"Unreliable figures and statistics on public health are not new in India, and field workers have long complained that they are being manipulated to support policies or programs being pushed by certain groups.

"But inflated statistics for the HIV/AIDS program stick out because of the vast funds available, while money for pressing public health problems are conspicuously missing."

-- From "Dark Ages return to plague India," AsiaTimes

NEW DELHI
When Indian Health Minister C P Thakur confirmed that pneumonic plague had killed four in northern Himachal Pradesh and Uttaranchal states, he touched off concerns about India's readiness to combat communicable diseases and the state of its public health system.

As with the plague outbreak in Surat in 1994 that left 500 people dead, fingers are being pointed at the government. The Hindu newspaper on Monday cited unnamed public health experts who said Himachal Pradesh, a known focal point for plague, had dismantled a surveillance system for the disease some 10 years ago because of a lack of funds. According to the Indian Express, former NICD director K K Datta admitted that Himachal Pradesh was not as prepared as it could be for plague. "Creating an extensive disease surveillance network for monitoring of diseases is one of the most important long-term measures in countering outbreaks," he said.

But while the government remains the most convenient villain, figures show that India in fact has increased its health-care spending over the years. According to the World Bank, India spent 6 percent of its gross domestic product (GDP) on public health in 1990, the equivalent of 320 rupees per capita; in 1993, it spent 334 rupees, a high proportion of GDP in comparison with other Asian countries, which spend between 2 and 5 percent of their GDP on health. And among members of the Organization of Economic Cooperation and Development, Canada, for example, spends only 7 percent of its GDP on public health.

However, quality-of-life factors such as infant mortality and life expectancy in India rate relatively poorly in comparison with many other countries. These discrepancies are blamed on the fact that the government's share of total health spending amounts to a mere 25 percent, with out-of-pocket expenses taking an enormous part of the burden (meanwhile, the Canadian government spends as much as 70-90 percent, and Southeast Asian governments 50-65 percent), according to the WHO. Additionally, India appears to be the exception to the rule that as countries get richer, they tend to spend more of their income on health care. Meanwhile, the government spends only a third of its health budget on such preventive health-care measures as immunization and prenatal care, as opposed to two-thirds in China and Sri Lanka.

Despite relatively swift development, India, where there are 2,460 inhabitants for every doctor, still faces a grave health problem, with the incidences of communicable diseases rising and an increase in the frequency of epidemics in different parts of the country. The Indian government has already been initiating health-system reform via privatization and cuts in public health-care spending in accordance with World Bank prescriptions. But Indian health expert K Rajasekharan Naya warns that this process could seriously affect the health system's ability to respond to communicable-disease outbreaks.

India's health system, then, needs more than a little fine-tuning. But the need to reform, combined with following World Bank advice to make the system economically viable, has put the Indian government in a difficult position. And then there are questions about the statistics themselves. Thakar expresses exasperation at suggestions that his Health Ministry, and the World Bank, benefit from inflating figures on communicable diseases, such as those recently used by the Joint United Nations Program on AIDS (UNAIDS).

UNAIDS said 4 million Indians had died of AIDS in 1999, an estimate Thakar said was incorrect, since only his ministry and the National AIDS Control Organization (NACO) have the machinery to gather and publicize the right statistics. UNAIDS country representative David Miller sheepishly admitted that they were looking at alternative ways to come up with more accurate figures. However, the government's information-gathering machinery also seems to be having problems: recently, the Health Ministry scaled down its 1998 estimates of people infected with AIDS from 8.1 million to 3.8 million.

But others charge that people are taking advantage of people's ignorance for their own ends. According to Purushottaman Mulloli of the Joint Action Council, which leads a group of health and human-rights non-governmental organizations (NGOs), the statistics are being deliberately skewed in a way that helps both the World Bank and the Health Ministry, but is to the detriment of real and pressing health concerns. "The people who run the Health Ministry now have access to large loans from the World Bank and in return, the Bank gets to interfere in India's health policies in a way which would not have been possible a few years ago," Mulloli said.

Mulloli said that if 4 million people in the country are actually infected with the human immunodeficiency virus (HIV), then annual treatment costs would run into several billions of dollars. This would create a huge new market for the pharmaceutical industry, while basic public-health issues fall to the wayside. NACO itself launched a pilot project in the national capital this month to try out the efficacy of zidovudine (AZT) in preventing mother-to-child transmission of HIV, although mechanisms for administration and close monitoring of ante-natal cases are missing. According to a member of the Independent Commission on Health in India, flawed estimates in HIV/AIDS could result in "enormous public expenditures and claims of averted infections when such high levels of infections never existed in the first place".

