New Internationalist

Killer sting

Issue 396

The World Bank has vowed to tackle corruption and fight for transparency in the development programmes it funds. In light of this Sandhya Srinivasan takes a close look at one of its pet programmes in India.

The thick forests and natural wealth of Gomia in Northern India conceal an appalling poverty and a variety of illness. Malaria is one of these illnesses.

Men and women survive by selling coal extracted from abandoned coal mines, or working for daily wages in brick kilns and stone quarries, or as agricultural labourers. Most live in mud huts, often along with their livestock.

The hospital in Gomia receives 20 to 30 malaria patients a month. But it has no facilities for routine pathology tests and it takes one month to get the results of blood smears – far too late to be relevant for treatment. In this area malaria is on the rise – especially in its deadly falciparum form.

Some 70 million Indians get the disease every year, according to a WHO estimate. Hundreds of thousands die of what can be described as the country’s single biggest public health problem – bigger even than tuberculosis.

But official Government figures record ‘only’ two million cases a year – with 1,000 deaths. And the World Bank hails the malaria control programme it has funded in India as a ‘success’ which resulted in a 45 per cent decline in cases.

What is going on?

Deception, some would say, with the World Bank peddling false data to claim false victories.

Let’s take a look at their star project. Called the Enhanced Malaria Control Project it ran in eight Indian states between 1997 and 2005. Transparency does not seem to have been a key feature – even the amount loaned by the World Bank is variously reported as $86 million, $119 million and $165 million.

The Bank claims that as a result of its programme, malaria in the states of Maharashtra, Gujarat, and Rajasthan declined by 93 per cent, 80 per cent and 40 per cent respectively from 1997 to 2002.

And it attributes this success to a fundamental change in approach to malaria control.

However, a study by a group of public health researchers holds the Bank’s claim to be a pack of lies. Writing in the 15 July 2006 issue of The Lancet, Amir Attaran and his colleagues quote government documents indicating a much smaller drop in malaria in the states where the programme was conducted. In some states it actually went up, they note. The Bank’s statistics for the states of Maharashtra, Gujarat and Rajasthan did not correspond to Indian government data between 1997 and 2002; in fact in 2004, there was more malaria in Gujarat than there had been in 1997.

Tellingly, the Bank refused researchers access to data needed to examine its claim that the programme has been a success.

Health professionals working in malaria-infested areas are unimpressed: ‘The Bank’s programme has made no difference in Orissa,’ says Johnny Oommen, a medical doctor working in Bishamcuttack for more than 13 years. ‘The Government’s figures are a fraction of the total number of cases. The ground situation is much, much worse. Malaria is our single biggest public health problem.’

Ravi Dsouza, who trains health workers to treat malaria and tuberculosis, reports: ‘I have seen villages where three out of four people have a swollen, palpable spleen – the effect of repeated, untreated malaria.’

Even when it doesn’t kill, untreated malaria leaves people with severe anaemia because it destroys the red blood cells. Children’s growth is stunted. ‘In tribal areas, where it is the most common, it is an important cause of infant and maternal mortality,’ says Dsouza.

And while the number of cases officially recorded is not increasing, the proportion of people with the deadly falciparum strain of malaria is up from a little under one-third of all cases to about half today.

‘The fact is that no one really cares about malaria because it is a poor person’s illness,’ says Yogesh Jain of Jan Swasthya Sahyog, a non-governmental organization running health programmes in the central Indian state of Chattisgarh.

Map the high-malaria districts and you’ve got the poorest districts in the country. Tribal or indigenous people living in heavily forested areas where the mosquito thrives are most susceptible. Pregnant women are more vulnerable, though women in general are less likely to receive treatment. Malaria also affects urban construction workers living in makeshift housing, surrounded by debris and stagnant water. A number of epidemics are directly linked to the environmental disruption caused by ‘development projects’ – such as the Bank-funded Indira Gandhi canal.

Health professionals like Jain wonder at how the Bank can take its own claim seriously when even the Indian Council of Medical Research has accepted that official records of malaria are only the tip of the iceberg.

‘These figures don’t mean anything because in more than 95 per cent of people treated a diagnosis is never made,’ explains Yogesh Jain. Few people go to government centres for treatment – the only places where the data is collected – and only those who test positive after a blood smear are recorded as cases. This excludes the millions who get treated for malaria without testing; it excludes those tested in private clinics; and it also excludes the millions who cannot afford to seek any treatment at all.

If no-one has credible figures for the number of malaria cases in India, how can the World Bank talk about reducing the numbers by 45 per cent?

But then the Bank’s false claims about its contribution to malaria reduction is of a piece with its systematic destruction of India’s public health services. It has done this in part by putting pressure on governments to provide ‘targeted interventions’ – like the enhanced malaria project – in place of comprehensive health care.

India’s expenditure on public health as a proportion of Gross Domestic Product (GDP) has always been one of the lowest in the world. Since 1991, when India took an IMF structural adjustment loan, this has fallen further still from 1.3 per cent to 0.95 per cent of the GDP. Rural health has been especially hard hit. There are now fewer than half the number of community health centres than the Government itself says are needed and these centres suffer from severe shortages of staff, equipment and drugs. Half the health centres don’t have microscopes; others don’t have technicians. There used to be one malaria inspector for every 10,000 people – now there’s just one for 40,000.

Blood smears for malaria are entirely possible in a properly equipped health system. But not within a healthcare system sabotaged by World Bank policies.

Why does the World Bank peddle false data and false victories? One reason it gives for its India ‘success’ is that it promoted a targeted intervention to ‘high-risk’ areas. We can only speculate: by claiming such ‘successes’ perhaps the World Bank seeks to divert attention away from its systematic destruction of the public health system. •

Sandhya Srinivasan edits a journal on medical ethics in Mumbai.

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