments with truth’’.
This clubbing of all sane, healthy mainstream attitudes — such as pre-marital abstinence for the young, monogamy, marital fidelity and long-term commitment in relationships that yet remain the norm for the vast majority — into an archaic, Gandhian celibacy concept is a clever ploy, insidiously distorting discourse. Those following the issues know this, although the ‘‘paradigm shift’’ is less clear.
Then, an editorial questioning of the Minister’s puritanical personal eccentricity and its incorporation into national policies having ‘‘vital impact on the lives of so many people’’. Warning: ‘‘The bulk of our population is below the age of 25, in other words sexually active. To expect them to curb their natural urges and practice abstinence is a recipe for disaster’’.
All below 25 labelled ‘‘sexually active’’? Surely, gross travesty of facts? Can the ‘‘natural urges’’ of the pre-teens, teens and mid-20s be cavalierly clubbed, homogeneously addressed? But such basics, much less sane discussion on appropriate age and life-stage linked practical lifestyle strategies, is conspicuously absent. Worrisomely, a strong case is media-plugged for a Thai-type condom blitz as the pragmatic solution for AIDS Prevention. The concerned newspaper buttresses arguments with its pseudo-scientific survey on the sex habits of Indians — an outrageously pornographic, home-manufactured portrait of society, earlier printed prominently, that is at piece with the innumerable snippets of salacious copy/sleazy photographs that it culls to bolster circulation, unmindful of media responsibility and citizen environment. But in these days of globalised liberalisation the Press Council, regulatory mechanisms, peers, citizens alike, appear impotent before omnipotent media-leaders; more so, when titillating sexual focus masquerades as freedom of speech/AIDS life-and-death-issues.
A TV channel synergies the print story; deferential discussion with the newspaper reporter and an AIDS activist who should have been probed on tall claims of massive condom distribution in Mumbai’s Kamathipura where two-thirds of the women in prostitution are HIV-infected, despite years of condom-centric projects. Instead, the anchor huffs about outraged public opinion that in more aware countries would have the minister’s resignation for her mindless moves; a telephonic viewer response-poll on the rightness of condom-centric AIDS Prevention is called.
More statistics? Another ‘‘open debate’’ on AIDS in the ‘‘public interest’’, pushing sex and sexuality out of the closet? Its open bottomline: sex when condom-protected is ‘‘safe sex’’. Never mind other dimensions of intimate relationships! Never mind intended/unintended impact on impressionable minds! The media’s bottomline — viewers/readership at all cost — is served.
The media onslaught has NACO — never ever known for its transparency — still more obdurate about policy documents. Most unfortunate. Even more unfortunate if the lambasting succeeds in scuttling badly required policy changes, stopping the astute, media-savvy minister in her tracks before she has begun! But perhaps that’s the idea.
A holistic, comprehensive HIV/AIDS prevention strategy is what innumerable public health experts in India have demanded over the past decade. As pertinently, international strategic thinking, earlier condom-obsessed, is recognising the futility of the past track. The explosive expansion of HIV/AIDS, despite billions of dollars spent on promoting condoms, is compelling changes. Also, evidence of HIV/AIDS containment in those countries/communities has inter alia developed a more socially and sexually responsible environment, accelerating avoidance of risk-behaviour, notwithstanding risk-reduction through mechanistic means.
Condoms reduce but do not eliminate risks. Family Health International (FHI), USAID’s major international NGO contractor for HIV/AIDS prevention, overseeing more than $500 million-worth of projects in over 50 countries centre-staging condoms/ harm-minimisation strategies, now admits: ‘‘FHI has learned that messages compelling people to use condoms and avoid risky sexual behaviour are not enough to halt the spread of HIV.’’
FHI publication Network notes: ‘‘They (condoms) do not work perfectly… what then is the appropriate role of an imperfect prevention method like condoms among strategies to reduce HIV spread?.. accurate messages about condoms must build on (and not substitute for) a wide range of HIV/STI risk avoidance and risk reduction approaches. These include delayed initiation of sexual intercourse, mutual faithfulness and selection of low risk partners.’’
A new $15 billion assistance programme for US Leadership Against HIV/AIDS recently cleared by the American Congress — with rare consensual unity by Republican and Democratic representatives — earmarks a third of the considerable prevention budget provision for education/ activities that will focus on avoiding exposure to risk-situations — the first line of defence in prevention. Upfront is delaying sexual debut, abstinence, fidelity, monogamy, reduction of casual sexual partnering, sexual violence and coercion, encouragement of male sexual responsibility and respect for women.
Qualifying phrases of correct, consistent, near universal use as the prerequisite for condom protection are peppering research literature; concomitantly, this remains a major challenge even in countries that have invested massively in education to this end. The US, for instance, has 40,000 new infections a year. Further, mass media has obvious limitations; inter-personal communication being far more effective for intimate intricacies.
But our media tirade stems from the Health Minister’s stoppage of TV communication developed by BBC/Prasar Bharati to break down embarrassment around the condom’s use — by peddling it through family members and friendly panwala/rickshaw puller etc. It drew wide protests, including by this writer. In the Prasar Bharati scenario the condom metaphors a breakdown of that which is sacred and valuable within our family and socio-cultural contexts and which actually serves as the major bulwark against a more rapid spread of HIV/AIDS in this country.
Sections of the media ridicule such thinking, uphold the misconceived BBC-Prasar Bharati campaign. BBC cites its scientific research base and Prasar Bharati’s endorsement. But anyone accessing the research would note 87 per cent of its sample totally monogamous, not requiring condom messages. Of the mere 4 per cent having multiple sex relationships, only 2 per cent not using/ erratic in condom use; also BBC’s clearly stated preconceived certitude that condoms are central to AIDS prevention.
Should public service communication channels be guided by external elements and jettison the reality of the majority to concentrate on minorities in AIDS prevention campaigning? Particularly, when channel-reach to such segments is at best chancy, while erosion of the protective norms of the larger majority sure-fire?
The mass media are the ideal vehicle of reinforcement — in this context, of existing protective cultural norms that build an ethos of sexual and societal responsibility public service channels have an obligation to this end, but other media channels also need to introspect their public obligations.
A re-alignment of the AIDS prevention programme — not just communication approaches — is overdue. Balanced thinking is particularly vital at this juncture.The ill-conceived World Bank/bilateral-supported five-year NACO Phase II programme heavily tilted to accord primacy to a limited Targeted Interventions to High Risk Behaviour Groups with condoms/ STD treatment/communication approach, is in its penultimate year, with little to show for the massive investments. Comprehensive strategies need to be much more than the focusing on all routes of HIV transmission that NACO has belatedly begun. A paradigm shift requires radical policy changes: namely, political will to attack basic root causes and conditions that accentuate human vulnerability to risk behaviour, the allocation of sufficient funds to build viable alternatives across a range of areas, massive overhauling of the health system to make it effective to tackle critical public health problems, including HIV/AIDS. In sum, prevention that promotes healthy lifestyles and good governance.
The international missions to assess funding for Phase III of the National Aids Control Programme are commencing. The stakes to prove past infructous investments successful are considerable, particularly as many of the elite are beneficiaries of the multi-million dollar programming and junketing of the earlier phases. The prism of the loot and scoot series applied to AIDS prevention work could yield a rich harvest of stories — and force corrective. But who will hold the mirror to the Emperor?
(The author is a New Delhi-based population expert)
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