Wall Street Journal - May 3, 2004
Marilyn Chase, Staff Reporter of The Wall Street Journal

$200 Million Program Uses Franchised Health Clinics To Reach Groups at Risk Controversy Over Projections

MYSORE, India -- At sundown one recent evening, a team of health workers piled into a sport-utility vehicle and roamed the streets of this city once ruled by a maharaja. Their marching orders came from software mogul Bill Gates: educate members of the world's oldest profession.

"There, by the railway station," said a team member, jumping out to greet two women with orange flowers in their hair -- the trademark of local streetwalkers. Next was a bus stop, where men hovered in the hot dusk seeking young male prostitutes. At each place, the health workers invited prostitutes to a community center for tea and condoms, courtesy of Mr. Gates.

Wooing prostitutes is part of the Bill and Melinda Gates Foundation's $200 million push to sell AIDS prevention in India -- its biggest grant program in any single country. Its unusual approach: a chain of clinics in the country's hardest-hit states to pitch safe sex to prostitutes and the truckers who are their primary clients. (See related article.)

Like burger franchises, 50 clinics, set up at highway truck stops, will be run by local partners, including trucking and oil companies. The foundation will also enlist prostitutes to sell the prevention message to their peers at other clinics, training them to help with research and even narrate PowerPoint presentations. The effort is getting marketing help from cricket stars and trying to enlist Bollywood icons. By 2008, the foundation hopes to arrest the spread of AIDS in six Indian states and go nationwide.

The foundation's aggressive tactics and warnings of an escalating crisis have stirred controversy in India. The country ranks second to South Africa in number of people infected by HIV, the virus that causes AIDS, with around five million cases. That's less than 1% of India's population about one billion.

But the foundation and other world health officials fear conditions are ripe for AIDS to explode across the country and beyond, as it did in Africa. In the state of Karnataka, which includes Mysore, 8% of all adults, or 2.6 million people, could be HIV-infected by 2013, swamping hospital beds and busting health budgets, according to a preliminary Gates Foundation estimate.

HIV cases are concentrated in six of India's 30 states, chiefly among its three million sex workers and six million long-distance truckers. Spot checks of prostitutes in some cities have found HIV infection running as high as 50%. Their mobility could spread the virus far and wide, reprising the early spread of AIDS along truck routes in Africa.

"The future of the global epidemic is really at stake in India," says Peter Piot, Geneva-based director of the United Nations AIDS program.

AIDS also poses a threat to the economy of India and South Asia, since India's HIV hot spots lie near the centers of its economic boom. The city of Mysore, with 1,840 prostitutes targeted for safe-sex education by the Gates clinic, is 90 miles southwest of Bangalore -- the engine of India's high-tech growth and the epicenter of the subcontinent's economic boom.

Rapid growth in AIDS cases could be "an economic catastrophe," says Meenakshi Datta Ghosh, the director of India's National AIDS Control Organization. "Those young girls and boys doing outsourcing -- if [AIDS] hits them, the edifice will collapse."

When the Gates team began working in India, the government questioned why the foundation wasn't channeling grant money through state agencies. Indian health officials wanted credit for their own recent AIDS-service improvements, such as blood-testing sites, bulk condom purchases and a new plan to give free antiviral drugs to 100,000 patients.

Moreover, Mr. Gates's warnings of exponential AIDS growth "raised blood pressures" in a government famously "prickly" about epidemic forecasts, says Teresita Schaffer, director of South Asian programs at the Center for Strategic and International Studies in Washington.

Officials in New Delhi have bristled at anyone who disputes the government's figures: 4.6 million HIV infections and 100,000 AIDS cases. Mrs. Ghosh, of India's AIDS office, says she accepts Mr. Gates's help and his dollars, but rejects forecasts of doom or statistical disputes. She even says in an interview that there may be declining spread of the disease from tainted blood products and drug use.

The foundation also faced questions from the Indian press, which theorized that Mr. Gates was seeking to protect his technology interests; Microsoft Corp. employs many Indian engineers in the U.S. and 1,000 employees in India. A headline in the Times of India paraphrased a Bollywood tune: Dil da maamla, or BILL da maamla? Loosely translated: A matter of the heart, or Bill's business?

Mr. Gates says the project has no business motivation. He also stands by forecasts that show exponential AIDS growth in India. "I would say almost every forecast for AIDS has ended up being on the low side if you go back through the 1980s or 1990s," he says. "The threshold question is, is there a risk of tens of millions of people dying in India, or perhaps more than that? Anybody who disagrees with that is missing a potential tragedy."

At the same time, Mr. Gates downplays the conflict with the Indian government. "There was skepticism. But we're past that stage. We're getting good partnerships," he says.

Barnstormers

India's wariness of foreign health aid dates back decades. In the 1970s, when smallpox struck, the World Health Organization mobilized a corps of young Western doctors who barnstormed through villages, vaccinating millions. Physicians ordered local officials around, leaving bruised feelings.

This time, India's government wanted to make sure it had a voice in the effort. Secretary of Health J.V.R. Prasada Rao says the foundation closely consults New Delhi, and Mr. Prasada Rao serves as co-chairman of board of the Gates project here. Mrs. Ghosh also was named a board member.

But being frank about AIDS transmission is difficult in a society where polite people don't discuss sex and the disease carries a powerful stigma. A woman was stoned to death in one state because she was HIV-positive, says Ashok Alexander, the project's director. On a fact-finding tour, the foundation had to relocate one local guide and his family for his safety after he went public about having AIDS.

