Unhealthy India: Only proper planning can reverse worrying disease trends

Unhealthy urban lifestyles have emerged as a leading risk factor causing death and disability among Indians. “Non-communicable diseases and injuries are creating more strains on health as communicable diseases and maternal health problems become less threatening,” finds a new study.

The Global Burden of Diseases, Injuries, and Risk Factors 2010 Study (GBD 2010) is a collaborative project led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.

In 2010, Ischemic heart disease or heart attack was the top cause of death among Indians, followed by chronic obstructive pulmonary disease, stroke, diarrhoeal diseases, lower respiratory infections, tuberculosis, preterm birth complications, self-harm, road injury, and diabetes. In 1990, the top killer was diarrhoeal diseases.

Dietary risk factors emerged as the number one risk factor to health in 2010, followed by high blood pressure, household air pollution from solid fuels, tobacco smoking, including second-hand smoking, and ambient particulate matter pollution.

Providing a grim reality check, findings of the GBD 2010 show that India lags behind its its neighbours – Sri Lanka, Nepal, Pakistan and Bangladesh - on key health parameters such as life expectancy and death rates.

Firstpost spoke to Lalit Dandona, Distinguished Research Professor, Public Health Foundation of India and Professor of Global Health at IHME on the implications of these new trends and what India should do now.

Excerpts from the interview

 Unhealthy India: Only proper planning can reverse worrying disease trends


In the light of the findings of the GBD 2010, what would you identify as some of the key areas the government should be focusing on?

What is striking, though not surprising for those working in the area of public health, but more so for the general public and the policy makers, is the clarity with which the risk factors related to chronic conditions have become a much larger issue than they were 20 years ago in India.

For example, infections and maternal and child health conditions contributed to about two-thirds of the disease burden in 1990, but now the disease burden due to chronic conditions exceeds that due to infectious and maternal and child health conditions.

While we still have a lot of unfinished business in infectious conditions – for instance, we have the highest burden of tuberculosis in the world and that needs to be taken care of – relatively speaking, the ischemic heart disease or heart attacks, stroke, diabetes, chronic obstructive lung disease, mental health problems such as major depression, and injuries, especially road traffic injuries and suicides, have become a relatively larger contributor to the disease burden in India as compared with the situation twenty years ago.

This is explained by the analysis which indicates that increase in risk factors such as unhealthy diet – less fresh fruit and vegetables, more fatty processed foods, high salt and sugar content, sweetened beverages – and less physical activity especially in the urban areas, is leading to a higher risk of cardiovascular disease.

Tobacco use or smoking which was high 20 years ago continues to be high and is a major contributor to this as well. All that put together, there is an increasing trend towards risk factors being more prevalent for cardiovascular disease.

In addition pollution, especially indoor pollution from burning of solid fuels is a big issue. It is one of the major contributors to the disease burden. This, plus tobacco use as well as outdoor pollution, are responsible for a high burden of chronic obstructive lung disease.

In terms of the shift over the past two decades, the relatively higher presence of these risk factors leading to higher magnitude of chronic conditions leading to deaths as well as disability is the major thing we have to plan for in India.

What should be the government’s response to the growing health risk from non-communicable or chronic conditions?

A lot of it will happen by trial and error as it generally does when a new problem becomes visible. However, the response will have to be inter-sectoral. What do I mean by that? As a simplistic example, infections can generally be dealt with directly by the health care system, but a trend towards unhealthy diet is influenced heavily by how society has made available and provided access to healthy or unhealthy foods.

There are a lot of factors determining which foods come into the market and how they are priced. For example, why is it that fruits and vegetables are expensive? We have to think through how we as a society can make more desirable foods available at lower cost.

The economics and the industry dynamics come into play here. Regulation that makes healthier foods more accessible and more reasonably priced would be beneficial for society as a whole. It is important to note that infections too are influenced by broader determinants, but the scope and complexity of broader determinants for chronic conditions is larger.  
So the response will have to move beyond health sector. A lot beyond the health sector.

Here’s another example – processed food and fatty fast food. Smart societies in some parts of the world are steering people in a healthy direction with policies that make unhealthy food less accessible and more expensive. It would be useful to remember though, that we have had fried stuff in our diets for a long time. But the magnitude is increasing and the overall diet is becoming unhealthier.

