• THE LOOMING CARDIOVASCULAR DISEASE EPIDEMIC IS NEITHER A GOOGLY NOR A DOOSRA, IT CAN BE TACKLED IF ONE POSSESSES THE WILL

    September 16th 2018

     

     

     

    HEALTH ACCESS AND QUALITY INDEX , LANCET 2017:390: 231-66. INDIA IS NO BETTER THAN SUBSAHARAN AFRICA.

     

     

    India apart from being an ancient civilisation never misses a chance to embraces a good humour. You have these massive jokes flying around all the time. For instance anchors of TV channels were given an extra lobe of the lung by the Almighty, but then He had to remove the spine in order to fit the lobe in. A doctor in Delhi states that rather than supporting corporate hospitals, doctors must support smaller hospitals run by a trust or a doctor.The good doctor seems oblivious of the fact that ,in reality,  more than 90% referrals for coronary angiography by doctors in Delhi are to corporate hospitals. The reasons for the referrals are manifold but the primary cause or incentive for this referral pattern is well known to most, and need not be dilated upon. So much for supporting small and medium sized hospitals.

     

    The manifestly plump chief coach of the Indian cricket team wants us to believe that the current cricket team is the best traveling team for the last 15 years, despite knowing very well that Dravid managed to win a series in England while Ganguly drew one. A 4-1 hammering in a cricket series cannot possibly suggest that the losing team is the ‘best’. Remarkable interpretation by a remarkable coach. But purists in sports will remind us that cricket is played by less than a dozen countries and so it really dos not matter if we get whitewashed in 3 consecutive series in England. They have a point. Especially when we are inching our way up in athletics, which involves the entire world. To have the best middle distance runners in Asia is no mean feat. To beat Japanese ,Chinese Middle Easter athletes in a 1500 m race or an 800 m finals is a terrific achievement by any standards.

    A editorial in the latest Lancet astonishingly lays blame for the sorry state of cardiovascular health in India to British colonialism. Look first at the figures. In terms of the Healthcare Access and Quality (HAQ) index ( Lancet 2017:390:231-66) . Our status in world foot ball is better. India ranks a dismal 154th among 195 countries. India’s football ranking in the world as per FIFA has gone up from 173 in 2015 to 96 this year.. But access to health is quite dismal despite repeated shrill announcements that India has the highest growth rate in the world. And yet only1% of the GDP is channeled towards healthcare in this country as opposed to the 6% spent (on an average) globally. It is clear that the government does not take health seriously. It never did, because if you check all previous health ministers you will find that they were all political lightweights. Father weights in fact.

     

    This brings me back to the mystifying Lancet editorial that quotes from the book ‘Inglorious Empire’ written by the politician Shashi Tharoor. Mr Tharoor makes his case that most if not all ills prevalent in this country are the consequence of the British empire. The British ,Mr Tharoor writes, systematically looted India for 2 centuries and more to bring a nation down to its economic knees. He has been emphasising on various opportune occasions that India, before the arrival of the English, was contributing 27% of the global economy. I cannot help but see a little of Tharoor in the prime minister and a bit of the prime minister in Tharoor. The prime minister never tires of lamenting about the misrule for decades by the grand old party (of which Tharoor is a member), while Tharoor as we see suggests the problems his party faced were created by the looting and tyranny practiced by the British ( Lancet September 12, 2018) for 200 year. I concede that the British did not consider developing healthcare in its colony as its top priority but to pin the blame entirely on them is a bit far fetched , even if the Lancet editorial supports this rather vacuous theory. India lags behind every other BRICS nation in the HAQ index. India is even below Bangladesh,Nepal, Ghana , Sudan and Equatorial Guinea. There are 153 countries providing better health care than India, so we are quite bad, inspite of all the strutting and machinations of the mandarins in Nirman Bhawan (housing the ministry of health and family welfare). I should know, I worked for the federal government as a consultant for almost 19 years. Its a bit silly blaming previous governments for every problem one faces today, but politicians seem to love doing so.

    LANCET 2018, SEPTEMBER 12.

     

     

    The above editorial is directed at the latest very comprehensive data provided by the India State-Level Disease Burden Initiative CVD Collaborators that reports increasing burden off cardiovascular diseases in India since 1990 to 2016. The researchers analysed the prevalence and disability adjusted lie years (DALY’s) because of cardiovascular diseases (CVD) in all Indian states. Mortality due to CVD increased from 15% of total deaths in 1990 to 28% of total deaths in 2016. Mortality rates have almost doubled despite all efforts by successive governments. The DALY’s rate has also doubled from 7% (1990) to 14% (2016). The risk factors involved in 2016 were poor diet (56%) , raised systolic blood pressure (55%), air pollution (31%), high total cholesterol (29%), use of tobacco (19%),high fasting plasma glucose (17%), and high body mass index (obesity) (15%). The prevalence of of high systolic blood pressure, high total cholesterol, and high fasting plasma glucose increased in all states, while smoking saw a decrease during this time ( Lancet Glob Health, September 12, 2018)

     

    According to the researchers the burden from ischaemic heart disease and stroke varies widely between states, but the increasing prevalence and major risk factors are observed across the country. The conclusion drawn is that the gaps need to be filled by “urgent” policy and health system response commensurate to the situation in each state. Now this business of “urgent” response has been going around since I was a medical student. It has been repeated so often that the hollowness has expanded to almost that of the universe.

     

    PREVALENCE OF ISCHAEMIC HEART DISEASE IN DIFFERENT STATES OF INDIA.

     

    The reality is that the crude prevalence of ischaemic hart disease and stroke has been rising all these years despite all “efforts” in every state since 1990. Moreover more than 50% of CVD deaths were in people less than 70 years of age. Worryingly this was seen in the less well developed states ( states with higher prevalence of communicable , maternal, neonatal, nutritional disease). Some of the explanation for the increasing prevalence of CVD in India is an ageing population and the steady increase of risk factors. Increase in risk factors can be accounted for by under-diagnosis ( of hypertension or diabetes) and little access to optimal medication. Also it is well known that certification of cause of death is sub optimal even in the big cities, and therefore this is the best data that we can rely upon to draw any conclusions. Addressing  risk factors is the need of the hour for any government serious about tackling the looming cardiovascular epidemic. It is not enough nor in good taste to criticise previous government. The job in hand has been identified , someone now must make sincere efforts. We cannot and should not  chase red balls swinging away from outside the off stump, we instead have to play the ball according to merit. After all we are not being subjected to a googly, doosra, reverse swing or an out swinger. Because gaps regarding cardiovascular disease have been identified the approaching ball (being reasonably straight)  can be negotiated firmly, but only if there is both will and purpose in our endeavour Empty rhetoric and blame games funded by the mightiest will not suffice. The grim fact is that heart attacks continue to be the biggest killer in this country.  It shall be so for many years to come.