Dialogue July-September 2007, Volume 9 No. 1
Drug Use, HIV/AIDS and Human Trafficking in the North-East
Drugs, HIV/AIDS, violent conflict, wide-spread poverty and underdevelopment are some of the similes of India’s troubled northeast region. This is a unique region of varying metaphors. The total geographical area of the region constitutes 8% of the country and houses 4% of its population. It has 98% international boundary and is home to 209 of the 533 odd tribal groups in the country. Out of the 365 languages and dialects in India nearly 50% are spoken in the region. Waves of migration from Southeast Asian countries brought people of Austro-Asiatic mongoloid origin to build much of the varied groups in the eight states forming an ethnic mosaic of anthropological delight. The diversity in this region is of astounding proportions. This is true of its problems too. While admitting that, of late, there have been some positive development trends in the region, we also sadly realize that problems in the Northeast region are far from over. Now, this resource-rich, infrastructure-poor, conflict-scarred region is faced with a complicated worry: the rising surge of Drug Abuse, HIV/AIDS and Human Trafficking.
Drug Abuse: Assam, Meghalaya, Sikkim, Tripura, Arunachal Pradesh, Manipur, Mizoram and Nagaland are the eight states of Northeast region, and the last four share a common international border with Myanmar the world’s second largest illicit opium producing country. Following the introduction of heroin in the early 1970s, drug use among local youth in the Northeast India, particularly in the states close to Myanmar, took a new turn. Injecting heroin (locally known as “number 4”) soon took over from heroin smoking- a non-traditional form of opiate use in the region. Many young males, and to a lesser extent young females, in their mid-teens started drug use around this time. They gradually switches from non-injecting to injecting method. It is important to recognize that a wide range of structural and environmental factors, including underdevelopment, increased the vulnerability of the young people to drug use. Stringent laws and enforcement activities against heroin trafficking and peddling in the early 1990s in Mizoram and in the early 2000s in Manipur also resulted in another shift towards the vein puncturing habit of injecting other pharmaceutical products like dextropropoxyphene which is a synthetic pain reliever capsule meant only for oral use. Easy availability of drugs, stress arising from socio-political unrest and frustration born of the lack of employment opportunities for the growing educated youth mass in the region are often cited as the major causes of drug use a serious social disease.
According to estimates by the National Aids Control Organization (NACO – 2006) there are 50,000 IDUs injecting drug use in the region, the majority of them in Manipur, Nagaland, Mizoram and, of late, Meghalaya. This figure does not perhaps include many IDUs belonging to affluent families who can deal with the problem of drug use themselves without having to seek help from NGOs and other service providers. They remain hidden for various reasons; stigma being the most important one. Experience shows that there is a sizable population of drug users in this section of society in the region. Therefore, the figure mentioned above can well be construed as a poor representation of the problem. We also understand that over the last two decades the causative factors for rampant drug use mentioned earlier have remained unchanged in the region and the situation as we see it today is not likely to improve in the near future. If this is true, we can safely predict that drug use in the region will rise. Empirical data of various NGOs working in the region in the field of Drug and HIV also suggest that drug use per se has not declined in the region over the last two decades inspite of the earnest efforts of the Government and other civil society organizations. This is a difficult battle – a disease whose cure is hard and farfetched for many. Though treatment is possible for drug addiction, as for any other disease, universally accepted success rate is very low.
According to the United Nations Office on Drug and Crime (UNODC) report 2005, alcohol is the most commonly abused substance in all the states in India except in Mizoram. Of the states of the northeast region, clients of treatment centres in Assam, Meghalaya and Tripura, seek help mainly for problems of alcohol abuse. Although the sale of alcohol is prohibited in Manipur, Nagaland and Mizoram alcohol users are the second largest group seeking treatment services in these states after opiate users. It is worth noting that intravenous use of pharmaceutical products, the use of opiate of choice for injecting in Mizoram has been associated, unlike heroin, with higher risk of abscesses, non healing ulcers and amputations thereby increasing the morbidity of drug users.