Similarly, pollution. To make less polluting cooking fuels available on a larger scale is beyond the health sector. It has to do with their production and distribution, and making them affordable and accessible. These things can only be done by linking the different sectors together. Linking different sectors is generally difficult but we have to move in that direction.

What developments and factors would you say are responsible for the relative increase in disease burden from communicable diseases to non-communicable or chronic conditions?

The improvement for infections is relative. I emphasise the relative bit because several infectious conditions are still a big problem. We have tuberculosis, diarrhoeal infections, and pneumonia which continue to be big challenges. But some of the improvements can be attributed to better sanitation and water, better hygiene practices, and better availability of antibiotics and other medications for treatment.

A combination of both preventive interventions and treatment has helped address this problem partly.

On the other hand, a lot more still needs to be done to control infections. And in addition we have the non-communicable conditions rising up very rapidly.

The trend towards poorer diet overall and less physical activity is leading to physiological risk factors such as higher blood pressure, cholesterol, and blood sugar. This combined with the high level of tobacco use is contributing to higher rates of heart attack, stroke and diabetes. Tobacco use along with air pollution is leading to a big burden of chronic obstructive lung disease.

What has been the increase in the disease burden from mental health in the last twenty years?  

Mental health is a big concern in India. It is one of the key components of chronic conditions that we must address. It causes a lot of disability. Major depression and anxiety disorders are major contributors to disability. If we pool all mental health and behavioural disorders they contribute about 5-6 per cent of the disease burden in India, which is not low.

The biggest component of this is major depression, which has increased in magnitude as a contributor to disease burden in India by about 50 per cent in the last 20 years.

While there is a relative improvement in the number of lives lost to communicable diseases, in absolute numbers they continue to pose a challenge for the government:

The big concerns are diarrhoeal disease and pneumonia, a large proportion of which are among children, and also tuberculosis which is more in adults.

Is this across rural and urban India?

The relative burden will be higher in rural India. But we have to note that urban is a mixed bag. A large proportion of urban population lives in slums, which are equally or even worse off than rural areas.

Infectious diseases are still quite common in the less privileged settings of the urban areas and because they are communicable they spread and so there may not be huge differences between rural and urban areas.

What are the main challenges before the government in reducing deaths and the disease burden in India? 

Several things. Budgetary allocation is clearly a key issue. Many experts for the past several years have been talking about the need for higher public health resource availability. The public health spending per capita in India is one of the lowest in the world.

There is some inclination towards improving this in the policy making circles but it hasn’t been actualized yet. It is encouraging that the Twelfth Five Year Plan recommends substantial increase in allocation for the health sector.

But budgetary allocation is only one aspect. It is equally important how we prioritise where we spend that money and how well we plan to make that spending effective. A smart society for policy decisions has systems which generate ongoing data that allow understanding of the disease trends, what determines the trends, and the health system response to it. This constitutes a good health information system.

Do we have it? 

We have a very rudimentary health information system. Consequently, we are limited in our ability to have good and timely data that we can use to make informed policy decisions. Not that nothing is available, we are talking relatively here. So the health information system improvement is one of the fundamental things we need to do.

The other thing is governance in the health system at the ground level. There have been lots of attempts and a lot of good has happened. But a lot more needs to be done in terms of ground level implementation of well thought out policies.

Why is India lagging behind its South Asian neighbours on key health parameters? 

The difference between India and our neighbours Pakistan, Bangladesh and Nepal are relatively small. Of course, there is no pride in being in that low bracket. The real striking thing is that a country like Sri Lanka has much higher life expectancy and a much lower per capita disease burden.

And that is primarily due to the fact that several decades ago they developed a practically sound primary health system, and the health policy and health system started addressing basic issues.

Consequently, some of the key indicators in health for example child mortality in Sri Lanka are substantially better than in India. We also have to remember that it is a much smaller country. But still even if we are a large country, we can plan for smaller units.

You cannot plan the same thing for 1.2 billion people. We have to have more decentralised planning.

In India, at the time of Independence there was a lot of interest in making good primary health a fundamental structure of the health system. Despite all the good intentions, we could not develop a practical implementable system.

I think the good intentions are there now too – the National Rural Health Mission, and recently the more comprehensive National Health Mission, as well as the Total Sanitation Campaign. This momentum has to be translated into practically effective outcomes for India’s people especially those that are most disadvantaged.

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Updated Date: Mar 22, 2013 14:48:48 IST