The great Indian AIDS crisis now looks a case of statistical blunders
and NGOs weaned on a share of the grants
DAVINDER KUMAR
The AIDS Lie In India
If the oft-repeated prophecy at every international health seminar and
countless entries in official directories of global funding and credit
agencies in the last few years were anything to go by, India should have
long become the aids capital of the world.
Thankfully, the predicted hiv holocaust hasn't come true and now experts
in the health sector are questioning the arbitrary manner in which
figures were arrived at by reputed international agencies. Union health
minister C.P. Thakur has even gone on record about the statistical
discrepancies: "I am at a loss as to how there can be so many different
estimates by different UN agencies."
Officials at unaids, the leading global body fighting hiv, admit to
statistical blunders in the past and blame it on human errors committed
at its Geneva office. Now, is it a coincidence that the errors seem to
be happening too often in India's case? However, the agency promises
that these will be rectified. Says Dr David Miller, country programme
advisor: "Estimation of figures in recent years has become a very
scientifically-based process in recognition of the need to have a
reliable estimate.
"I am at a loss to explain the different estimates," says health
minister Thakur. "We would rather be late and right than premature and
wrong," feels Dr Miller.
The agencies involved in the analysis of surveillance data are the
National Institute of Health and Family Welfare, the National Aids
Control Organisation (naco), who, unaids and some international experts.
In order to avoid confusion, we have decided to release a figure arrived
at by consensus."
Now that hiv estimates have come under a cloud, doubts are being
expressed about the projected enormity of the aids epidemic and the
wisdom of spending the Rs 1,450 crore earmarked by the government for
its prevention. Health activists are demanding that the government come
out with credible hiv/aids data. This demand is not without reason. Ever
since the first case of aids was reported in 1986, a multitude of
wavering figures and projections mapping the epidemic have been dished
out by the government-run naco and international agencies like unaids,
who and the World Bank, the key players in the fight against hiv. Here
are some of their inexplicable conclusions:
UNAIDS has in its epidemiological factsheets, brought out regularly
since '97, carried estimates of hiv/aids in India from '87 onwards. It
shows an incredible jump in hiv/aids cases from just one in 1986 to 5.19
lakh in 1987. No one's sure where these figures came from. Both unaids
and naco were non-existent at the time. Neither was any credible
surveillance system in place in
India.
The 73rd parliamentary standing committee report on dreaded diseases,
released in October 1998, put the number of those infected by hiv at
81.3 lakh. For the same year, the projection by naco and unaids was
40-50 lakh cases.
In September 1999, the figure of 85 lakh hiv/aids cases in India was
quoted in the UN General Assembly.
The World Bank project appraisal document for proposed credit for the
second phase of the national hiv/aids control project in 1999 made
sweeping assumptions about the spread of the disease and the means to
reduce it. One postulation was that one per cent of India's sexually
active female population is involved in commercial sex work.
In June and December 2000, unaids released hiv/aids data for India in
1999. It quoted 3.10 lakh aids deaths in 1999. The number of aids
orphans was 5.58 lakh. Both figures were subsequently deleted in the
revised update released in June 2001.
NACO figures are at extreme variance. Cumulative deaths due to aids from
1986 to December 2000 was
1,759.
After the confusion over various projections, the health ministry
introduced a new surveillance system in August 2000. The results were
startling. The national average for hiv prevalence fell from 2.2 per
cent to 0.35 per cent. Even more shocking were the revised figures for
Manipur which was till then the target of most hiv/aids campaigns. From
18 per cent (highest in the country), the hiv/aids prevalence rate for
the state fell to 0.4, one of the lowest in the country!
The erroneous calculations and faulty estimation has had a drastic
impact on government priorities vis-a-vis financial outlay for the
health sector. The aids scare meant that naco's campaign has been
prioritised above health programmes for diseases like malaria,
tuberculosis and kala azar. Even leprosy eradication has got
stepmotherly treatment.
The second phase of the National hiv/aids Control Programme currently
being implemented has a rich reserve of Rs 1,450 crore earmarked for it.
Most of this amount has been sanctioned as credit by the World Bank and
will have to be paid back from the public exchequer. Further, there is
an even bigger share of funds directly flowing into the country from
foreign donors to ngos.
Says Amit Sengupta, member of the Jana Swasthya Abhiyan—a network of
over 1,000 grassroots ngos in the health sector: "Manipulating the
figures suits both donor agencies and the ministry of health. The former
because it allows them to push loans to combat the 'problem'. It allows
agencies such as the World Bank to make domestic health policies
'captive' to their diktats and deflects criticism away from concerns
that health problems in countries like India have accentuated as a
result of the imf/wb-led economic policies. On the other hand, it is
convenient for the health ministry because it allows it access to large
loans."
There is also the bigger issue of the economics of combating the
epidemic. "If one is to believe the claim that there are 35 lakh
hiv/aids persons in the country, then annual treatment costs would
amount to Rs 16,100 crore, according to the World Bank. Obviously, there
is a vast market for creating the hiv/aids treatment infrastructure and
enormous potential for the multinational pharmaceuticals to sell their
drugs," says Purushothaman Mulloli of Joint Action Council Kannur
(jack), which is leading the agitation against 'fraudulent' hiv/aids
figures. Ramesh Sharma of the Gandhi Peace Foundation echoes the
sentiment: "The entire campaign is being driven by multinational forces
which are eyeing the huge market potential in the country."
Now consider the fact that unaids had reported 3.1 lakh aids deaths in
India in 1999—which it later deleted. Dr Miller has this to say about
the goof-up: "The mortality rate does need some scientific basis. We are
looking at a number of alternatives to arrive at some accurate number.
We would rather be late and right than be premature and wrong. We have
been working with naco to get the correct figures. First thing would be
to get the methodology straight and then derive figures based on that."
But naco officials blame unaids for projecting faulty figures. Notes Dr
Mohammed Shaukat, deputy director (technical), naco: "By the year 1998,
they (unaids) had calculated 41 lakh hiv/aids cases whereas our
estimation was 35 lakh. unaids has its own mathematical models and their
projections were based on mathematical guesses." If Shaukat is to be
believed, the estimation of 5 lakh infections within a year after the
first aids case was detected in 1986 by unaids could be at best
guesswork for "sero-surveillance figures till '94 showed only some
50,000 infections."
Says Rami Chhabra of the Independent Commission on Health in India:
"Flawed estimates in hiv/aids cases could result in scams of enormous
public expenditures, vindicated through proclaiming success in
'infections averted' when such levels are not scaled in the first place.
It is also leading to a scenario of fudged figures for 'sterilisation
and births averted' in the family planning programme."
According to Chhabra, the worst impact is being felt on the Public
Health Service (phs). "In the name of decentralized implementation,
brand new registered societies in states, union territories and
municipal corporations for hiv/aids have been formed. This
compartmentalises the whole issue and creates a parallel
infrastructure—highly resource-wasting and also less accountable," she
says.
The only positive step in the anti-aids campaign is that everyone agrees
that the figures in hand do not reflect ground realities. It is now for
the health ministry to give its official stamp to what are the actual
numbers.
outlookindia.com 02/25/02