Faltering Progress in Combating Infectious Diseases: India’s Record in Achieving Millennium Development Goals

LAST month saw the release of the India Country report for 2010, regarding progress made till date towards achieving specific targets in eight different areas, set by the United Nations in 2001 – known as the Millennium Development Goals (MDGs). The MDG targets are supposed to be achieved by 2015. While official pronouncements were an occasion to indulge in self congratulatory claims, a closer look at the real progress made, paints an entirely different picture. We examine here the claims being made and the reality as regards Goal 6 of the MDGs, titled: “Combat HIV/AIDS, malaria, and other diseases”.

HIV-AIDS: NO ROOM FOR COMPLACENCY

The 2010 India country report on MDGs states that: “However, the spread of HIV/AIDS in the country shows a downward trend: from 2.73 million (0.45 per cent) people living with HIV/AIDS in 2002, the number has declined to 2.31 million (0.34 per cent) by 2007. The prevalence rate of HIV infection in the country also seems to have stabilised over the last few years”. These figures are, at best, an educated guess based on surveillance data generated by the National Aids Control Organisation (NACO). We may recollect that in 2007 the estimate of HIV positive cases in India was drastically reduced from 5.7 million cases (as estimated then by UNAIDS) to less than 3 million. This reduction was not a consequence of any remarkable public health effort but because it was felt that earlier estimates were based on faulty data. The crux of the problem lies in the fact that data on HIV is estimated from that generated by surveillance centres, numbering just a few thousand. This again is a function of the moribund public health system in India, which is not geared to serve as medium of surveillance and treatment. The National Aids Control Organisation (NACO) has, as a consequence, built up a parallel structure that intersects very little with the government health system. In addition to the obvious problem of duplication of efforts, this means that data available on HIV in India has a narrow base and cannot be relied upon entirely.

The table below provides comparison with other countries in a similar situation (low and middle income countries where the HIV epidemic is characterised as “concentrated,” i.e. limited largely to specific ‘high risk’ groups) regarding availability of HIV testing and counseling services. In India one such centre is available per 1,30,000 population of people over 15 years of age. India continues to lag behind most countries in a similar situation, in spite of recent efforts to scale up the availability of counseling and testing centres.

Table: Facilities with HIV Testing and Counseling Services

Country	>15 population per   Testing and Counseling Centre
Niger	36,000
Senegal	21,000
Somalia	215,000
Cambodia	37,000
China	125,000
India	130,000
Indonesia	231,000
Nepal	107,000
Thailand	37,000
Viet Nam	203,000
Bolivia	21,000
El Salvador	6 000
Kazakhstan	3 000
Ukraine	13,000

Source: Towards Universal Access: Progress Report 2009, World Health Organisation

There has been significant scaling up of antiretroviral treatment (ART) availability but it still lags significantly behind requirement. The following table from NACO’s annual report for 2010 gives details of ART treatment access.

Table: People on ART in India

Persons registered for ART	8,93.567
Persons ever Started ART	4,37,435
Persons alive and on ART	2,94,900

Source: NACO, Annual Report, 2010 (Data Till January 2010)

Thus less than 50 per cent of those registered actually have been started on ART. More importantly about 33 per cent of those who started treatment have either died or not continued treatment (meaning that they are at risk of succumbing to the disease). Moreover, if we take the estimate of 23 million HIV positive cases as the baseline, we would expect that an excess of 7,00,000 patients would require to be on ART. In contrast, only about 40 per cent of them are receiving ART.

An emerging threat is the poor roll out of second line ART, i.e. treatment with newer (and more expensive drugs) for those who become resistant to the first line drugs. At present there are just 10 centres in the entire country that provide treatment with second line drugs. NACO reports that 2,750 patients have been referred for second line treatment and 970 patients are on such a regimen. This is a clear under-reporting of the requirement, and a large number of patients are being denied second line treatment because of lack of infrastructure and medicines. It is, furthermore, a problem that is likely to increase exponentially in the coming years.

To sum up, there is clearly little room for complacency. While significant progress has taken place in the last decade, India still sits on the brink of a generalised HIV epidemic. The claim that India is poised to meet its MDG targets vis a vis HIV is foolhardy and can disarm continuing efforts to scale up interventions.

MALARIA: VERY LITTLE PROGRESS

The Country Progress report of 2010 states that: “The incidence rate of Malaria and deaths due to Malaria in recent years show that while incidence of Malaria has declined … the percentage of deaths of Malaria patients has not declined”. Evidently this is not a very encouraging report! The official data indicates a marginal decrease in incidence with no significant decrease in the number of deaths. All mortality and morbidity data in India is open to being questioned, because of the poor state of the public health system, and its ability to carry out surveillance in any meaningful manner. This is particularly so in the case of malaria, where several reports and expert opinions indicate that actual incidence rates are 10 times or more higher than reported rates. Even scientists at the National Institute of Malaria research have commented on this in a paper published in 2007, stating: “It is now well accepted that the reported incidence of malaria at the national level on the basis of surveillance carried out in the primary health care system at best reflects a trend and not the true burden of malaria.”

