India Can Tackle the Looming Cardiovascular Disease Epidemic, But Only If There Is Political Will

Unless the government makes serious efforts towards tackling the risk factors of cardiovascular diseases, heart attacks will continue to be the biggest killer in the country.

India, apart from being an ancient civilisation, never misses a chance to embrace good humour. You have jokes flying around all the time. For instance, did you know that TV anchors 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 says, rather than supporting corporate hospitals, doctors must support smaller hospitals run by a trust or a doctor. The good doctor seems oblivious to the fact that, in reality, more than 90% referrals for coronary angiography by Delhi doctors are to corporate hospitals. The reasons for these referrals are manifold, but the primary cause or incentive for this pattern is well-known and need not be dilated upon. So much for supporting small- and medium-sized hospitals.

The chief coach of Indian cricket insists that the current team is the best travelling side in the last 15 years, despite knowing very well that Rahul 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 – a 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 doesn’t matter if we get whitewashed in three consecutive test 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 and West Asian athletes in a 1500 metre race or an 800 metre finals is a terrific achievement by any standards.

An editorial in the December 2017 issue of the journal Lancet astonishingly blames British colonialism for the sorry state of cardiovascular health in India. Look first at the figures in terms of the Healthcare Access and Quality (HAQ) index (Lancet 2017:390:231-66). Our status in world football is better. India ranks a dismal 154th among 195 countries. India’s world football ranking 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, only 1% of the GDP is channeled towards healthcare in this country as opposed to the 6% spent (on an average) globally. The government clearly 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. Tharoor makes his case that most, if not all, ills prevalent in this country are the consequence of the British empire. The British, Tharoor writes, systematically looted India for two centuries and more to bring a nation down to its economic knees. He has said on various occasions that India, before the arrival of the English, contributed 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 suggests that the problems his party faced were created by the looting and tyranny practised by the British for 200 years. I concede that the British did not consider developing healthcare in their colony, 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, below Bangladesh and Nepal. Worldwide, it figures below Ghana, Sudan and Equatorial Guinea, which are among the 153 countries providing better healthcare than India. This shows how bad a situation we are in, despite all the strutting and machinations of the mandarins at Nirman Bhawan (housing the ministry of health and family welfare). I should know, as I worked for the Central government as a consultant for almost 19 years. It’s a bit silly blaming previous governments for every problem one faces today, but politicians seem to love doing so.

The Lancet editorial is directed at the latest, very comprehensive data provided by the India State-Level Disease Burden Initiative that reports increasing burden of cardiovascular diseases in India from 1990 to 2016. The researchers analysed the prevalence and disability-adjusted life years (DALYs) because of cardiovascular diseases (CVD) in all Indian states. Mortality due to CVD increased from 15% of total deaths in 1990 to 28% in 2016. Mortality rates have almost doubled despite efforts by successive governments. The DALY rate has also doubled, from 7% in 1990 to 14% in 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 high systolic blood pressure, high total cholesterol and high fasting plasma glucose increased in all states, while smoking saw a decrease during this time.

According to the researchers, the burden from ischemic 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 an urgent policy and health system response commensurate to the situation in each state. Now this business of an 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.

The reality is that the crude prevalence of ischemic heart 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 big cities; therefore, this is the best data that we can rely upon to draw any conclusions. Addressing the 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 governments. The job in hand has been identified, and 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 outswinger. Because gaps regarding cardiovascular disease have been identified, the approaching ball (being reasonably straight) can be firmly negotiated, 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 are the biggest killer in this country and will remain so for many years to come.

Deepak Natarajan is a cardiologist based in New Delhi.