In Churachandpur in Manipur, 50-year-old Mimin Haokip has made multiple visits in the last three months to the nearest antiretroviral centre in the district hospital for the monthly stock of free HIV medication. Grappling with a shortage, the centre could only dispense medicines for a few days and has been asking him to return.

Haokip is infected with human immunodeficiency virus, or HIV. It can cause the acquired immune deficiency syndrome, or AIDS, which weakens the immune system. He requires third-line medication every day to keep the viral load in control. Third-line medication is the most potent combination of drugs that a patient can be put on after they fail to respond to first-line and second-line treatment.

“Earlier, I would get medicines to last a month,” Haokip said. “Now I get medicines for 10 days and then I have to return for more.” The centre has no stock of Darunavir 600 mg, used for third-line treatment.

Haokip also requires a viral load test, to measure the viral load in his blood, and a CD4 test to measure his immunity levels. But the machine that carries out the CD4 test at the Churachandpur Hospital has broken down while the viral load test cannot be undertaken since the samples have to be sent to a government laboratory in the capital Imphal. “Which is impossible at this point,” said Reuben Pauneilian, counsellor at the antiretroviral centre.

Since May, Manipur has been wracked by ethnic violence between the majority Meitei community and minority Kuki-Zo groups in the state. Three months on, and 190 deaths later, the volatile situation has resulted in an unofficial partition of the state with the Meiteis residing in Imphal Valley and the Kuki-Zo groups retreating to the Manipur Hills.

Supply lines to the Manipur Hills pass through a buffer zone between the two communities where firing is reported nearly every day, making it difficult to transport essentials, including medicines, from Imphal.

Kuki-Zo groups allege that Meitei-dominated mobs are disrupting the supply of essentials to the Manipur Hills. The state government, however, says the transport problem has been resolved and claims that there is no shortage of HIV medication.

But on the ground, a medical crisis continues to unfold.

Low stock, disrupted supply

With 28,500 HIV infections, Manipur accounts for 1.04% of HIV cases in India, even though the state makes up just 0.24% of the country’s total population. According to the National AIDS Control Organisation, Manipur has 36,955 people in the high-risk group vulnerable to HIV infection who require close monitoring. But their monitoring has faltered since the ethnic violence broke out.

HIV patients require anti-retroviral medication every day depending on their viral load. These medications are available for free at government-run antiretroviral therapy, or ART, centres.

Under normal circumstances, HIV patients are provided with a monthly stock of medicines. Stock, then, must be replenished to keep pace with the needs of patients.

But the Churachandpur antiretroviral centre last received medicines from the Manipur State AIDS Control Society on June 24. “After that no supply has come,” Pauneilian, the counsellor at the centre, told Scroll in mid-August. The official in charge of the centre, a Meitei, had fled to Imphal in May.

There is no stock of Lopinavir 40 mg and Ritonavir 10 mg tablets that are required for children. “Since the stock is over, we are breaking adult tablets into half to give to children,” said Pauneilian.

The hospital has also been struggling with a shortage of hepatitis C medicines, often required by HIV patients who contract a hepatitis virus co-infection due to poor immunity.

Pauneilian said he has contacted the State AIDS Control Society to transport the stock with the help of the Assam Rifles. “The deputy director [of the State AIDS Control Society] said he is trying,” he said. “The principal secretary has also been notified about this.”

Credit: Reuters.

Some ART centres in the Manipur Hills have had to rely on the neighbouring state of Mizoram to supply medicines. A senior official from the Mizoram State AIDS Control Society, told Scroll that they had received a request from Churachandpur to supply HIV medicines in June.

The official said permission was taken from the National AIDS Control Organisation to transport medication till the Manipur border. “From there, the Churachandpur centre sent a vehicle to collect the medicines,” the official said. Mizoram borders the southern part of Manipur.

The Mizoram AIDS Control Society official said the situation remains volatile and despite multiple attempts, “even security convoys are not able to transport medicines”. “These are life-saving drugs and HIV patients need them daily,” the official said.

On July 28, the Indigenous Tribal Leaders Forum flagged the shortage of the medical supplies in Churachandpur. In response to the group’s appeal, the Mizoram health ministry transported medical supplies worth Rs 5 lakh. The forum on August 18 issued a notice saying that the supplies had been received.

Ginza Vualzong, one of the leaders of the Indigenous Tribal Leaders Forum, said the conflict has made it difficult for life-saving medicines to be transported from Imphal to the Manipur hills due to multiple blockades on the highway.

National Highway 2 connects the Kuki-Zo inhabited hill district Churachandpur, which lies in the southern part of the state, with capital city Imphal. The distance between Imphal and Churachandpur is about 65 km, but due to violence, the region between the hills and Imphal Valley has become a buffer zone with daily firing reported.

Supply lines to the Churachandpur Hills pass through Meitei-dominated Bishnupur district. There have been multiple instances of Meitei mobs intercepting supplies to Churachandpur, say health activists working in the Manipur Hills. Meitei health activists, however, say that the supply of medicines is not being stopped.

