Fixing An Epidemic

In another part of Churachandpur town, a still groggy-eyed S. Benjamin attends to a group of Manipuri tribal youth who have called at his house. A theologian by training, he patiently gathers their used syringes and needles and replaces them with fresh ones, free of cost. After an early brunch, he rushes to his office where a larger group is waiting to exchange their works. During the day, among other things, Benjamin goes about distributing fresh works to addicts at designated street corners at specified times and even goes hunting absentees and new faces who may or may not do him the'favour' of accepting the freebies.

Ordinarily, in Manipur, the very possession of the works could have landed Mangcha and Benjamin in prison for suspected drug abuse and, possibly, charged under the Narcotics, Drugs and Psychotropic Substances Act. But they carry special identity cards which keep both the district police and local vigilantes at bay. Mangcha is one of the 100 'clients', all of them injecting drug users (IDUs), registered with the Society for HIV/AIDS and Lifeline Operation in Manipur (SHALOM), an Australian-funded Christian NGO, with which Benjamin is a counsellor. On August 17, 1995, ChurachandpurSuperintendent of Police L.M. Khaute issued orders that SHALOM clients and staff should not be detained for the possession of works.

This is not to say that the Manipur government or the Churachandpur district administration have legalised drugs. But, after months of intense discussion last year between the state health department, district administration, police, community leaders and SHALOM representatives, the NGO got the go-ahead to conduct, on an experimental basis, its Syringe and Needle Exchange Programme (SNEP) in Churachandpur. This is aimed at containing the galloping spread of HIV. Though SNEP has been in operation for just six months, its success has inspired Health Commissioner P.L. Thanga to contemplate encouraging and funding similar programmes in Imphal and Thoubal.

The enthusiasm generated by SNEP and the fact that Chief Minister Rishang Keishing and the entire state legislature are willing to back any effective 'preventive' measures are understandable in the light of the menace at hand. There are an estimated40,000 drug addicts in Manipur whose habit has been sustained by narcotics smuggled through the porous 352-km-long border the state shares with Burma. Half of them are IDUs, over 70 per cent of whom have contracted the HIV virus, mostly through shared needles. By January-end, 4,128 Manipuris had tested HIV positive and there were 104 full-blown AIDS cases.

And so, while the state accounts for barely 0.2 per cent of India's population, it has contributed 17 per cent of all known HIV cases in the country. Says Thanga: "Not a single day goes by without an HIV case being reported or a person dying of AIDS in the state. Despite the high levels of awareness about using condoms and safe needles, addicts refuse to change their habits." Within Manipur, Churachandpur district alone has around 3,000 IDUs, some 800 of whom live in the town itself.

Says Khaute: "We have chosen to live with the lesser evil of drug abuse in order to curb the AIDS menace, and so far I have not had occasion to regret my decision to allow theSNEP." According to Additional Deputy Commissioner P. Vaiphei, the principal argument against SNEP had been that it may encourage drug abuse, but in view of the ground reality it is a practical option. "When all the anti-drug campaigns and rehabilitation programmes have failed to check abuse and needle sharing, resulting in HIV, the only option is to supply clean needles," he says. "A realistic view of the ground situation suggests that we are not in a position to stop drug abuse, but through SNEP we can at least check the spread of HIV."

THE main aim of SNEP, explains SHALOM Co-Director B. Langkham, is to break the needle-sharing psychology amongIDUs which persists despite awareness of the danger of contracting HIV. Says he: "If syringes and needles are made available free, we will not only be able to curb HIV transmission but, in a few years, even change peer behaviour which would obviate other serious complications like injection abscess, a common occurrence among IDUs."

 Most hard-core addicts not only share and reuse their works, they fix drugs so often that after a while their upper bodies and legs are either too sore or they can no longer find a vein, leaving them no option but to inject into the veins around the groin. Puii, a 25-year-old addict, paid the price for injecting in her groin when she developed a serious abcess last year. For the past couple of months she has been under SHALOM's unique home-care programme for people with injection-related complications or the HIV virus.

What drives addicts to share needles despite being aware of inherent dangers? Reasons range from circumstantial and financial to notions of friendship and trust stemming from a peculiar drug sub-culture. Addicts often desperately need a fix. On such occasions, getting the money and locating a peddler assume far greater importance than taking precautions. More often, however, they barely have enough money to buy the dose, priced at around Rs 50 to Rs 70 per 'piece'—a small quantity of heroin wrapped in paper—and cannot afford a new syringe for Rs 5.

And sometimes addicts pool resources to buy a single 'piece' which, if it is too small to divide at the powder stage, is mixed and placed in a single syringe and divided with the help of outer markings. Benjamin, two of whose brothers have been addicts (one of them is dead), adds that social stigma breeds a peculiar sub-culture among IDUs: "They begin to see themselves as a separate community wherein refusal to share amounts to selfishness. They take pride in sharing everything, even death."

Langkham emphasises that SNEP is not about random, indiscriminate distribution of syringes and needles, for that wouldindeed encourage drug abuse. At SHALOM, it is a last resort measure and is accompanied by counselling. Says he: "We fully endorse and advocate abstinence from drugs as well as rehabilitation. SHALOM offers detoxification to addicts either in their home or in an institution, as per their choice. It is only when all else fails and the addict is unwilling or unable to give up the habit that we offer to list him or her as a SNEP client."

But the mere offer of free syringes and needles is not enough. Says Paul, a relapsed, HIV-positive addict and former SHALOM volunteer: "Addicts don't come and queue up to collect free works. You need to take it to dropping centres or to their homes even."

The past six months have taught Benjamin what a difficult lot IDUs are: "You have to really chase some of them who may even try and take advantage of you. A number of them make it a point to rub it in that it is they who are doing you a 'favour', whether by accepting a syringe, undergoing detoxification or abstaining afterwards. Yet, I have no complaints so long as they stick with the programme."

A positive spin-off of the project is that SNEP clients are beginning to opt for rehabilitation. Among the 13 per cent who have sought detoxification is Mangcha who says he cannot afford both his drug habit and a family, and so is keen to quit drugs. For the past several weeks he has been visiting Benjamin every day for counselling and to exchange works. Not only is he confident that he will be able to successfully give up drugs, he has begun roping in other addicts into the SHALOM fold, too.

Last week he brought in 18-year-old Thangpu, who has been on drugs for three years and has now opted to undergo detoxification at home. Therefore, it comes as no surprise when Langkham says he is confident of expanding the SNEP clientele in Churachandpur to 300 by the year-end. Says he: "We are conducting SNEP in a very small way and the results have been encouraging. It can be easily replicated elsewhere."

 This is evident from the fact that NGOs and health authorities in neighbouring northeastern states, where drug abuse and HIV are rampant, are also keen to sponsor SNEP in a big way. In this connection, a 'harm minimisation' workshop was held by SHALOM in Guwahati last October, which drew around 50 participants from neighbouring states.

However, the fate of SNEP as a weapon to combat AIDS in the north-east is in the hands of the Union Health Ministry. Officials at the National Aids Control Organisation in Delhi say that the file is 'somewhere' in the Health Ministry and the final decision will be influenced by a 'pilot project' being conducted by the Indian Council for Medical Research (ICMR) 'somewhere' in Manipur (not Churachandpur). Intrue bureaucratic style, senior ICMR officials say they are unaware whether the project has taken off yet and 'think' that it is still awaiting clearance from NACO. With every day the two central agencies and the ministry lose in taking a decision, the incidence of HIV among IDUs continues to mount, as does the AIDS toll.

(Names of drug addicts and HIV/AIDS victims have been changed.)