AIDS’ first casualty in India: Truth
A few days ago, I came across the BBC new story on why the numbers for AIDS patients in India may be an overestimate: India ‘overestimates’ HIV/Aids” (Wednesday, 13 December 2006).
The study suggested that “methods used to estimate the number of people infected by HIV/Aids in India” were “flawed and the actual number of cases may be far lower”. The survey of blood samples reported by British journal BMC Medicine suggests the true figure may be 40% of that.
Now, a lot has been written about how an AIDS epidemic could tear apart India’s hopes and dreams of a developed and advanced nation.
So the report not only gave hope to optimists like me but also revealed how the hunger for publicity and sensationalism sometime gets the better of researchers and scientists. E.g. it appears that the “nationwide” figures that had widely been quoted were actually an extrapolation of a study conducted in (just) one district in South India. Not just was the extrapolation done on the basis of a single district’s figures but the district chosen was one of the also “worst-hit by the infection”.
Then, I stumbled across Tosh Sheshabalaya’s report on this subject, Of AIDS, Indian disasters and Apple IIe mindsets.
Tosh presents a very different reality which once again proves how sensationalism often gets the better of accuracy and balance in the chase for headlines.
Some excerpts:
“In the late 1980s, when I headed a team writing market researcher Frost & Sullivan’s first report on AIDS, a cynical colleague told me that the dizzying growth rates of the disease would make it a godsend for all kinds of vested interests.
Why? Because nobody would have the time to figure out the maths behind dramatic headlines.
“I recalled my cynical colleague’s words last week, when I glimpsed my local newspaper. India, beamed the mammoth headline, becomes the world’s AIDS capital, overtaking South Africa as home to “the most people with HIV”.
True as true as any litany. And this was splashed across other print and online newspapers, both here in Europe and elsewhere not least of all, India itself.
(but) I find it hard to figure out the absence of HIV prevalence data for countries as a whole, or even an entry on overall population sizes. This would have brought many things into perspective, not least the true proportion and implications of the AIDS crisis. Of course, the price would have been the loss of a glitzy headline, just before the summer holidays.
For it is important to bear in mind that there are quite a few Indians, in fact almost 1.1 billion of us. And India’s slight lead in the high-visibility AIDS sweepstakes (5.7 million HIV infected versus South Africa’s 5.5 million) acquires an altogether different significance when one takes account of the fact that South Africa’s population is only 44 million.
The reality, beyond the headlines, is therefore harsh, especially for South Africa. HIV prevalence is 12.4 per 100 South Africans. In India, it is 25 times lower, at 0.52. Rather than South Africa, we are, in fact, much closer to places like the United States (0.4), or even Spain and Portugal (respectively, 0.3 and 0.35).
As I explained to the editor of my local paper, there are many more dangerous spots for his readers in between India and South Africa – sexual tourism honeypots like the Dominican Republic and Thailand (0.72 and 0.90), or for that matter Russia and Ukraine (0.66 and 0.88).
In the second part of his story, Tosh peeks behind the headlines to understand what drives these comparisons:
“In all cross-country comparisons, one needs to explain a simple truth: it is the denominator, stupid.
Of course, being a demographic colossus hardly helps India’s case. Take, for example, the debate about the environment and global warming. With per capita primary energy consumption 15-20 times lower than the US or Europe, and a typical apartment block in the West consuming more energy than a dozen Indian villages, India is still routinely hauled up as a global greenhouse gas mega-problem. Using national-level statistics and the weight of our population, we naturally fall on the wrong side of many a bed’most recently, in our AIDS superstardom.
Such reasoning should of course apply also to another demographic giant, namely the People’s Republic of China. But here lies a Big Puzzle – as far as the latest exercise in HIV headlining is concerned.
China reports 9 times fewer HIV cases than India. Who has counted?
