As a medical student in India in the early 1980s, the biggest problems I encountered were under-nutrition, sanitation, high burden of infectious diseases and woefully inadequate vaccination of children. The number of children who died in infancy was much too high – around 11%. Those of us who were posted in paediatrics used to frequently treat conditions that arise from malnutrition like kwashiorkor, which causes body swelling, and marasmus, which leaves people looking skeletal – both of which are hardly seen now.
The burden of chronic diseases such as diabetes was low and confined to the affluent. Rheumatic heart disease was the major cardiovascular disease. Impressive strides in the last 30 years have changed the picture. Maternal and infant mortality rates are down to less than a half of what they were.
But 40% of Indian children are still undernourished. Maternal death is still four times that of China and Brazil. We still lose 1.4m infants each year – that’s 4,000 who die each day – and a half of all children aren’t immunised at all.
These, along with infant deaths that are needless, premature and avoidable, mean we are nowhere near achieving the Millennium Development Goals – the eight targets) agreed by UN members, including reducing child deaths by two-thirds by 2015 – despite the huge economic strides India has made. In this regard we are actually worse than our neighbours – Bangladesh and Nepal.
Bigger numbers, more cases
We now also face epidemics of chronic diseases such as diabetes and other major cardiovascular diseases including heart attacks and strokes.
India appears to have a special place on the world stage when it comes to diabetes; the country is a major epicentre of the world with 61m cases. And every year more than a million people die from it.
Of course we have one of the world’s biggest populations at 1.2 billion, but relatively speaking the percentage of the population with diabetes is higher in India (about 9%) than in the UK (5%) or Germany (8%), for example. And diabetes is much more prevalent in urban populations.
Unhealthy diets with too much fat, salt and sugar are a problem as they are in the west. And the risks are made worse by too little exercise and smoking.
Tobacco continues to take its toll with about 1.5m tobacco-related deaths a year, while almost a quarter of Indians have hypertension (high blood pressure). The World Health Organisation estimates that India could stand to lose almost US$237bn between 2005-2015 from income lost because of non-communicable diseases in the workforce.
Unlike the largely short-term effects of communicable diseases, the dual health and economic impacts of non-communicable diseases on individuals, families and households are both crippling and long-lasting. And there are huge differences between rural and urban populations, income classes, education categories, gender and community. We only have half the health services we need, like 24-hour care, clinical staff positions, basic infrastructure.
So while we claim global attention as an economic powerhouse, India’s health status significantly lags behind.
On the upside
These are all really depressing statistics but there is some good news. Every challenge has an opportunity and every problem has a solution. Rudolph Virchow, the great 19th-century German physician and philosopher, said medicine was “a social science and politics is nothing else but medicine on a large scale”. We therefore need a political solution to these problems.
Currently our expenditure on health is among the lowest in the world. A doubling of public health spending to at least 2% of GDP has the potential to substantially reduce the huge out-of-pocket costs most people have to shoulder themselves. Getting trained professionals to deliver public health programmes and promote better health behaviours would save a lot of rupees in the long run.
Apart from initiatives such as food security, universal immunisation to reduce problems such childhood and maternal mortality, infections and anaemia, we need financial protection through some form of universal health coverage. The India Diabetes Educator Project, a four-year, multi-million dollar programme to train over 3600 health professionals in diabetes prevention and management, is internationally acclaimed and has been adopted by several state governments in India.
Mobile phone technology is ubiquitous, affordable and could be used to drive better health.
We should also use our traditional knowledge and wisdom to the fullest extent possible. Yoga is a low-hanging fruit and if adopted on a large scale could be a low-cost substitute for post-stroke and post-heart attack rehabilitation and could help in the management of difficult to control diabetes.
To make a change we need to think differently. Thomas Jefferson, one of America’s founding fathers, said: “If you want something you never had, you must be willing to do something you have never done”. The great 10th-century Persian philosopher Ibn Sina said: “There are no incurable diseases – only a lack of will.” Both are very apt for India and I hope provide food for thought.