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Journalism of Courage
Panic buttons have been pushed the world over to initiate action against the killer disease. But in India, agencies are still quibbling over the number of AIDS patients in the country. The National AIDS Control Organisation NACO 8212; the nodal body for monitoring and carrying out surveillance of the disease 8212; puts the number of AIDS cases in the country at 3,551 and the HIV-infected persons at 56,000. According to the World Health Organisation WHO estimates, however, there are not less than half a million HIV-infected persons in India. And the number will spiral up to five million in the next three years.
Experts say the real number lies somewhere in between. But they all agree that NACO has failed to achieve its aim 8212; of spreading awareness and taking preventive steps. NACO was set-up in 1987, under the Ministry of Health and Family Welfare with a soft loan of 84 million from the World Bank. Trapped between the local needs of the country and the stringent guidelines laid by the World Bank WB and WHO, NACO has been unable to define its own work area or even to come up with an effective surveillance system.
Under Sentinel Surveillance, a few groups are chosen as markers and the incidence of HIV infection in those is taken as an indication for the whole country. 8220;There is nothing wrong with the Sentinel Surveillance method, in the way it has been designed, but it is not being implemented properly,8221; says Dr L.M. Nath, former Director of All India Institute of Medical Sciences AIIMS and head of community medicine. He is also a member of the international organisation, Monitoring of AIDS Pandemic MAP and a consultant with WHO.
For the correct picture, he says, a similar group has to be tested every few years so that it can be estimated whether the incidence of infection has gone up or not and a trend established. But it is not done. Dr Nath adds that NACO also does sero-surveillance and gets monthly reports from 62 centres all over the country.
8220;But even these reports are open to incorrect interpretation and is epidemiologically badly designed. The drawback of this method is that it does not define methodology, that is, who is to be tested. For example, at one time, they may decide to test a group of nuns and the next time, a group of commercial sex workers. The results are bound to vary drastically as there are no denominators,8221; he says.
Even the WHO officials have repeatedly said that the data on AIDS cases and HIV positive patients has no denominators which causes problems in monitoring.
And even after a decade it still grapples with utilisation of funds. In its report, NACO admits: 8220;Expenditure has been less than expected, partly because programme implementation was delayed, partly because many states are not carrying out the AIDS-related activities for which these funds are earmarked.8221;
But the undoing of NACO, according to experts, is that it has been given more responsibility than it can handle 8212; everything to do with AIDS and its prevention, including funding of the NGOs. With the formation of NACO, the implementation of entire National AIDS Control Programme NACP, hitherto under the Director General Health Services, was entrusted to it. NACO was also given the responsibility of carrying out research on AIDS, the sole domain of ICMR.
It was also supposed to bring about collaborative effort among the various agencies. NACO was to function as a multi-sectoral body involving other ministries 8212; Welfare, Youth, Railways, Human Resource Development, Information and Broadcasting, Labour and Defence 8212; in the AIDS prevention programme. It was to coordinate efforts of experts and NGOs, and take steps on all issues relating to the spread of the virus.
The problem, according to Dr Nath is that NACO has failed to make up its mind about its role, whether it is simply supposed to be guiding the AIDS control programmes or controlling them completely. He says it is essential that NACO decide only to provide the basic guidelines in AIDS control.
8220;NACO has taken upon itself all AIDS-related activities. It has a major human resource constraint. How can half-a-dozen people sitting in Delhi effectively monitor what the AIDS cells in the States are doing. And health being a State subject, NACO can only expect the States to cooperate,8221; he says.
At present, he adds, NACO has various roles at different levels. 8220;At the international level, NACO has failed completely in clearing the warped impression about the AIDS situation in India. It does nothing when the country is wrongly called the AIDS Capital of the world. NACO must counter this impression.8221; A major problem with NACO, says Dr Ramalingaswamy, is its ineffective Information, Education and Communication IEC programme, the mainstay in controlling the spread of AIDS.
8220;NACO8217;s IEC strategies must be greatly improved. NACO needs to adopt a multiple approach, targeting different groups in different ways the educated, the labour work force, defence establishment and schools,8221; says the former ICMR director general, stressing that 8220;it is not merely a ministry of health responsibility8221;.
Additional secretary in the Ministry of Health and project director of NACO J.V.R. Prasada Rao agrees but says everything cannot be left to the Government. The involvement of the community is a must in tackling the disease. He shrugs off criticism of NACO and says that 8220;in any disease control programme, criticism is bound to be there8221;.
He admits that 8220;the surveillance system is very patchy and addresses only the high-risk groups like commercial sex workers and drug users8221;. He recognises the drawback. 8220;The surveillance system has to aim at the general public and also remote areas and villages. We are going to undertake a countrywide survey to get a more realistic picture of the disease,8221; says Prasada. The problem was the same with the IEC programme 8212; it was concentrated in cities and high-risk groups. 8220;The entire IEC strategy is undergoing a change and becoming more focused. There will be more use of audio-visual media and folklore in the villages. Intervention programmes will also be started. Merely putting posters is not enough,8221; he admits.
Explaining the intervention programme, Neelam Kapoor, incharge of the IEC at NACO quotes the example of commercial sex workers. 8220;This will mean much more than just spreading awareness about the disease. We will provide the sex workers with condoms, referral facilities, counselling about sexually-transmitted diseases and also testing facilities. This is a major shift from the initial strategy of merely spreading general awareness,8221; she says.
Prasada adds that the problem with AIDS is that it is still considered the 8220;other man8217;s disease8221;. And with a total staff of 25 people, which includes the office and clerical staff, Prasada feels NACO cannot be expected to do much. On the issue of the non-utilisation of funds Prasada says, 8220;there was a problem initially but last year 1996-97 we spent Rs 115 crore which was more than the sanctioned budget of Rs 100 crore. Even for the current year, I have asked for Rs 125 crore against the Rs 100 crore sanctioned amount.8221; In the next phase, beginning mid-1998, Prasada will lay stress on the Research and Development Ramp;D component, hitherto totally ignored by NACO.
8220;Trials of new drugs, new vaccines and indigenous systems of homoeopathy and Ayurveda will be carried out. The ICMR and the National AIDS Research Institute will be the focal point of all Ramp;D activities,8221; he says.