Users of inhalants in Manipur and users of codeine-based cough syrups in Mizoram are the third largest number of youths demanding treatment services. Cannabis (ganja) users are the second highest group of treatment seekers in Assam, Meghalaya and Tripura. Heroin use has also made inroads in Assam and Meghalaya. Tripura has lower levels of the abuse of tranquilizers as reflected in the records of addiction treatment centres.
Drug trafficking across the common border of Myanmar and the eastern-most three states of India (Manipur, Mizoram and Nagaland) occurs with ease. Production and drug trafficking in Northeast India feature the following dimensions:
1. the illicit cultivation of opium and cannabis;
2. the smuggling of heroin and amphetamines from Myanmar in moderate quantities;
3. the trafficking of pharmaceuticals such as dextropropoxyphene and codeine-containing cough syrups from other parts of the country and
4. the trafficking of ephedrine and pseudo-ephedrine precursors for the manufacture of amphetamines from India to Myanmar.
Now the question is, what happens if we have many drug users in our society? Why is it called a social disease? Findings of a study conducted by Impulse NGO Network, Shillong, 2002 suggest that 80% of the IDUs are introduced to drug use while they are below twenty years: a very critical stage in one’s life. Drug use is also associated with a lot of petty crimes within the family and outside. Crimes like thefts are most common and it is done to fund their drug habits. This disease affects a person’s physical and psycho-social aspects and, often, the person is unable to or unwilling to engage in any productive work beyond what is required for procuring drugs. Most drug users are educated and are the smarter lot in the community they belong to. The society the thus unfortunately loses such otherwise capable people through whom it could achieve better growth and development.
To top it all, injecting drug use falls in the category of the high risk behaviour for HIV infection through sharing of injecting equipment. As per the same study mentioned above, more than 40% of the IDU share their needles and syringes inspite of their knowledge of possible HIV transmission through such risky practices. This is what makes it lethal, as there is no hope of having a cure for HIV in the near predictable future.
HIV and AIDS:
The havoc created by HIV in some of the Northeast States over the last one-and-half decades demands that any discussion on HIV and AIDS in the region should also take drug use into account. Two out of the six high HIV-prevalence states in India – Manipur and Nagaland – are in the Northeast and now feature what epidemiologists call a ‘generalized’ epidemic with a strong IDU-HIV link. In a third state – Mizoram – the epidemic appears to be headed in the same direction. Equally worrying is the increasing evidence that non injecting sex partners of IDU are becoming infected with HIV in many Northeastern states (UNODC-2005).
In some of the Northeastern States, the rate of HIV infection among the IDUs was as high as 50-60% six years ago. The spread of the virus continued unabated because of numerous reasons in the early 1990s. One of the more important but less talked about reasons is the way fear driven information on drug use, HIV and AIDS was disseminated to the general public with insensitive and discriminatory tones towards IDUs as the epidemic spread. People began to understand IDU as synonymous with HIV paying no heed to the fact that injecting drugs, per se, does not spread HIV; it is the sharing infected injecting equipment that does so. As a result, driven by such regrettable ignorance, IDUs in the region were unfortunately subjected to a high level of stigma and discrimination. Until such time, there was almost no stigma and discrimination against IDUs. Drug use was, rather, looked at as a fashion and a fad of the young in the region. The unfortunate rise of such stigma on the IDUs made them hide their habit. They stopped accessing the services provided for their safety and well being. This meant that they continued sharing HIV infected needles and syringes galloping the HIV epidemic. This is how Northeast, came to occupy a prominent place in India’s HIV map along with Maharastra, Tamilnadu, Andhra Pradesh and Karnataka, adding yet another negative feather in the cap of India’s already troubled region.
