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 figure
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 aid 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 figh 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 (highes 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 figure 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 thei
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 abou 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 estimatio
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.