Others, such as Amit Sengupta of the Jana Swasthya Abhiyan (People's Health Movement) and Ramesh Sharma of the prestigious Gandhi Peace Foundation, are seeing a deeper, bigger game in what they say is the apparently undue emphasis given by the Bank and the UN agencies toward containing HIV/AIDS. "This is an attempt to recolonize this country," said Sharma. "Last time they came in with weighing scales saying all they were interested in was trade - this time around they are coming in saying they want to fight HIV/AIDS."

Meanwhile, others blame the NGOs themselves. "There are scores of NGOs which exist on paper and have made a fortune out of the AIDS scare. Go to anyone who knows the situation in Manipur and the northeast," said Sanjoy Hazarika, a well-known writer from the northeastern region. Hazarika has suggested that the rise in the number of HIV cases in Manipur (which dropped from a high of 18 percent to the current 0.4 percent), as projected by NACO for several years, has more to do with generous funding coming in from international organizations than with actual infections.

UNAIDS said 4 million Indians had died of AIDS in 1999, an estimate Thakar said was incorrect, since only his ministry and the National AIDS Control Organization (NACO) have the machinery to gather and publicize the right statistics. UNAIDS country representative David Miller sheepishly admitted that they were looking at alternative ways to come up with more accurate figures. However, the government's information-gathering machinery also seems to be having problems: recently, the Health Ministry scaled down its 1998 estimates of people infected with AIDS from 8.1 million to 3.8 million."

Unreliable figures and statistics on public health are not new in India, and field workers have long complained that they are being manipulated to support policies or programs being pushed by certain groups. But inflated statistics for the HIV/AIDS program stick out because of the vast funds available, while money for pressing public health problems are conspicuously missing. This is evident, for example, in the neglected state of primary health care centers. And NACO's high-profile second phase, which has more than US$350 million worth of loans available to it from the World Bank alone, has certainly dwarfed programs for ordinary tropical diseases that continue to kill people including malaria, tuberculosis, and kala azar.

That discrepancy may have manifested itself in the most recent outbreak of plague in India. Yet because the incubation period is 2-7 days, experts say they are sure the disease has been contained. "There is no need for panic as no new cases have been reported beyond the incubation period of the disease," Dr Pallab Ray, associate professor at the Post Graduate Institute of Medical Education and Research (PGIMER), was quoted as telling reporters in Chandigarh. The WHO echoed official assurances. Thakar also ruled out any possibility of a bioterrorism attack, reported the Indian Express.

On Monday, the director of the PGIMER at Chandigarh, S K Sharma, said the symptoms of nine patients placed under his care indicated a pneumonic plague-like illness, but he preferred to wait for final identification through "molecular characterization". One of the nine patients being treated at the PGIMER, a woman named Anu Devi, died on Sunday, while at least five others are being treated at other centers for the disease, which broke out in the Rhoru district of Himachal Pradesh.

Indian government officials are adopting what they called a "presumptive strategy". Therefore, the government's acknowledgement of the disease as a "plague" will not change its policies in treating those infected. Immediate steps involve quarantining the affected areas, isolating patients, providing antibiotic cover for at least one week, and educating the public.

The disease has so far claimed at least four lives - two in Himachal Pradesh and two in Uttaranchal. In all, 15 people have been undergoing treatment for plague since the first reported case in Hat Koti village in the Shimla district, including nine admitted at the PGIMER.

Tablets of tetracycline, the drug of choice against plague, are being distributed in Rhoru and nearby Jhubal village. News reports from the two remote Himalayan villages, about 100 kilometers east of Shimla, a well-known tourist resort and capital of Himachal Pradesh, spoke of hundreds of panic-stricken people flocking around public health centers and small medical facilities demanding tetracycline tablets.

Both Rhoru and Jubbal villages have been placed under quarantine. Educational institutions have closed down, although no new cases have been reported since Saturday. The symptoms of pneumonic plague, which is spread through the air and therefore considered highly contagious, includes the rapid onset of fever, chills, headaches, malaise, prostration, and nausea. Plague is also manifested as bubonic plague (the "Black Death" of medieval times) in which the lymph glands in the armpits, groin and neck swell, and also as septicemic plague.

(Asia Times Online/Inter Press Service; February 22, 2002)

Technorati Tags: