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3 India’s Response to HIV/AIDS and Obesity By the 1980s, India’s emerging demo­ cratic and economic system, like Brazil’s, was confronting the HIV/AIDS and obesity epidemics. With both epidemics highly contested among the country’s politicians and bureaucrats, for a variety of reasons—­ often nothing to do with public health—­ India’s government did not immediately respond. However, with the arrival of international criticism and pressure, by the early 1990s the situation began to change: politicians pursued a stronger policy response to HIV/AIDS and obesity in order to promote the government’s international reputation for being capable of eradicating disease and of developing. Shortly thereafter, with the intent of furthering its international reputation, the government provided foreign aid assistance to other nations for HIV/AIDS prevention and the production of medi­ cations. ­ These reputation-­ building interests, as well as a receptivity to international financial and technical assistance, reflected the government’s positive geopo­ liti­ cal positioning . As we saw in Brazil, this positioning had a long historical pre­ ce­ dent, spanning back to the early twentieth ­ century when po­ liti­ cal leaders sought to enhance India’s international image, importance, and position in the world. However, even though the government’s positive geopo­ liti­ cal positioning served as an impor­ tant catalyst for reform, the absence of strong bureaucratic–­ civil societal partnerships prohibited the emergence of a centrist policy response. Responding to HIV/AIDS The HIV/AIDS epidemic emerged ­ later in India than in Brazil. The first reported case of AIDS in India arose in 1986, when an NGO in the city of Chennai (previously known as Madras), in the southern state of Tamil Nadu, reported 78   Geopolitics in Health a female sex worker with the virus. The virus subsequently spread throughout the southern states, hitting major urban centers such as Mumbai (formerly Bombay) in the state of Maharashtra (which by 1996 reported approximately 50% of all AIDS cases in India), Andhra Pradesh, Karnataka, and the northern states of Manipur and Nagaland (Lieberman, 2009; Solomon and Ganesh, 2002). AIDS was initially concentrated among sex workers, IDUs, and gay men, but by the early 2000s it had traveled to the rural population and blood transfusion recipients. Since the early 2000s, moreover, HIV/AIDS has been mainly concentrated among heterosexual ­ couples, sex workers, and men who have sex with men (Solomon and Ganesh, 2002). Figure 3.1 shows the numbers of HIV/AIDS cases through 2007. As occurred in Brazil, India’s government did not immediately respond to the HIV/AIDS epidemic. The prime minister, parliament, and officials in the Ministry of Health and ­ Family Welfare (MHFW) ­ were essentially apathetic about the issue, even ­ after ­ these leaders became aware that HIV/AIDS was spreading like wildfire in other nations (Kadiyala and Barnett, 2004). In 1994, at the Twelfth Annual Convention of the American Association of Physicians in India, the government’s health minister, B. Shankarahand, commented that “AIDS is not a prob­ lem in India,” reflecting the government’s denial of the new disease (quoted in Jayapal, 1996, 1). No elected politician publicly mentioned AIDS ­ until 2001, when Prime Minister Atal Bihari Vajpayee proclaimed his commitment to what the government fi­ nally considered a “national crisis” (Lieberman, 2009). The government’s initial inaction was mainly the result 0 0.5 1 1.5 1986 1993 Millions 2000 2007 2 2.5 3 Figure 3.1. HIV/AIDS cases in India (millions). Source: India, Ministry of Health and­ Family Welfare, 2010. India’s Response to HIV/AIDS and Obesity   79 of conservative cultural beliefs—­ open discourse on sex was taboo—­ and of stigma that tainted the views of the parliament, the prime minister, and MHFW officials (Kadiyala and Barnett, 2004; Lieberman, 2009; Mawar et al., 2005; Schaffer and Mitra, 2004). ­ People living with HIV/AIDS ­ were seen as immoral outcasts, the “naughty them,” subject to punishment for their embarrassing sins (Lieberman, 2009; Schaffer and Mitra, 2004), deemed unworthy of government support. While the government did respond by creating the National Committee on AIDS in 1987, the National AIDS Control Organ­ ization (NACO) in 1992, and the first of three National AIDS Control Plans (NACPs) in 1992, ­ these initiatives lacked the strong support of the prime minister and parliament and ­ were poorly staffed and underfunded (Kadiyala and Barnett, 2004; Lieberman, 2009). Lieberman (2009, 183) describes NACO during this period as a mere “bureaucratic shell,” hollow and inept. ­ Others referred to NACO as a “semi-­ autonomous” agency (Mitra, Hat...


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