Last week, the 36 Assam Rifles transported a medical consignment to Churachandpur by chopper. But that is not always an option.

Supply hampered since May

Jangkholam Haokip, president of Bethesda-Khankho Foundation that works towards sustainable community development, said the Kuki-Zo tribes are dependent on Imphal for their medical needs. “Several HIV patients would travel from Churachandpur to Imphal to get their monthly HIV medicine stock,” he said. Some would travel to get their regular viral load and CD4 test done. With the conflict, “no one can dare to go there”, he said.

Across India, patients often prefer visiting nodal ART centres where they are guaranteed better diagnostic facilities and medication availability. For instance, an ART centre in a remote area may not have one or two of the full regimen of required medicines.

“We tried to connect patients with the nearest ART centre since they could no longer visit the ones they were registered in,” said Olivia Chingboi, who works with a local non-profit in Chandel district. “But since we have not gone to our office for a month due to the violence, we are not in touch with many patients.”

Chingboi said antiretroviral medicines remain in short supply in Chandel district, Tengnoupal and Moreh town, all Kuki-majority hill areas.

Jangkholam Haokip said the supply of medicines from Imphal has been a problem since the ethnic violence broke out.

He said that while he was raising money in May to procure medicines for the local community, he came across a family of three, all HIV-positive. “They were unable to get medicines locally,” he said. “Finally, they travelled to Aizawl to get it.” Aizawl is the capital of neighbouring Mizoram.

In July, Jangkholam Haokip said that he had to gather funds from the local community to place an order for antibiotics, pain killers, multivitamins and several drugs in Kolkata. The stock reached Aizawl in Mizoram from where it was transported to Churachandpur via road. The journey by road from Aizawl to Churachandpur takes 12-15 hours.

Supply of medicines in antiretroviral centres in Imphal remains smoother. The State AIDS Control Society is located in the capital and gets a direct supply of medication from NACO which is then distributed to districts.

“The government is not sending us medicines,” said Jangkholam Haokip. “If this is not politics, then what is?”

Limited efforts to break impasse

Haobam Nanao, who is attached with Family Health International and works in HIV relief, said Meiteis in Imphal are not stopping the supply of medicines. “As part of the humanitarian effort we are sending medicines and providing unconditional support to Kukis when it comes to health supplies,” Nanao said.

He said that there are blockades on the national highway which connects Imphal to Churachandpur, and medicines may be getting stopped there by the Meira Paibis, a collective of Meitei women who fight for community rights.

The Meira Paibis have been patrolling Meitei-dominated regions, blocking highways and intercepting vehicles carrying supplies to the hills. Though, it was not clear if the Meira Paibis were targeting medical supplies in particular. Army security personnel have alleged that the Meira Paibis have disrupted peace-keeping efforts as well.

A Meitei health activist who works with a group of HIV-positive people in Imphal alleged that the Meitei women have been blocking highways and inspecting vehicles.“Even Assam Rifles are unable to transport medicines from Imphal to hills,” he said.

On August 20, media reports said that medical supplies for routine immunisation enroute to Kangpokpi district north of Imphal were stopped at Sekmai, close to the capital. All supplies for Kankpokpi were identified and destroyed.

But Dr Hemlata Thokchom, additional project director at the Manipur State AIDS Control society, told Scroll there is no shortage of HIV medication across the state. “We have resolved the transport problem,” she said, refusing to comment on the allegations that the supply of medicines to the hills was purposely being blocked.

Conflict divides health community

The conflict has divided the health community as well.

On July 28, AIDS activist Loon Gangte gave a fiery speech calling for the splitting up of Manipur, at an event organised in New Delhi’s Jantar Mantar by the Kuki-Zo groups.

Gangte is the regional director of International Treatment Preparedness Coalition South Asia and the founder of Delhi Network of Positive People.

Jogesh Maibam, convenor of Manipur Users Collective, said that Gangte’s speech instigated Kukis against the Meiteis. Maibam said Gangte’s partisan stance was “unbecoming” as someone working for a “noble humanitarian cause”. “His act of declaring his thoughts on a public platform in total disregard of his work ethics and the established law of land is extremely condemnable,” said Maibam.

The Imphal police station has registered a first information report against Gangte under Section 153 A and 505 for promoting enmity between religious groups.

Gangte told Scroll that he has received no official communication from the Manipur police about the FIR. “This is the trend. They (Meiteis) are filing multiple FIRs against us for making statements about the conflict,” Gangte said. “Nobody is talking about the lack of ART supply to HIV patients.”

Nanao of the Family Health International said that animosity is generated when health activists make controversial remarks. “A person of his [Gangte’s] stature should refrain from such communal tone,” he said.

Meanwhile, in Churachandpur, Jangkholam Haokip of the Bethesda-Khankho Foundation, said he has requested doctors from the Christian Medical College in Vellore to visit local camps. “Two physicians from CMC will be travelling here to treat locals,” he said. “Soon, in a few days.”

With inputs from Rokibuz Zaman.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.