The following article by Yangchen Dolkar MD appeared in the August, 2005 issue of the Tibetan Review magazine. There are several major risk factors for the Tibetan community concerning HIV. They are: 1) receiving HIV infected blood at a non-Tibetan hospitals; 2) lack of access to HIV barrier contraceptives in remote communities; 3) migrant work which takes men and women away from their homes for more than 6 months at a time putting them at higher risk for engaging in unsafe sexual practices; 4) stress of immigration and of having international "stateless status" where general uncertainty over the future leads to employment limitations which in turn may lead to drug and alcohol use and abuse.
[AIDS in India and its potential impact on the Tibetan refugee community, 2001, Spencer Seidman, L.C.S.W.]
I read Seidman’s article months ago when a friend of mine sent it to me. The article is a couple of years old but the situation has not changed for the better. I did not think much about the article at that point in time even though HIV/AIDS is an epidemic in the Indian sub-continent (India comes a close second to South Africa as the country with the largest number of HIV/AIDS cases in the world and with the present rate of infection, it can easily out-run South Africa within one year) and by extension should have alarmed me about the situation in my own community. Thus I began my work as a medical officer in the Tibetan community of Mundgod, in Karnataka state, South India.
I went back to the article again afterwards, this time with a new sense of urgency and concern. What made me go back to the article? It was this patient who walked into the OPD room one day. He said that he was not feeling well, that he has been having chest pain on the right side for several days and that he had several episodes of watery diarrhea for one week. As I was performing a physical exam on him, he told me that he was diagnosed with HIV several weeks ago and that he is on medication now. The news and his frank confidence shocked me but I continued on with my examination and later, asked him to show me the medicines which he was already searching for in his backpack to show me. He was only 30. He was my first HIV positive Tibetan patient (I did not recheck his status).
Just as Seidman mentions about the fluidity of Tibetan settlements, the Tibetan community of Mundgod is ‘extremely’ mobile. ‘Extremely’ because young people (who have either dropped out of school or stopped short of going to college due to lack of financial back-up or dropped out of colleges or went to college but failed to find any jobs) are out of town for four to five months in a year, for sweater business mainly. Other young people drive vehicles in and out of the camps and to the nearest hub called Hubli. This is the common mode of transportation for Tibetans living here when they have to go for shopping either to the local Indian market in ‘Indian Mundgod’ or to the hub. Local buses are available but few.
The drivers end up spending time over night at the hub a lot of times in order that they have passengers to full capacity both ways, up and down.
The Tibetan settlement of Mundgod is one of the two largest Tibetan settlements in India.
Just as young people spend time away from their families on ‘business’, a number of them also spend years apart with the telephone and email as the only source of communication with their other halves. Occasional parcels and money through Western Union are the only proof of their commitment to each other and these are those husbands and wives who have paid good money to go to the U.S. or Canada or any of the European countries for a better future for their children and themselves. It takes as long as four years for families to reunite in the U.S. and Canada. I salute these young fathers and mothers who have brought up their child or children without the physical presence and support of their other halves, who continue to believe that they are a happy family soon to be reunited. Such temporarily fragmented families are ‘The Face’ of our community in exile, the impact of which is unmeasured/unstudied in all its various consequences, health and otherwise.
Also, on an average 2000 Tibetans cross over the border from Tibet into Nepal every year, thus adding to the exiled community’s fluidity as they begin a new life in exile. The transit to India from Tibet can take much time. Many times, groups get stuck at the border or end up setting up camp in Lhasa temporarily. Such unexpected stops make people vulnerable to harassment from the border police and other people. Also, prolonged transit increases the likelihood of contact with sex workers and unsafe sexual practices. Once in exile, they become part of any of the Tibetan settlements in India and Nepal wherever they settle down. 50% of the small eating places here in the Tibetan Settlement of Mundgod are owned and run by people who are latterarrivals
from Tibet and more than 50% of monks and nuns in the various monasteries and the nunnery here are also such people.
We have an existing problem with young people getting hooked on to substances like pain medications, tobacco products, alcoholic drinks and recreational drugs. There are programs rehabilitating such young people, both indigenous and collaborative efforts, but in no way does such programs have the resources currently to deal with the problem adequately.