A 17-year veteran of McKinsey & Co., the 49-year-old Mr. Alexander helped transform Indian industries into global powerhouses in the 1990s. He contends that the same management methodology he applied to that task could transform risky sexual behavior in India. Mr. Alexander hired a banker, information-technology executive and management consultant to help him run the program, called the Avahan India AIDS Initiative. Avahan means "call to action" in Sanskrit.

Many prostitutes were wary of the Avahan community center in Mysore at first. Rumors spread that the center wanted to steal their kidneys for transplants. So Gates doctors James Blanchard and Sushena Reza-Paul, from the University of Manitoba, enlisted prostitutes as guides, data collectors and recruiters of patients.

The prostitutes circulated among their peers with invitations to drop in for refreshments and to take part in a lottery. About 120 showed up for a chance at the prizes: a sewing machine and a "Mixi" or food processor. Clinic workers followed up with offers of free condoms, AIDS education and basic health checks.

Another early move the clinic made, using a methodology borrowed from wildlife ecology, was to take a census and map Mysore's flesh trade. In addition to men and women, the Mysore scene features hijras, a class of eunuchs and transvestites who don saris and hair weaves. Only 5 o'clock shadow mars the illusion.

Many prostitutes in the Gates survey are married. Akram, who would only give his first name, is a 12-year veteran of the sex trade who has a wife and four children. He just started using condoms this year, he says.

The clinic used the data it gleaned from the survey to hone its messages and target the populations most at risk. On a recent afternoon at the clinic, in a spacious upstairs room freshly painted with a seaside mural, 32 prostitutes in rainbow saris listened to a presentation from their peers. Dr. Reza-Paul ran a PowerPoint slide show presenting data on Mysore's sex solicitation and service styles, while several prostitutes narrated the report, and discussed their occupational risks.

While the health message isn't lost on the audience, it often loses out to financial needs. "One sex worker told me, 'What you say is true. With the virus, I may die 10 years from now. But if my kid is sick today, and a client offers me [more] rupees to have sex without a condom...' " recounts Mr. Alexander.

Chandan, a streetwalker with long crimson nails who would only give his first name, moonlights for the Gates effort, giving AIDS-prevention chats at bus stops. But he says he feels financial pressure to go without a condom, which can quintuple a prostitute's fee to as much as 500 rupees -- or about $10. "Money becomes the first priority," Chandan says. "And even though we know it's not safe, we may not use condoms." The Gates foundation pays 100 rupees for a three-hour shift of prevention teaching.

Carrying condoms has its own dangers. Police can point to condoms in a woman's purse as evidence of prostitution. There is also the risk of discovery by families unaware of her job. One woman, offered five condoms, took only two -- enough for that afternoon's clients -- saying she didn't want her husband or kids to find spares in her purse.

'We Want Them to Be Safe'

The foundation isn't trying to regulate prostitution, or push "forced rehabilitation" on patients, Mr. Alexander says. "Some groups say we should get commercial sex workers out of sex work, that we are enabling them," he says. "We are in no way supporting sex work. We think it's sad, but we want them to be safe."

Mr. Alexander says he'll deploy yet another business tool to counter India's large population of folk healers. Many poor Indians consult these traditional practitioners, who encourage myths such as the idea that bathing the penis in lemonade will cure AIDS. Mr. Alexander plans to give folk healers incentives for referring patients to clinics.

The Gates program will also target truckers, among the biggest customers for prostitution. To reach this population, Mr. Gates recruited big companies -- Transport Corp. of India and Indian Oil Corp. -- as strategic partners. They will allow a chain of 50 clinics to be set up at existing truck stops. The clinics will be co-managed by Population Services International, a nongovernmental organization with experience in controlling sexually transmitted diseases. At the truck stops, says Mr. Alexander, "there will be banners, condom supply, demonstrations, health check-ups."

One site now being surveyed for such a clinic is the Sanjay Gandhi Transport Nagar, a truck stop set on a 77-acre lot outside Delhi. In the 100-degree heat, drivers pull up in rigs sporting tinsel garlands and pictures of lotuses, peacocks and Hindu gods. In the open air, the men can buy shoes, get barbered, weld parts, drink and relax. They also can get sex.

Some Indian truckers believe in garmi (literally, "heat"), a negative energy that requires sexual release or makes them go blind. In addition to sex with prostitutes, drivers often couple with young male assistants who ride along with them. After months on the road, some return to their wives with sexually transmitted diseases. Mr. Alexander says some truckers put ghee, or clarified butter, on their condoms, which erodes the latex. Others believe AIDS can be cured by having sex with a donkey or a virgin.

In simmering heat of a fly-specked drink shop called Gold Dhaba, 30 truckers lounged between shifts. "Earlier, I didn't have information about AIDS, and so I had some risk," said 23-year-old Megh Singh. Initially, he said, "just like you eat everywhere," you have sex everywhere. "Now I use condoms," he added.

His colleague, 20-year-old Faizal Ahmed, agreed that "you get [sex] on the highway." Trucking is a dangerous job anyway, he said, adding, "I am in the mouth of death."

To remedy this blend of testosterone and fatalism, Krishna Jafa, of Population Services International, a Gates grantee, says she is test-marketing slogans to hook truckers without breaching decorum or "offending the grannies." One idea: "If your manhood is dear to you, protect yourself." Or: Condoms are "the macho thing to do."

Mr. Alexander aims to make a clinic visit as routine and as convenient as changing tires or buying a cold drink. "These are ordinary people," he says. "They want a solution that is practical and doesn't screw things up."

Write to Marilyn Chase at marilyn.chase@wsj.com

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