The epidemic in the region has already crossed from the IDU community to their sex partners and to the larger community. This means it is no longer an epidemic concentrated within a particular group of people with High Risk Behaviour like Injecting Drug Use (IDU), Commercial Sex Work (CSW) and Men having Sex with Men (MSM). A research done by Manipur Network of HIV positive people (MNP+) in 2005 finds that Manipur registered a steep rise in the commercial sex worker population during the past one decade. HIV is believed to be both a cause and a consequence of such dissolute practices. The case cannot be different in Nagaland, Mizoram and other states in the region. According to an NGO estimate there are 2000 CSWs in Dimapur town alone and a similar number in Imphal. The increasing visibility of MSM population as a high risk group is also a concern for the preventive work in the region. According to a survey conducted in 2006 by SASO a drug user Community Based Organization (CBO) and a pioneer NGO working with MSM community in Manipur, there are 1000+ MSM in Imphal town and HIV infection rate among them was as high as 33% in the year 2003. The situation, here too, cannot be different in the other states. Just three years ago MSM was a term unheard of in Nagaland and today there are an estimated 800+ MSMs in Dimapur town alone and they have a 40% HIV infection rate, says Ms. Inatoly of Guardian Angel, Dimapur, working in the field of HIV prevention in Nagaland. There could be similar number of their heterosexual partners who remain mostly hidden; whose HIV status is unknown and who could be serving as active agents of spreading the virus even in their families. This is a larger challenge for Government and NGOs fighting the epidemic in the region in particular and the world at large.
In India as a whole, 86% of HIV transmission happens through the sexual route and over the last two decades this figure has remained more-or-less steady. In the Northeast, instead, the rate of transmission through the sexual route has been increasing steadily indicating clearly that the epidemic is getting generalized and has moved from high-risk groups (like IDU) to the general population and from the urban to the rural. More and more pregnant mothers are found to be HIV positive. In a matter of just ten years (1995 to 2004), prevalence rate among the Anti-Natal Care (ANC) attendees in Manipur jumped from 0.4% to 1.7%. There is a growing prevalence among women (40%) in the world today which is clear evidence of a generalized epidemic. The diagram (UNDP Report) given below illustrates the centrality of women in the epidemic, and Northeast is not an exception.
Further, it is of even greater concern that the region is beginning to witness more and more orphans and infected children. Specifically targeting care and support of such Orphans and Vulnerable Children (OVC), in a region marked by poor infrastructure for health care, is a mighty challenge.
There is yet another reason, however sensitive the issue may be, why HIV prevalence became high in the Northeast: its Socio-cultural and religious barriers to prevention initiatives. Nagaland, Mizoram, Meghalaya (and hills of Manipur) are Christian states and churches have strong and matchless influence on the people. Unfortunately the churches’ attitude and their resultant actions have not been very conducive for HIV prevention work in the region. Many a time, taking position from a narrow moral angle, churches all over the world, and more particularly in Northeast, saw Drug use, HIV and AIDS as a matter of sin and shame. This helped no one. The spread continued unimpeded as the most effective platform of influence – the pulpit that churches alone have – did not play the role it could have to make a significant impact on the situation. Further, it is also true that a great number of the numerous ethnic communities that constitute the population of the region are close-knit small tribal societies with strong cultural bonds and strict social norms. Many of these tribal communities have effective traditional social institutions and structures such as the VDB in Nagaland, Dorbar Snong in Meghalaya, Village Authorities in the hills of Manipur and YMA and the like in Mizoram which could have played an effective role in HIV prevention. Plagued by ignorance and fed with incomplete and incorrect information on drug use, HIV and AIDS, these institutions and social structures too acted as a major source of stigma and discrimination which only compounded the spread of the virus. Since these attitudes persist the spread still continues.
Another interesting and noteworthy fact is that in the Northeast people generally tend to take sex lightly. There are numerous cases of casual sex among the young and old alike in some of the states in the region. Promiscuity is taken as normal practice among many tribal societies. Only among a few is it considered a taboo by tradition. At the wake of the epidemic in the region there was a massive campaign for HIV prevention and an advertisement was put up everywhere which said, “Don’t just do it. Use a condom”. This advertisement, which was chosen after much serious thought and found to be most relevant in the local situation, speaks volumes on the casual attitude of people towards sex. It implied that people just do it. Given this standard, NACO’s unexpressed fear is that the HIV epidemic in the Northeast may easily go the South Africa way. We hope that the people of the region will not develop a casual attitude to HIV, too.
