Sunday, February 12, 2017

NCDs and poverty

First of all, you must be wondering what NCD stands for. Well, NCD stands for non-communicable diseases, diseases such as cancer, diabetes, chronic respiratory diseases, chronic obstructive pulmonary disease (COPD). These diseases are essentially chronic in nature. NCDs are becoming a major public health burden globally, which can be explained by the fact that of the 57 million global deaths in 2008, 36 million or 63% were due to NCDs, a figure which now stands at 68%.

Just like any other person who has not read much about the dynamics of NCDs , I also used to believe, quite ignorantly,  that NCDs are diseases of affluence, ailments which afflict rich people, those living in urban areas until I stumbled resource after resource, report after report upon the premise of chronic diseases in poverty. The fact that poor people can also be affected by diseases such as these seemed implausible to me. I used to wonder that sedentary lifestyle, over-weight, obesity, unhealthy eating habits all contribute to NCDs, and that was right but somewhere I was missing another important point, a point which would later contribute towards more clarity on the risk of poor people  developing chronic diseases. The point was that poor socio-economic conditions were a big determinant of chronic diseases. 

According to WHO report titled, "Global status report on non-communicable diseases 2010", NCDs are the leading global cause of death causing more deaths than all the other causes combined, and they strike hardest at the world's low and middle-income populations. Over 80% of cardiovascular and diabetes death, and almost 90% of deaths from COPD occur in LMIC (low and middle-income countries). More than two-thirds of all cancer deaths occur in LMIC.  In LMIC, a higher proportion (48%) of all NCD deaths are estimated to occur in people under the age of 70 (premature deaths) compared with high-income countries (26%). In LMIC, 29% of NCD deaths occur among people under the age of 60, compared to 13% in high-income countries (HIC).

 The NCD epidemic strikes disproportionately among people of lower social positions. NCDs and poverty create a vicious cycle whereby poverty exposes people to behavioral risk factors. You might be wondering how poverty is related to NCDs. Let us understand. The four major behavioral risk factors for NCD epidemic are tobacco, insufficient physical activity, unhealthy diet and harmful use of alcohol. Now, poor people are more prone to bad behavioral habits such as chewing tobacco and drinking. Further, since they are not able to afford nutritious food, they usually eat energy dense food, for example a soda or even deep fried chips, high oil, high salt and high sugary foods. Uneducated as they are, these people are not aware about the good eating habits, and even if they are, their health is not the first priority, their first priority, you guessed it right, is to have two square meals a day, an employment. Chronic exposure to tobacco and unchecked drinking traps them into an addictive cycle, which is very difficult to break and this further translates into social vices like domestic violence.
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 Since in poorer countries most health-care costs must be paid by patients out-of-pocket, the cost of health care for NCDs creates significant strain on household budgets, particularly for low and middle-income families. Treatment for diabetes, cancer, cardio-vascular diseases (CVD) and chronic respiratory diseases can be protracted and therefore extremely expensive. Such costs can force families into catastrophic spending and impoverishment. Household spending on NCDs, and on the behavioral risk factors (tobacco, alcohol) translates into less money for necessities such as food and shelter, and for the basic requirement for escaping poverty - education. Each year an estimated 100 million people are pushed into poverty because they have to pay directly for health services. One of the findings of a study titled, "Increasing expenditure on health care incurred by diabetic subjects in a developing country" was that subjects with the lowest income spend as much as 25% of their annual income on diabetes. The economic burden on urban families in developing countries is rising and the total direct cost has doubled from 1998 to 2005. 

Thus, it is clear that the danger is very real. India being an upper-middle income country, faces a significant challenge in managing NCDs, more so because of lack of health information systems, surveillance and monitoring facilities of various data related to health outcomes such as morbidity and mortality. India is also accelerating in economy, and with rapid unplanned urbanization people are further prone to developing the NCDs. Our health ministry has not yet woken up to the needs of the health reform in India and maintains an eerie silence despite the deluge of public health interns who come from abroad to India to learn lessons while observing the health challenges of those in destitution and perpetual neglected state. Health seems to have taken a back seat in this headlong rush for increasing GDP. TB is still not out of India and India is already the diabetic capital of the world. This double whammy is going to cost a lot to the health economy of the nation of 1.2 billion. 

The least we can do is to maintain a healthy lifestyle ourselves so that our families are healthier. If all of us begin to think like that we can control the current situation, while ensuring that the future burden is not as big as today's.

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