The insights from the Global Burden of Disease Study 2010 published recently by The Lancet , underscore significant public health challenges before India. The headline message from the research data is that public health policy must, in coming years, be directed as much towards non-communicable diseases as infectious ones. There is considerable scope to build on the GBD analysis by adopting sound epidemiological approaches at the national level.
The emphasis of the GBD is on well-known risk factors such as tobacco use, alcohol consumption, deficient diet and exposure to air pollutants, all of which display unhealthy trends in the country.
Hypertension is third on the risk chart based on attributable disease burden in 2010. But household air pollution caused primarily by burning unclean fuels is right at the top. Metabolic disorders and other traditional concerns such as infectious diseases, underweight children and dietary deficiency also rank high. Diabetes, a major issue in India, requires a lot more epidemiological surveillance work in order to present strong conclusions.
Again, there is a rise in the number of people dying in road traffic accidents globally — a rise of almost 50 per cent over a 20-year period — and the trend is equally true for India. Without strong intervention, that risk factor also continues to grow.
If national public health policy is to be turned around, the country has to embark on a mission to turn tobacco fields into fruit orchards, as one expert puts it. That is necessary because tobacco use, including second-hand smoke, is linked to the rising incidence of various cancers and absence of sufficient fruit in the diet and consumption of high levels of salt are raising the risk of cardiovascular diseases. Fruits with potassium help stabilise blood pressure at healthy levels, while salt, which is commonly added to packaged foods, produces the opposite, negative effect.
The coming shock
Alcohol consumption is part of the growing national problem of NCDs. From an epidemiological standpoint, it is a risk factor for many cancers, ischaemic heart disease, and gastrointestinal problems including irreversible organ failure. State governments that view growing alcohol sales as a revenue-spinner are obviously unable to see the coming health crisis. For instance, in Tamil Nadu, government-owned Tasmac declared provisional revenues of Rs.18,081 crore for 2011-12 from liquor trade. That represents 20-per-cent growth over the previous year. The Associated Chambers of Commerce and Industry of India (Assocham) projects a 30-per-cent year-on-year national growth in liquor consumption, more than doubling the present offtake by 2015. The size of the market for beer, wine and spirits stood at Rs. 50,700 crore in 2011. More and more young people are getting initiated into drinking early and the problem is therefore not confined to older adults.
In the case of tobacco, a well-known disease agent causing a great deal of social distress, India has a massive market although consumption patterns differ from other countries. Published data from the Global Adult Tobacco Survey indicate that the number of tobacco users (age 15 and higher) in India is 274.9 million, compared to 300.8 million in China. The intensity of smoking is 6.1 cigarettes a day, while various other forms such as bidi , chewing tobacco and snuff are consumed heavily, often as a combination.
India’s public health policy is thus pitted against three powerful sectors with enormous political influence: tobacco, alcohol and the packaged food industry. Can the government then muster the will to tighten controls on agents of harm and unhealthy products, including high-sodium food that is promoted aggressively? Both tobacco and alcohol are now accessible to adolescents and young adults, with a strong influence on their entire life course. The policy response must therefore adopt a far-sighted approach and focus on prevention and management.
It is important to note that disease burdens attributable to tobacco use and hypertension are on the decline in the West, but increasing in India. By regulating sodium levels in packaged food, for instance, the risk of heart disease, stroke, hypertensive heart disease, and kidney failure, among others, can be significantly lowered. This calls for regulation of salt content and compulsory labelling to encourage salt-free or low sodium products.
The GBD project also highlights gaps in top-level programmes such as the Millennium Development Goals. The approach to disability is one. This area, which did not enjoy a high profile when the MDGs were formulated, needs extensive study, given that disability caused by multiple factors — musculoskeletal problems, back and neck pain — is now reported by people living in both rural and urban areas in India.
Mental health as a form of disability is also acutely missing from such evaluations. The role of social determinants such as education, income, safe transport access, water and sanitation, and good housing in reducing exposure to risk factors needs to be analysed rigorously.
The weakest link in the Indian approach to assessing disease burdens is its surveillance system for non-communicable diseases. As it stands, it is unable to determine mortality, actual disease burden, morbidity and risk factors with any degree of clarity, because statistical pathways are not robust. Patients often do not report for follow-up and fall off the map for a variety of reasons including high costs that they must bear out-of-pocket. The Lancet ’s reports serve as a base on which to build a strong national system to assess the burden of disease.