Biologically, the difference between you and me is 7 or 8 layers of skin. In other ways, it’s not that much more profound.

Today was our first day at Sahara Michael’s Care Home. We got a really good intro to Sahara’s programs (one of which is last Monday’s transgender drop-in center/clinic site visit) and I’m really impressed with all of them. There’s socioeconomic empowerment, emotional counseling, and a host of other details that run the gamut from individual to social-ecological health promotion methods. What was most inspiring to me was the fact that both of the people who gave us the grand tour and briefed us on the care home (Francis and Philip) were former patients themselves—injected-drug users (the clinic caters mostly to IDUs who are HIV positive) who found just what they needed to get their lives back on track at Sahara. Interacting with affected people these past few days, and meeting rehabilitated, dedicated health workers (92% of staff are former clients), it hit me how little separates me from a high-risk, HIV-positive person. Physically and mentally, we’re made of similar stuff. It’s not about how low you go, or how much you mess up. It’s about how you come out of it, how you move on.

Sahara’s programs are truly comprehensive—they reach out to the most marginalized groups of society (IDUs, transgender MSM, street children, trafficked women). And they don’t just offer medical services. They emphasize spirituality, mental health services, family therapy, skills re-training and income generation programs, too. It was interesting to hear Francis and Philip talk about the barriers they face in doing their work….unexpectedly, some important global health issues came up.

Funding is a big issue not just for Sahara but for all health programs in India. As a developing country, it has relied inordinately on donor agencies who are starting to phase out (or actually already have phased out) their financial support for projects like Sahara. One donor agency stopped funding on June 1, just a couple days ago. This means fewer beds, lower salaries (staff at Sahara haven’t been paid for 4 months), and less food—recently, a local donor had to come in to provide meals. Where is the donor agency funding going instead? They see India advancing, health workers everywhere in Delhi tell us. It’s going to Africa now.

Another big challenge is stigma and discrimination, of course. Just yesterday, two people from the care home expired. They died in government hospitals at the ages of 20 and 25. Their bodies were still in the morgue today, because family members didn’t want them. Even in death, when they’re no longer alive to be HIV positive, they are still shunned. They don’t have anyone when they come to Sahara, so staff members don’t have families to partner with in caring for clients. They’re on their own, and it’s up to these ex-addict health workers to provide a little bit of everything that their broken patients need.

Health professionals are one of the most dangerous groups, in terms of perpetuating stigma. Their discrimination does more damage than the rest. Three years ago in the clinic, a patient was dehydrated and needed an IV drip to be started. There was a nearby doctor living in the community so they called him; apparently there were no medical staff on call at that hour . He was asked to wear gloves in the process, but he said no, it’s ok, this is my daily job. Afterward, he was sitting with the staff at Sahara chatting, and came to know the patient he had just treated was HIV positive. He threw a fit, raising his voice, arguing, and washing his hands with urgency. A doctor.

While Sahara provides skills training for clients so that they can eventually reintegrate into society, one of the toughest aspects of this kind of work is that many times the cycle of outreach, detoxification, rehabilitation, skills training and job placement repeats itself. IDUs are a very sensitive bunch, Philip told us. They feel self-stigma because of their life. Even more important, it is really hard for a chronically ill person to hold down a steady job—with treatment and opportunistic infections, a lot of time is taken off work, and the client can’t explain why without facing stigma or being fired…all of this makes successful reintegration a big challenge.

Sahara gets no funding from the government. In fact, government services are so poorly planned in comparison that patients can’t get what they need there and come to the care home instead. The quality of care is so much better. At government-run establishments, HIV testing is a crude process, and HIV positive patients are directed in an assembly-line fashion to the queue for free ARVs (first-line treatment only).

Dr. Deep Gupta, the medical director, also gave us a really informative overview of broad issues in treatment options for HIV/AIDS. While developed countries have 4 or 5 ARVs to work with, fewer are available in countries like India. They also start treatment with ARVs later in India, at a CD4 count of 200 rather than 400. This is because of resistance, viral mutation and of course the Bottom Line: cost. When you have fewer ARVs to work with, they must be started later on in the disease progression to guard against patient resistance, viral mutation, and the cost of being on ARVs. HIV is an RNA virus, which not only has a higher rate of mutation (rendering ARV cocktails less effective) but it also replicates faster. There are positives and negatives to waiting until the CD4 count is so low; on the positive side, ARVs do have toxic side effects so not being on them for a long time is a good thing. Managing the health care problems that arise from being on ARVs is mentally, physically and financially draining. On the negative side, starting ARVs late in the game means that the HIV positive patient is more prone to opportunistic infections which must be constantly managed. This also taxes resources though; we’re talking about a developing country with a billion people in it. This is an interesting debate that points out fundamental differences in how health care systems are run in the US and India.

What else happened today: the Gujjars finally got what they want by planting bombs in buses in Delhi. As a result of all the ruckus, we rode home to Vasant Kunj from the care home in an ambulance. But whoever said bombs don’t distinguish between rich or poor was wrong as far as today’s violence goes. The kind of people who take buses in India are of low to middle socioeconomic status; those who are “well-off” have their own vehicles. So the people in the three burning buses today were at a disproportionate risk for terrorist acts. Disparity, disparity, disparity. But it seems that the government has come to an agreement whereby the Gujjars will get what they’re asking for (Scheduled Tribe status)…that means we might be going to Mewat on Thursday, and Jaipur on Saturday! Lesson for other tribes: violent protesting in the capital city might get Parliament to give you what you want...