AIDS cases in NE and Recipients of ART
(Reported to NACO as in August 2006 and July 2007)
Sl. STATE AUG 06 JULY 07 No of people
1 Assam 372 465 250
2 Arunachal 13 NA NA
3 Nagaland 736 1600 490
4 Manipur 2946 4065 4019
5 Mizoram 106 216 84
6 Meghalaya 8 NA NA
7 Sikkim 8 NA NA
8 Tripura 5 NA NA
There is also the larger issue of lack of adequate access to treatment, care and support for People Living with HIV and AIDS (PLHA). More and more of HIV+ people today are getting AIDS and states like Manipur and Nagaland are at an advanced stage of the epidemic. The following table shows the number of AIDS cases in the states and the rate at which it has been growing during the last two years. It also shows how many people are under treatment as part of the free Antiretroviral Therapy (ART) of NACO. PLHA who have developed AIDS need treatment and, as we see from the table, there are many not benefiting from these facilities provided by the Government.
We know that stigma being the culprit there are many in our close-knit communities who secretly suffer from the disease and will die of it unnoticed, unreported and often, uncared for. This indicates that the problem is much bigger than we tend to see apparently and understand. The figures officially reported are only a tip of the iceberg. This will remain so till the time when we are able to provide a stigma-free enabling environment for the PLHAs to come out openly and have access to treatment services provided for them, however inadequate they may be. Until such an environment is created, the problem of HIV and AIDS will continue to be the guess-work of a few and will be targeted only by ineffective measures. But this is not generally an easy task and all the more so in the context of the Northeast where there are other numerous problems which decidedly are considered more important and of priority for the governments to attend to.
Many NGOs active in the field of HIV and AIDS and PLHA were overjoyed when the free ART was rolled out in the Northeast in April 2004. This helped reduce the death rate to a great extent during the last few years. However, inspite of ART, many PLHAs continue to die in the region. There are many reasons for this. An important one among them is the high prevalence of Hepatitis-C (Hep-C) co-infection among the IDUs. Studies conducted by the Indian Council of Medical Research (ICMR) way back in 2000 in Imphal found prevalence of 80-90% Hep-C co-infection among the IDUs. This record conforms to the data maintained by some of the renowned private medical practitioners active in the area of HIV/AIDS treatment in Manipur. Though treatment for Hep-C is possible, but is expensive. The treatment costs Rs. 6-7 lakhs for a person and usually lasts a year. There is only a 40-70% success rate depending on the genotypes of each infected person. This is tricky. If 80-90% of the generally accepted figure of 50 thousand IDUs in the region have Hep-C co-infection, their treatment cost will run into nearly Rs. 3000 crores and only 40-70% of them will be cured. In a country like India, with its poor public health infra-structure and resources. Developed western countries, treatment of Hep-C is never considered important and of priority. Thus, given these facts as regards the present situation, we can safely predict that unlike ART, free treatment for Hep-C will not see the light of day in the near future. Which means PLHAs with IDU background will continue to die despite ART.
Another problem related to HIV is NACO’s classification of states on the basis of its prevalence and, as a consequence, the strategies adopted in these states. According to this classification, as given in the table below, Manipur and Nagaland are in the high HIV prevalent category and have the maximum number of programmes in the region. You will notice that I have referred mostly to the experiences of Manipur and Nagaland in my writing here.
NACO’s Categories of NE state on HIV prevalence
Nagaland Assam Arunachal Pradesh
The rest of the six states of the region are in the low prevalence category. I do not know what this actually means. I only know that there are less of preventive and other care & support and treatment programmes happening in these low prevalent states. It looks as though we will wait for these low prevalent states to become like Manipur and Nagaland and only then will we plan more programmes on HIV. The very fact that these states are in the low prevalent category warrants more prevention programmes so that they do not become like Manipur and Nagaland. But this is not what is happening. Sadly!
