Nagpur: We are on track to become a sick nation — both mentally and physically — unless, of course, we act fast and move towards a more universal coverage of healthcare.
On September 12, Lancet, the critically acclaimed journal, released five India-specific health studies that, if read in tandem, raise an alarm on the country’s deteriorating public health.
Prime Minister Narendra Modi’s Ayushman Bharat — Pradhan Mantri Jan Arogya Yojana — an insurance-based health scheme isn’t adequate to fix it.
Last November, Lancet had released a comprehensive study that red-flagged a story of nations within a nation of growing health inequalities, saying we now bear a very high burden of diseases.
Between 1990 and 2016, while we had a robust growth rate (we perhaps removed more people out of poverty than we previously did in independent India), we also managed to turn ourselves into one of the sickest nations on the planet, which, in turn, now threatens to put people back into poverty.
Take this paradox: We are a young nation today — nearly 42 per cent of our population is below 36 years of age, but our youth are among an overwhelming majority of those killing themselves. Suicides, one of the five studies Lancet published in September 2018 said, is the top reason for deaths among youths in the 18-36 years age group. Worse, four in 10 young women committing suicide the world-over are in India.
The other four studies show that we have an epidemic of asthma on our table and our burden of respiratory illnesses is growing. Our diabetic population is spiralling exponentially, and in some states, alarmingly. That’s not all. We have several times more cases of ischaemic heart disease, strokes, and rheumatic heart illness today than we had in 1990. And, we have doubled our cancer incidence.
Each of those studies pleads us to treat the situation as an emergency. That we won’t is anybody’s guess.
But if the transition between 1990 and 2016 from being a nation of communicable diseases to the one with an array of non-communicable diseases (NCD) is any indication, we are in a new league of nations, the Lancet studies point out. There’s been a trade-off: we are relatively better off today than we were in 1990s with vast inequalities. But we have a bigger problem on our hands. For instance, diarrhoea may not be the top most cause of deaths today though it still is in some backward regions; cardio-vascular disease, lung ailments or even suicides are bigger causes of health crisis and fatalities in a new India.
What this means is that India needs a comprehensive but flexible and region-specific health strategy and that the rhetoric of slogans the Prime Minister is so good at won’t work. It might work to pull votes and win elections, but his acronyms won’t help save gullible lives.
Let’s take a quick look at what each of those studies found.
One: The increase in the health burden from diabetes since 1990 in India is the highest among major non-communicable diseases. The number of people with diabetes in India increased from 26 million in 1990 to 65 million in 2016, the study found. The prevalence of diabetes in adults aged 20 years or older in India increased from 5.5% in 1990 to 7.7% in 2016.
Two: Deaths due to cardiovascular diseases in India increased from 1.3 million in 1990 to 2.8 million in 2016. The contribution of cardiovascular diseases to total deaths and disease burden has doubled since 1990. Ischaemic heart disease was the leading individual cause of disease burden in 2016, and stroke was the fifth leading cause. More than half of the total cardiovascular disease deaths in India in 2016 were in people younger than 70 years.
Three: The estimated number of incident cancer cases increased from 5,48,000 in 1990 to 10,69,000 in 2016. The crude cancer incidence rate in India increased by 28.2% from 63.4 per 1,00,000 in 1990 to 81.2 per 1,00,000 in 2016, but there was no change in the age-standardised incidence rate. Crude cancer incidence rate was highest in Kerala and Mizoram, followed by Haryana, Delhi, Karnataka, Goa, Himachal Pradesh, Uttarakhand, and Assam.
Four: India has 18% of the global population and an increasing burden of chronic respiratory diseases. The contribution of chronic respiratory diseases to the total DALYs in India increased from 4.5% in 1990 to 6.4% in 2016. Of the total global DALYs due to chronic respiratory diseases in 2016, 32% occurred in India. The World Health Organisation defines DALY — or Disability-Adjusted Life Year — as a measure to quantify the burden of disease from mortality and morbidity.
One DALY can be thought of as one lost year of "healthy" life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability.
DALYs for a disease are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences.
So India has a disproportionately high 32% of the global DALYs from chronic respiratory diseases. In other words, a third of the total global health loss from chronic respiratory diseases occurs in India.
Five: India had 18% of the global population in 2016, but accounted for 36.6% of the global suicide deaths among women and 24.3% among men. Suicide deaths ranked first among all causes of death in women aged 15–29 years in 26 of the 31 states, and in women aged 15–39 years in 24 states; for men, suicide was the leading cause of death in nine states for those aged 15–29 years and 10 states in those aged 15–39 years.
There were 2,30,314 suicide deaths in India in 2016. An estimated 8,17,000 suicide deaths occurred globally in 2016, accounting for 1.5% of all deaths, with a global suicide death rate (SDR) of 11 per 1,00,000 population (seven per 1,00,000 for women and 15 per 1,00,000 for men). The findings highlight that suicide death rates were higher in India than the global average in 2016, and most states had rates much higher than would be expected for their socio-demographic index level.
Lancet findings become worrisome in the context of an expensive private health system and the tattering public health infrastructure. We also have a huge paucity of doctors and health workers. From here on, we shall continue to ignore the health of our public health at our own peril.
Almost every study starts with a strikingly similar background: That “the burden” of these diseases “is increasing in India”, but “a systematic understanding of its distribution and time trends across all the states is not readily available”. We don’t have any data on anything, or inclination to understand the gravity of our sickness and the traumatic events it scripts in the lives of everyday Indians. We see that all the time in the clinics, the hospitals, we hear about it every time, but then we shirk and move on with our lives. The governments, too, move on, announcing new slogans as the old ones die down.
India is seeing a transition from the domination of communicable diseases to non-communicable diseases as putting a greater burden on the population, indicating generally the transition of society from an under-developed to a developing or developed stage, but the burden varies greatly from state to state, a Lancet study led by India-led team of authors said in late 2017. However, huge variations in disease burden exist across states, with communicable, maternal, neonatal, and nutritional diseases still high in many states and NCDs and injuries increasing in every state, with major health inequalities.
In early 2017, another major study published in the same journal analysed access to and quality of health care among and within countries using a new metric, the Healthcare Access and Quality (HAQ) index. Despite India’s HAQ index increasing from 31 in 1990 to 45 in 2015, India still ranked a woeful 154th among 195 countries. We also underperform in the universal health coverage (UHC).
In that study, the authors saw two factors would challenge India’s health system in the coming decades: urbanisation and ageing of the population. The fact that the Modi-government is investing barely 2.5% of GDP into health care when the global average is about 6%, does not bode well for the poorest.
(The author is a Nagpur-based journalist. The views expressed are personal.)