The urgency of an effective and sustained effort on the HIV/AIDS front is still unfelt. There is no specific data on the prevalence of HIV/AIDS in our community in exile. More than 80% of HIV infected people in India fall in the 18-49 age group and the major route of transmission is heterosexual that is, woman to man or man to woman. HIV/AIDS is also of major growing concern in China and there is information on the status of Tibetans inside TAR but we all know the famous face of Chinese pretension and lie and therefore, whatever numbers they give to the world, it is hard to believe them. We have all heard about the Lhasa-Barkhor karaoke bars, brothels and their painted girls lining the streets and luring people. Ignorance can no longer be considered bliss. Nobody really knows the facts. From the Tibetan government in exile, information is scarce and vague with reportedly only one case of death from HIV infection (full blown AIDS) in the history of HIV/AIDS awareness in the Tibetan community in exile. The health related news releases from the exile govt. as well as from international study groups raise the issue often but offer little else.
Since my first encounter with the HIV patient, I have had many informal discussions with my colleagues and there are a number of stories going around. It is hard to tell fact from mere gossip but the amount of stories and the number of suspected victims makes me wish that we knew better.
There are various possible reasons for the lack of data on HIV/AIDS;
- The subject is a taboo
- We are shy by nature
- Close knit rural community- everybody knows everyone else’s name
- Inadequate preventive measures
- Lack of treatment/management/psychological support
- Lack of awareness
The risks are defined: unemployed youths, statelessness, fragmented families, community mobility and fluidity.
There are health talks, there are pamphlet distributions, posters with sophisticated illustrations but we need more. We need running and sustained projects just like we have for Tuberculosis. We need a standing committee or a rolling committee (whatever you may call it) on HIV/AIDS which will find cases, study the epidemiology, keep records and provide appropriate help and guidance to the patient, his family and the community at large. The committee should have representatives from all the sections of the society; medical, pharmaceutical, religious, political and social work/welfare organizations.
Worldwide, MDR TB (Multiple Drug Resistant TB) association with HIV is also a growing concern, considered a fatal combination by the international health community which is trying its best to contain, create awareness about and prevent the deadly duo from getting any further. In India, we have just the ‘tip of the iceberg’ information on that. And in our community, we know nothing about the combination because we do not know how prevalent HIV is and just how many has AIDS.
I, as a medical officer, presume lack of adequate finance, technical assistance and expert opinion as the major reasons why we still do not have a running program on HIV/AIDS. A running project needs continuous sums of money, expert opinions cost money and money is limited. Collaborative efforts with international HIV/AIDS volunteer service organizations or giving the complete initiative to such an organization would be wise and timely.
What about political will? HIV/AIDS is as much a social issue as it is a health issue.
What is the environment like at the level of the Assembly of the Tibetan People’s Deputies, our equivalent of parliament? Has it ever been on the list of issues of any ‘chithue’ (deputy/representative) during any of their biannual meetings? Not that I know of. What about discussions within our own medical community, both allopathic and Tibetan medicine and the Health Department? Where will bureaucracy end and genuine efforts start? Who will raise the first voice and become the scapegoat for the sake of the population at large?
When that HIV patient walked out of the OPD room that day, I felt uncomfortable with the information he gave me. I guess I had been waiting for that patient though. It was because I had not, personally, come across any Tibetan with HIV/AIDS and that whatever information there is came from the pandemic ‘outside of my community’ that I failed to think more about it as a Tibetan problem also. I guess every Tibetan is waiting for that one HIV positive Tibetan to cross his/her path to think seriously about the issue. And therefore, I have cause to worry for the community that I live in.
I have no solutions to offer but I hope that this would be a timely reminder for people, who wield the power and act as our representatives, to help clear a field where more discussions/actions on HIV/AIDS can take place. What is being done so far is a good preliminary, but HIV/AIDS is breathing next to us. Shouldn’t we be getting down together to see how big the giant is?
The 2006 IAS AIDS conference will be hosted by Canada. HIV/AIDS Confidential Discussion
In the coming weeks phayul.com will try a confidential health consultation for Tibetans with specific health concerns related to HIV/AIDS. The format will be a confidential e-mail question and answer exchange between the enquirer and 2 physicians, John Lambert MD and Yangchen Dolkar MD based in the USA.
All enquiries can be sent to firstname.lastname@example.org with the following disclaimer
The exchange is meant to be a way to provide health information to Tibetans who are interested in finding out more about HIV/AIDS. The e-mail does NOT
replace the need to consult with a physician and should only be used as a supplementary tool for educating oneself and as a way to get the latest, most accurate update on HIV/AIDS related issues. The discussion is a voluntary educational service of the aforementioned physicians and is not
sanctioned by any political organization or the Tibetan Government in Exile.
Please do not disclose your actual identity. All e-mails will be best kept confidential in this manner. Please keep your questions to HIV/AIDS related topics only.