NETHERWORLD
The best way to solve a problem is by empowering those most affected by it. Ashok Alexander’s book is about his journey into the world of HIV in India
Diseases change people. Smallpox marks you forever; diarrhea can ruin your social life; polio alters the way you walk for good. But in my years of working in health communication, the only disease I have come across that changes you even before you are infected is AIDS. The very thought of a virus that will lurk innocuously inside you, passing between bodies during their moments of greatest pleasure and eventually devastate both mercilessly is terrifying. Ashok Alexander’s transformation, detailed in his absorbing book A Stranger Truth, stems not from fear of HIV but his intense proximity to it. That started in 2003, when he left the venerable Mckinsey and Company upon the invitation of the Bill & Melinda Gates Foundation to start what would become the world’s largest single
HIV prevention project. Its name was Avahan, meaning ‘a call to action’.
People who have earned their stripes at Mckinsey are generally regarded as Masters of the Universe. Alexander himself admits that they “combine amazing cockiness with a certain deep sense of insecurity”. The cockiness probably comes from a belief that there is no problem in the universe that the Mckinseytrained mind cannot dismantle, analyze and then systematically solve. Alexander knew nothing about HIV and less about public health, but he felt sure he would find nothing insuperable about this new problem.
In A Stranger Truth, you will see a confident, dynamic and highly competent man wade into the dark netherworlds of HIV in the world’s most populous and sexually repressed democracy, and discover demons and verities there that Mckinsey had never prepared him for. It is a journey marked in turns by discovery, almost touristy incredulousness, humility and awe. Alexander, as chief honcho of Avahan, wanted to see, touch, feel and understand the deepest darkness and daily savagery in the lives of commercial sex workers, men who have sex with men, injecting drug users and truck drivers, the four groups assessed to be most at risk of HIV and also most likely to be its main vectors of transmission. Avahan concentrated on the six Indian states where HIV prevalence was the highest in India — Nagaland, Manipur, Andhra Pradesh, Tamil Nadu, Karnataka and Maharashtra. The focus was on 83 districts in these states, covering hundreds of towns. Numbers showed that two in three people at greatest risk in these states were not being reached by any intervention. Enumeration has always been a thorny issue in AIDS. Claiming giant populations at risk and tremendous odds against achieving quick results have been common NGO strategies for seeking generous and sustained funding. Avahan was wellknown for its low tolerance of inefficiency and inertia. Where numbers are concerned, Alexander is mostly scientific and careful, but I did pause a moment when he claimed that there were 100,000 transgenders in India. How on earth does one count transgenders when the census forms only provide for male or female?
The book is the work of a man who misses no detail, almost as though he’d anticipated that one day he’d be writing this book. From the “array of slightly offbeat sodas” in a fridge to a happy tail-wagging puppy half of whose head had been eaten up, the writing puts you squarely in the surreal streets where desperate people live in a furtive twilight zone of risk and secrets, driven to acts and choices that propel them into violence or death, sometimes sudden, sometimes lingering.
It is not a recognizable India.
There is Manipur’s Danny, abandoned as a baby by his grandparents after both parents perished from AIDS caused by injecting drugs with infected needles. You meet Kamla, married at 15 to a man who disappeared two years and three infants later. As she is hammered and raped by five men after being paid Rs 20, all she can think of is whether her baby would have been eaten by a street dog by the time she returned.
There was a moment during Avahan when Alexander outgrew Mckinsey and began to realize that “it was not we who could provide a solution, it was the consumer herself because she was the one who lived with the problem”.
“The answer lay in saying those words that never would have come to my lips earlier,” he writes. “I don’t know how to do this. How should we go about it?” For a Mckinsey man to say these words is almost sacrilege.
If there is a trap that I wished Alexander had avoided, it would be the canonization of the sex worker. Over the centuries, qualities such as wisdom, insight, compassion and sensitivity have been ascribed to members of the world’s oldest profession. Alexander detects extraordinary leadership skills in them. “They exercise leadership in the highest sense of the word,” he writes, “and with a combination of attributes I have rarely seen in business leaders.” It is true; some sex workers are born leaders, but then so are some coal miners, construction workers and dabbawalas. The same rough lives leave some of them calloused and spiteful and others tender and empathetic. Most of them are deeply disempowered, and many others use humour and cynicism to deal with the jagged edges of daily life. To paint them all as leaders seems like an unnecessary glossing of the brutal reality the rest of the book unflinchingly describes. In part two, the focus shifts to a single flagship project, Ashodaya. The programme still exists and has become a global learning site for those trying to navigate the numbing currents and undercurrents of HIV prevention. And it was from Sushena, one of the workers of Ashodaya, that Alexander hears an enduring lesson of public health. The Ashodaya way of working, she said, was “very simple”. “Trust and compassion spread like wildfire. They scale up very easily.”
It is a long pilgrimage for a man to come from the dizzy heights of scientific certitude to acknowledge that measurable change is finally the work of human hearts and caring hands.