In 1953 when a national eradication programme was launched, some 75 million malaria cases and eight lakh deaths were estimated to be occurring in India which then had a population then of about 360 million. With the eradication programme in full swing, incidence of the disease dropped rapidly. By 1965-66, there were just one lakh cases and deaths were completely eliminated. But malaria, instead of being wiped out from the country, made a comeback. After renewed efforts (in a period when the malaria eradication programme was renamed as the malaria “control” programme, reported incidence ranged between 2-3 million per year, and deaths reported were between 200 – 1,000 per year. As against this the MDG 2010 report indicates that between 2005 and 2008, the number of reported cases ranged between 15 and 18 million and reported deaths were between 10,000 to 17,000 per year. In other words, official data indicates that there has been a ten fold rise in the number of malaria cases and in the number of malaria deaths in this decade, as compared to the last decade! If we extrapolate the official data with the widespread understanding about under reporting, we are looking at 50-100 million cases in a year and 50,000 to a 100,000 deaths each year due to malaria. Even this may be an under-estimation — a paper published in the open-access journal PLoS Medicine, put the extent of disease caused by P falciparum (which currently accounts for about half of malaria cases) in India at about 102 million cases in 2007. Clearly, we are nowhere near a situation where we can claim that the country is on its way towards meeting its MDG goal as regards malaria control.

Of particular concern is the fact that about half, and in some districts a large majority (such as the forested areas inhabited by adivasis in the states of Orissa, Jharkhand, Madhya Pradesh and Chhattisgarh), of the cases of malaria are being caused by the most virulent strain of malaria – plasmodium falciparum. The emergence of falciparum malaria in such a large epidemic form has complicated malaria treatment, and in endemic areas conventional treatment with drugs such as chloroquine are proving to be virtually useless. Newer drugs, such as mefloquine and the artemisinin based combinations have been introduced. These are more expensive (Artemesinin is 20-30 times more expensive than chloroquine) and toxic and have made the treatment of malaria more complicated. After the introduction of Artemesinin, there are no new drugs on the horizon. There is a real threat that the widespread (and often unnecessary use of this last line drug) will lead to resistance, and the emergence of malarial super-parasites that would be immune to all available drugs.

TUBERCULOSIS: AT THE BRINK OF A RESURGENCE

Tuberculosis is a disease of poverty and poor environment. The developed world saw the eradication of TB in the 1920s (including in most countries in the entire continent of Europe) a good 15 years before the introduction of the first medicine to treat Tuberculosis. Yet about a quarter of a million people die of TB in India every year. India is clearly indicated as the Tuberculosis capital of the world – every fifth person suffering from TB in the world is an Indian.

There have been fairly impressive advances made in India in the last decade and a half, since the rollout of the Revised National TB Control Programme(RNTCP). As a consequence the number of deaths due to TB has halved, from about half a million to a quarter of a million each year. Much of this advance has taken place, not because of improved public health measures, but because of global technological advances – especially with the introduction of new ant-TB drugs that are more effective and have reduced the average duration of treatment from 18 months to just 6 months. However prevalence rates and the number of deaths due to TB remain unacceptably high.

Further, a new threat looms large. With widespread use of the new anti-TB drugs, we are witnessing the emergence of what is known as multi drug resistance TB (MDR TB). The present short course therapy is ineffective in MDR-TB and cure rates have generally been less than 60 per cent. Treating such cases can be extremely expensive – up to 10 times as expensive as with the short course therapy. A recent paper published in the Indian Journal of Tuberculosis estimates about half a million MDR-TB cases emerge every year amongst new and previously treated cases, with half being in China and India. Estimates for 2007 suggest that India has the highest burden of MDR-TB in the world, with 131,000 cases of MDR-TB. In India, MDR-TB amongst new cases is estimated at 2.8 per cent and amongst previously treated patients at 17 per cent. As long as the RNTCP does not offer easy and heavily subsidised (or free!) access to quality assured diagnostic and treatment services for MDR-TB, patients will seek unaffordable and inappropriate care in the private sector, which will result in further emergence and spread of highly resistant M/XDR-TB strains. There are thus indications that we are poised on the brink of a resurgence of a new TB epidemic unless steps are taken to remedy the situation.

GROSS NEGLECT OF PUBLIC HEALTH

The above situation needs to be seen in a context. India continues to be one of the worst performers in world as regards public provision of health services. The Indian health system is one of the most privatised in the world and government expenditure (as per cent of GDP and in real terms) one of the lowest in the world (see following table).

Per Capita Public Expenditure on Health (in ‘purchasing power parity’ US dollars)

Country	2000	2006
Bangladesh	7	12
China	42	88
India	14	22
Iran	143	344
Laos	13	15
Malaysia	151	242
Nepal	10	16
Sri Lanka	47	81
Thailand	97	170

It is no mystery, thus, why India is poised to miss out on achieving the targets set in the MDGs as regards health care. Only a sustained and incremental strengthening of the public health system can remedy the situation. Till then pronouncements of “achievements” will continue to obfuscate the real situation.