On the other hand, let us take the case of PLHAs living in these low prevalence states. Their problems are not less because they live in low prevalence states. In fact, the problems are more. HIV is HIV; PLHA are PLHA no matter where they are or how many of their kind are around them. The spread which can only come from infected persons is the same, irrespective of where they live. The difference is that it is more likely that PLHAs living in the low prevalence states are less cared for as compared to the ones living in high prevalence states. Stigma and discrimination could also be higher in the low prevalence states. As a result the spread can continue unchecked in these states. This is where the problem lies.
The state of Assam which has nearly 70% of the entire population of the Northeast needs a special mention here. Among the six low HIV prevalence states of the region, it falls into a special sub-category of highly vulnerable state. We should not take this lightly. Assam has every possibility to explode with the epidemic in the near future. Guwahati city, the gateway to the Northeast is also the biggest transit city, with a very large floating population that goes in and out of Northeast. Migrant workers, truckers and security personnel are categorized as ‘bridge population’ and are much more vulnerable to HIV infection. Guwahati is the major hub of this population. There are also reports from AIDS Prevention Society (APS), Guwahati, an NGO working in the field of HIV and AIDS, which says that number of CSWs in the city of Guwahati has increased considerably during last few years. Assam is a highly conservative society and stigma and discrimination around the issues of drug use, HIV and AIDS are still very high and this will exacerbate the spread of epidemic.
Yet another visibly growing problem of the Northeast is the increasing incidence of human trafficking. Human traffickers are increasingly turning to India’s poverty-ridden and insurgency-wracked northeastern states in their search for young girls to work in the brothels of the big cities. Over the past five years there has been a rise in reports of girls gone missing from the remote region of these eight states, an increase which authorities believe is due to trafficking. Police say that at least 700 girls from the region have been reported missing over the last five years, 300 of whom disappeared in 2005 alone. But NGOs estimate that thousands of northeastern girls disappear every year. Most of them are not reported by families due to the stigma associated with being a part of the sex trade. The rise in the number of girls disappearing from states like Assam, Meghalaya and Arunachal Pradesh is partly due to tighter surveillance on India’s northeastern border with Nepal, from where most of the trafficking took place earlier. Mr. Pachuau, IPS, Director of North East Police Academy (NEPA) says increased security along the border to curb Maoist insurgencies in both countries has deterred many traffickers, and the number of Nepali girls being brought into India annually has halved from around 10,000 three or four years ago.
According to another research report of 2005 by Nedan Foundation, “Poverty and conflict are fuelling trafficking in the north eastern states. This opens up huge possibilities for the spread of HIV. The fear is that many such girls are extremely susceptible to HIV/AIDS and that many have already been infected. “Young girls and women from poor, desperate families are dually vulnerable: to being trafficked into the sex trade and to catching HIV. Kokrajhar is one of several hot spots in conflict-ridden northeast India. Since the late 1990s, hundreds of thousands of people have been displaced in the region by regular clashes between various militant and tribal groups. The Norwegian Refugee Council (NRC) said that up to 200,000 people were displaced in 2003 in Assam state alone and a further 15,000 in neighbouring Tripura state.
The research also revealed that the trafficking problem is more widespread in the region than previously thought. Interviews by Nedan’s field teams with 60 teenage sex workers at Dimapur, Nagaland, revealed that many of the girls had been trafficked from the Naga countryside with false promises of sales jobs in big cities. Most of the girls were from broken families, having lost one or both parents in the region’s protracted ethnic conflicts. Almost all had dropped out of school and faced a bleak future.
Development Trends in NE
To the Government of India, during the past 50 years, this region has served as a socio-economic and political laboratory. Different policies and approaches to growth and development that came from the indifferent minds of mainstream India were tried and tested in the region. In the ‘50s the approach was cultural: that the Northeast is a phenomenally diverse mosaic of cultures that have to be preserved and enriched. This paradigm was perhaps predominant up to the ’60s. And then, somewhere in the mid ’60s, the ‘Security Approach’ came into greater prominence due to the unexpected Chinese invasion of 1962 after which the region was considered a strategically significant region not only in a geophysical sense but in a larger geopolitical sense. Further in the 70s there was a transition to a political approach: where diverse ethnic groups need to participate in the mainstream democratic processes with a view to reducing the problems faced by the region. It was during this period that vigorous political re-organization took place and many smaller states as we have them today were created chopping them off from the larger Assam.
