Mind the numbers

Global TB report reveals that India has been massively underestimating the disease

The results of an unpublished government survey, now used by the WHO, show that India has almost twice the number of TB cases as previously reported.

India has been underreporting its tuberculosis burden by almost half, it appears. The new Global Tuberculosis Report 2016 released on Thursday by the World Health Organisation updated the estimate of incidence – that is, the number of new tuberculosis cases in a year – from 1.7 million cases to 2.8 million in 2015. The report used estimates from a prevalence study done in Gujarat in 2011, the results of which were never made public till the WHO decided to use it in its global report.

The WHO also updated incidence figures for 2014 from 1.6 million cases to 2.9 million cases. This would effectively mean that the reported incidence in the national programme was only 56% in 2014 and 59% in 2015 of the actual disease burden.

The updated estimate of tuberculosis deaths, excluding deaths of HIV-positive people, is 478,000 in 2015 and 483,000 in 2014, according to the WHO report. The estimates for deaths in 2014 as per last year's Global TB Report were at half the number at only 220,000 deaths.

The government's undercount of 1.7 million new and relapse cases were reported through the Revised National Tuberculosis Control Programme. The WHO report, meanwhile, clarifies that its updated numbers for India are interim estimates, pending results from a national tuberculosis prevalence survey that is scheduled to begin in 2017.

Globally, there are an estimated 10.4 million new cases of tuberculosis. Only 6.1 million new cases were, however, notified to the national authorities. India, along with Indonesia and Nigeria, accounted for almost half of the 4.3 million gap between incident and notified cases globally.

Unpublished TB survey

In 2011, the first statewide survey on tuberculosis prevalence was conducted in Gujarat by the state government using a representative population. The results indicated a prevalence of 390 cases per one lakh population – much higher than the national estimate of 250 cases per one lakh population.

“Gujarat is among the wealthiest states in India, and given the link between overall levels of income and the burden of TB disease it seems unlikely that TB prevalence in Gujarat would be higher than the national average,” the WHO report said.

The results of this survey have not been published or made available publicly, but were only shared with the WHO in 2015. Though the results of the survey and the revised estimates may not surprise public health watchers who suspected gross undercounting of tuberculosis cases, the question remains as to why the results were not shared either online or through the media.

“The results of this survey has only just come out,” said Dr Jagdish Prasad, director general of health services with the Ministry of Health and Family Welfare.

A government official who did not wish to be named said that the health department had been sitting on the report for nearly three years.

India accounts for more than a quarter of the world's tuberculosis cases and deaths based on the global estimates, the report stated. But Prasad differs.

"Globally, WHO is saying, we account for 27% of the incidence," he said. "We do not agree with that. They should apply the same formulas and methods [that was used to calculate the revised Indian estimates] for other countries too, especially Brazil, China, South Africa, and other South Asian countries."

Private TB treatment

Other data used to revise the estimates of incidence in the Global Tuberculosis Report come from a study done earlier this year on the sales of anti-TB drugs in 2014, which estimated as many patients in treatment at private facilities as at public health centres.

Prasad acknowledges this gap in India's counting methods. “The results are not wrong," he said. "We were not picking up cases that were being treated by the private practitioners.”

"The private sector accounts for more than 60% of the TB cases," said Dr Sunil Khaparde, deputy director general of the TB control programme. "We plan to engage the private sector more in our programme. With our pilot in Mehsana, Gujarat, and Patna, the notifications have already increased substantially."

The WHO report's estimates of tuberculosis mortality are derived from numbers published by the Institute of Health Metrics and Evaluation, after adjustment for differences between WHO and IHME estimates of the total number of deaths each year. The earlier WHO estimates of TB incidence published in 2011-2015 were based on outcomes of a national consensus workshop in Delhi.

“I am convinced the higher TB estimates from India reflect the underlying reality,” said Madhukar Pai, director at McGill Global Health Programs in Canada. “For a long time, India ignored TB patients managed in the private sector, and national prevalence and drug-resistance surveys were not periodically done [unlike in other countries such as China].”

The notification rates for tuberculosis from the private sector have actually improved since it was made mandatory in 2012. There is a 34% increase in notifications in 2015, as compared to the notifications in 2013. The improved coverage of notifications were mostly from the private sector in a few districts like Mehsana, Patna and Mumbai. More than one lakh private laboratories are now notifying cases to the government, but many more still need to be brought into the fold of the national programme.

The Indian government is also heavily reliant on insensitive diagnostic tools such as sputum smears that miss nearly 30% to 40% of tuberculosis cases, which could add to the problem of under-diagnosing and, therefore, underreporting.

“Overall, the message for India is very clear – acknowledge the reality, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem,” said Pai.

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.