public health response to lifestyle diseases

 sickle_s.gif (30476 bytes) People’s Democracy

(Weekly Organ of the Communist Party of
India (Marxist)


No. 19

May 19,2002

Public Health
Response To Lifestyle Diseases

Amit Sen Gupta

IN recent years
there has been increasing focus on what are termed as “lifestyle diseases”.
These are diseases that are brought on by an unhealthy lifestyle – sedentary habits (low
physical activity), preference for unhealthy “junk foods”, over-indulgence in
addictions like tobacco and alcohol, etc. MNCs led globalisation encourages trade in
unhealthy products – alcohol, tobacco, and baby foods. As a consequence people in the
third world are suffering from the ill effects of “development” superimposed on
the problems of underdevelopment. The WHO estimates that approximately 2 million deaths
every year are attributable to physical inactivity; and preliminary findings from a WHO
study on risk factors suggest that sedentary lifestyle is one of the ten leading causes of
death and disability in the world.


In a country
like India a large percentage of the population suffers from under nutrition and are
forced into long hours of backbreaking physical labour. But at the same time there is a
significant section of the poor who are prey to lifestyles diseases because of changes in
the work environment and conditions of living. In the rapidly growing large cities of the
developing world, physical inactivity among large parts of the population is assuming
alarming proportions. Crowding, poverty, crime, traffic, low air quality, and a lack of
parks, sports and recreation facilities, and sidewalks make physical activity a difficult
choice. Even in rural areas of developing countries sedentary pastimes, such as watching
television, are increasingly popular. Inevitably, the results are increased levels of
obesity, diabetes, and cardiovascular disease.
In the entire world, with the exception
of sub-Saharan Africa, chronic diseases (a majority of which are related to changing
lifestyles) are now the leading causes of death.

It is thus not
possible to argue that lifestyle diseases are a concern of the rich and the public health
system need not respond to the challenge posed by them. In fact recent studies have shown
that South Asians are more prone to diseases like heart disease and diabetes. The question
then is, how should the creation of medical infrastructure reflect the changing pattern of
disease among large sections of the population.


While the
concern on lifestyle diseases is correctly premised, the prescriptions from a public
health standpoint have often been misplaced. Lifestyle diseases mean diseases like heart
disease, diabetes, cancers, etc. As a result, a perception has been created that any
strategy to tackle these problems needs to look at the creation of
“super-specialty” hospitals with “state of the art” facilities. This
is an erroneous perception that has been carefully orchestrated to develop a
“market” for expensive health care. The fundamentals of public health
apply as much to lifestyle diseases as to communicable diseases. In both cases, greater
emphasis on improved services at the primary level, that is the level where the patient
first comes in contact with the health care provider, is the most effective.

There is a trend
today towards creation of facilities for treating lifestyle diseases, which are distinct
from the existing infrastructure. In recent years there has been a mushrooming of such
facilities, especially on metropolitan centres and large cities. Many of these have been
set up by the corporate sector, with large dollops of help from the government in the form
of land at concessional rates, concessions on imported equipment and other forms of tax
relief. On the other hand the New Health Policy explicitly states that the private sector
would play an increasing role in providing tertiary care, that is care in large
institutional settings. The combination of a private sector trying to create a market for
high cost care and the government’s support is creating a class divide in health
care. What is not understood is that lifestyle diseases do not affect only those who are


What we need to
understand is that medical infrastructure needs to be structured like a pyramid. In this
pyramid the maximum emphasis has to be at the primary level, i.e. at the level of first
contact that should be easily accessible (both physically and in terms of affordability)
by everyone. Thus the first contact would be at the village (or panchayat) level, and in
urban areas through dispensaries that are widely dispersed. From here there should be
successive rungs of the infrastructure, at the sub-Block, Block, District, State levels.
Each successive rung needs to be equipped to perform more complex tasks and take care of
more complex conditions. This has to be followed up with a referral system along this
pyramid. Such a system minimises waste (viz. in the form of trivial or self-limiting
illnesses being treated at District or state level hospitals) and enhances accessibility.

In India we, on
paper, have such a system in operation. Unfortunately, on the ground, this system is
woefully inadequate. Thus the infrastructure below the District level is non-existent or
rudimentary. This places enormous burden on patients who have to travel large distances
and a huge load on the facilities available at state and district levels. The reason for
this is two-fold. First, while in a pyramid the strength of the base is most important, we
somehow have this erroneous notion that the excellence of the system depends on the
apex—i.e. specialty hospitals in metropolitan centres. The other reason is that India
(among any country of significant size) has the most privatised health system in the
world. Private expenditure accounts for 84 per cent of health care costs in the country.
In contrast in most of the developed world it is as high as 70-90 per cent, even in the US
(with the most privatised system in the North) public (i.e. government.) health
expenditure is 44 per cent of the total. In GDP terms too, at 0.9 per cent of the
GDP health care spending in India is one of the lowest in the world. Significantly there
has been a decline in this from 1.3 per cent during the last decade, i.e. the decade of
economic reforms.


The above has
many implications. As far as the government sector is concerned, health care expenditure
tends to be skewed in favour of the metropolitan centres (i.e. the apex of the pyramid),
because this is the most visible part. Spending on large hospitals and super-specialties
satisfies, to an extent, the vocal elite and middle classes. On the other hand low
government expenditure leads to a proliferation of the private sector. Interestingly the
latter is the largest unregulated sector of the economy, with a turnover that exceeds
30,000 crore. In recent years this has spawned interest by the corporate sector, aided by
the government in the form of tax concessions, land at subsidised rates, freedom to import
equipment without duties, etc. The entry of the corporate sector has further skewed
medical infrastructure creation towards super-specialty hospitals, because that is really
where big money lies. Further the lack of basic facilities in the government sector,
especially in the districts, has led to medical manpower being concentrated in big cities
and metropolitan areas.

The issue of
medical infrastructure creation needs to be located in the above background. While we
cannot argue that we do not need super-specialties, we need to argue that we need primary
care more, and super-specialty hospitals should not be built at the cost of such care.

the National Health Policy Draft, 2001, talks about using Indian health facilities to
attract patients from other countries. It also suggests that such incomes can be termed
“deemed export” and should be exempt from taxes. This formulation draws from
recommendations that the industry has been making and specifically from the “Policy
Framework for Reforms in Health Care”, drafted by the prime minister’s Advisory
Council on Trade and Industry, and headed by Mukesh Ambani and Kumaramangalam Birla. Such
a proposal, termed by many as “health tourism”, will divert our best resources
to serve the interests of the global health market and create islands of brain and
resource drain within the country.

The issue of
lifestyle diseases is being projected as though they can be treated only in tertiary high
technology institutions. It is true that as India passes through a phase of demographic
transition (with people living longer) incidence of diseases like heart disease, diabetes,
cancers, hypertension, will increase. But the same pyramid analogy, used earlier, applies
here too. These diseases can be tackled at an early stage only if facilities at the
primary and secondary level are improved. The cost of treating many of these conditions
becomes prohibitive (and unaffordable for most) if they are encountered late and have to
be treated in super-specialty centres.

All the above,
of course, requires a complete overhauling of the medical infrastructure in the country,
and above all greatly enhanced public spending on health care. It also requires a change
in the mindset, which posits that good health care is always synonymous with
super-specialties and high technology.

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