Then came the much needed approach of development in the 80s. In this approach India understood that Northeast needed to be developed and believed that people would forget their problems of identity, assertion, separate nationhood, etc. This brought about an increase in public expenditure in this region. While the correctness of the development approach could still be debated, we can safely say that, finally, some positive trends and results emerged. There has been no prime minister 1980s onwards, who has not announced a package for the Northeast. And if you look at all the packages announced by successive prime ministers – they were all based on an assumption that development will solve the problem of Northeast. For example, the finance minister announced that 10% of the budget of every government department would be spent in the Northeast –revealing a mindset that has governed recent policy thinking towards this region.
In effect, there has been a paradigm shift in the way the Government of India looks at Northeast Region and today development is the buzz word. There are many more opportunities beginning and are waiting to happen in the region. One such opportunity is the increase in trade and commerce between India and the ASEAN countries fueled by India’s Look East Policy (LEP) which began in the early ‘90s. Northeastern States of India together share 1643 km of border with Myanmar border. Arunachal Pradesh, Mizoram, Manipur and Nagaland share borders of 520 kms, 510 kms, 398 kms and 215 kms long respectively with Myanmar. Myanmar is the lone ASEAN country with which India shares both land and maritime boundaries because of which it is accorded a special position in India’s LEP. Consequent to the visit of Senior General Than Shwe, Chairman SPDC, to India in 2004, the bilateral relations are at an all time high. This led to a steep increase in the volume of trade between the two countries. It can be said that Indo-Myanmar Trade alone can help in attaining significant increase in the economic growth of Northeast Region and in fact we are now able to see some light on the positive development trend it has set.
But this development trend could be endangered if the problem of drug, HIV/AIDS and trafficking is not fought on a war footing. These problems affect the income earning, particularly of the sexually active young population. More than 85% of the HIV infected population in the region is among the age group of 21-50 years. Globally 90% of the epidemic is concentrated in poor countries. Therefore, it is evident that the HIV epidemic has its roots in the widespread poverty present in the region, although poverty is not the only factor driving the epidemic. Sadly the HIV epidemic intensifies poverty and deprivation and increases social exclusion both for those infected and those affected. As such the epidemic makes the achievement of Sustainable Human Development (SHD) that much more unlikely given that poverty in the region is already a major problem and the epidemic has the capacity to increase its level and incidence. The HIV epidemic makes the task of SHD greater than it would otherwise have been in the absence of HIV, and simultaneously reduces the human resource capacity in the region for undertaking those activities that would promote growth and development.
HIV can reverse human development as a result of reduced life expectancy. Botswana is a classic case. In a matter of just 10 years (1992-2002) Botswana’s life expectancy rate fell from 67 to 27 years. During the same period, it registered a very marginal growth in its GDP and its Human Development Index (HDI) fell from 67 to 52.
The presently high level of stigma and discrimination in all the states of the region gives birth to the denial of the rights of people infected and affected by the virus and ultimately creates an environment where the virus spreads rampantly and secretly. The following diagram
(UNDP report) explains the link between poverty and HIV reinforcing the fact that drugs and HIV are very much development issues and are to be rightly looked at from this perspective while attempting to solve the problem.
The epidemic can further hamper the growth and development of any society with a slower growth in population and supply of labour due to AIDS-related deaths. It can have much a greater impact on unskilled labour. Lower labour productivity of HIV-affected workers can also happen due to sickness, staff turnover, frequent leave and care of ill family members, etc. There could be an increase in the share of health expenditure in the household economy, which will cut into other non-food expenditures of the families. Increase in the share of health spending in overall government expenditure leads to less expenditure on other development and welfare plans. Thus it will not be too much to conclude that the development benefits expected in to the Northeastern States from India’s Look East Policy could be adversely affected if we do not first curtail the problem of Drugs, HIV/AIDS and Trafficking in the region.
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