“Before I listen to any parallels here – who counts in India ? I would point to a June 1997 finding by the World Bank (incidentally, not always a good friend of India): “In many respects, India stands out from other countries in terms of its tradition of data collection and its pioneering of many of the techniques of data analysis, which have now become common currency throughout the world.
China abhors being reminded of its weakness in concocting statistics, and leans heavily on those who think otherwise. Consultants Ernst & Young were recently compelled to “withdraw” a detailed study on the near one trillion dollars in bad debt within the Chinese banking system.
But still, one cannot help wondering. For a country like China, which took several months in early 2003 to acknowledge/confirm the existence of SARS and permit a WHO team to make its first investigative visit, the certainty about its “reporting” of HIV infections is mindboggling, especially on the part of people ready to lynch India on the slightest pretext.
As Britain’s respected medical journal Lancet notes, “In all likelihood, new HIV infections have peaked globally. For Stephen Lewis, the UN secretary general’s special envoy for HIV/AIDS in Africa: “There were very dramatic words a couple of years ago about India, about China, about what was coming tremendously alarmist words. And it doesn’t seem to have happened.
Tremendously alarmist words like those from Richard Gere. China, of course, has clearly escaped such hysteria. India, as clearly, has not.
On a final note, I hope that Richard Gere, star of the 1980s hit Officer and a Gentleman, is gentlemanly enough to do two things: firstly, apologise to Indian NGOs, and secondly, take up a more meaningful cause volunteer a few more hours to lobby in Geneva for patent exemptions on HIV treatments.
For the global fight against AIDS, too, has another very Indian face: India’s ability to provide generic versions of AIDS medicines makes the difference “between life and death for millions of people at home and abroad”, the New York Times noted in March last year.
**
Now, India’s data re. malnourishment comes into question too:
Is India as Malnourished as Data Suggest?:
Arvind Panagariya, a professor of public and international affairs at Columbia University..has questioned accepting the results of such studies at face value.
..According to him, in the state of Kerala, which exhibits social indicators close to developed country standards and almost as high as China’s, 25% of children are apparently stunted, whereas in, for example, Senegal, which is much poorer and fares worse in just about any social indicator, the figure is 20%. Likewise, he asks, how plausible is it that 37% of children in Punjab, “the breadbasket and the dairy of India,†are stunted?
Here’s the crux: all these studies rest on one crucial assumption, the World Health Organization’s norm for measuring child malnutrition, called the “Child Growth Standard.†This is based on a sample or “reference population†of 8,440 healthy young children (0-60 months) from Brazil, Ghana, Oman, Norway, India and the U.S. The idea behind the index is that no matter where children are born, they should be able to grow equally well if they’re adequately nourished regardless of genetics or ethnicity.
The WHO norm assumes that the bottom 2.14% is malnourished (or stunted) and the rest are normal. All comparisons of whether a child is malnourished in India or anywhere else is made against this reference group of well-nourished kids and this cut-off.
The 2.14% cut-off is hard to argue with. It corresponds to two “standard deviations†(a measure of the spread of data) below the median (the midpoint, whereby 50% lies above and 50% lies below), assuming a “normal†or bell-shaped distribution. The bottom line is that this is a standard assumption in statistics.
But how about the selection of the reference population?
Mr. Panagariya suggests that the only plausible explanation for the wide discrepancy between India’s performance on malnutrition and stunting measures and its overall socio-economic performance is that “at any given age sub-Saharan African children and those defining WHO reference population are on average genetically taller and weigh more than Indian children.†In other words, a child who is in fact healthy is being measured as stunted or malnourished simply because he or she is likely to be smaller than the norms of the reference population. Indeed, as Mr. Panagariya points out, even most rich Indian kids would be considered malnourished or stunted by this metric.
The underlying problem is that imputing malnutrition or stunting by using a cut-off defined for an external reference group is making an inference based on an assumption, not on direct observation.
…Mr. Panagariya’s hypothesis is an important and provocative one that bears further investigation and careful scrutiny. If it is validated by future research, things might not be as bleak as the numbers suggest.