| (L-R) Dr Ratna Devi, CEO, DakshamA Health and Education, Dr Kenneth Thorpe, Chairman of the Partnership to Fight Chronic Disease (PFCD) and Dr Shashank Joshi, President, Indian Diabetic Association |
Viveka Roychowdhury, Editor, Express Healthcare:
We welcome our guests on the panel: Dr Kenneth Thorpe who is the Chairman of the Partnership to Fight Chronic Disease (PFCD), Dr Shashank Joshi, a renowned diabetologist and Dr Ratna Devi, CEO and Co-founder of DakshamA Health and Education.
Between them, we have three important stakeholders in the fight against NCDs: a policy expert, a clinician and a health management professional who has worked in private and government health facilities and now bridges the gap between the two and patients.
Let me start by asking Dr Thorpe to share his experiences while engaging with policy makers in India on the topic of NCDs. I will ask him to juxtapose this with his experience in the US where he has been associated formulating healthcare policy. Are we on the right path in India?
Dr Thorpe: We’ve seen a number of interesting things during our trip to India. One is that there is obviously a consensus that the magnitude of the problem of chronic diseases (NCDs) in India is substantial and is growing. There are currently around 65 million diabetics and going by current trends this is going to increase to well over 100 million diabetics pretty soon. The magnitude of the problem is substantial. I think people have a common understanding that there is a substantial problem.
Second, I think that there is a common understanding that the capacity of the prevention and delivery system that is currently in place is not well equipped to deal with that problem.
Third, if you look at the gap between what’s needed in terms of system delivery and patient treatment, I think there is growing interest in coming up with a blueprint and broad thinking nationally about a comprehensive healthcare reform framework that really focuses on three issues:
How do we do a better job of preventing the growth in chronic disease?
How do we increase disease detection rates so that we can clinically intervene earlier?
And thirdly, building a primary care team-based care management system that really deals with patients that have not just one but multiple chronic conditions.
The other realisation is that most times, we tend to categorise and look at silos whether its diabetes, hypertension and so on.
The reality is that most patients having chronic disease have several chronic diseases ranging from mental disorders, diabetes, other cardiovascular risk factors and so on. So having a system in place that really effectively engages patients to keep them healthy is the third part which I think still needs to happen.
Roychowdhury: Dr Shashank Joshi, Dr Thorpe mentioned that patients have multiple diseases. What is your perspective coming from your clinical experience? You have published many papers based on your research on the Indian population on this aspect and your conclusions are that early detection and early diagnosis is part of it. How do you actually implement those kind of things here in India?
Dr Shashank Joshi: There is no simple answer. We as Asian Indians are based out of India but we have this huge change happening in the last 200 years. To be more specific, in the last 30 to 40 years which is development and growth. We have abandoned our ancestral habits. We have moved from tribes to villages to small towns, from small towns to big towns to big cities within India. Asian Indians are also one of the the largest migrant communities across the world.
Whenever you migrate and improve your socio-economic status, you become affluent and sedentary and that is giving rise to a whole cluster of NCDs, whether it mental health which leads to stress leading to depression, anxiety or disease like blood pressure or diabetes or coronary artery disease.
They all have a common thread, which is clustering of these metabolic risk factors. They are all fundamentally due to sedentary work habits, probably improper diet and probably some genetic transformation. We were a famine ridden economically deprived country and physically very active. So obviously, over the last few hundred years we have conserved the fuel storage needs in our stomach. And that abdominal fat has led to the metabolic syndrome.
So we cannot have disease specific options. I think you have to have NCDs as a common goal, common theme and deliverables which can be done (at the level of) healthcare workers, lay persons.
On the other hand, we are one of the largest exporters of healthcare workers, whether it is doctors or nurses, across the world. Our best graduates are migrating to different parts of the world, whether it is to the Middle East, Europe and North America. So our healthcare system is grossly understaffed. We have one of the worst doctor:patient ratios.
But the bigger challenge in prevention is looking at pre-disease, into hidden disease. That burden of disease is very large and that needs political will as well as individual will to make a change. And we have not yet empowered either our policy makers or our individuals to make the change.
It has to be a movement. Unless and until we are able to crystallised it into a movement, we will not be able to make a dent on the numbers. For example, in diabetes, we are committed that we want to change our diabetes numbers. So when I was president of RSSDI, we had only a prevention mantra but that time we were the number one country in the world in the diabetes. Now we are happy that we are number two! We would be happy to be in last in this list!
But we are not stopping there. As healthcare providers, our theme is very clear: we want to be the diabetes care capital of the world. We want to give the best care, we want to get the best prevention strategy in place. And we have to do capacity building for our own healthcare providers. Our capacity building is very woefully lacking.
Also remember, compared to Western populations, we are a completely non-reimbursed market. Health is number 22 (on the priority list) so we cannot expect the government to do any change. Everybody in India pays for healthcare out-of-pocket. Our public health infrastructure is not commensurate with our general population. 92 per cent of our healthcare delivery, even today in urban India, is through the private sector. More than 82 per cent of our healthcare delivery even in rural areas, occurs though the private sector, which speaks a lot for our public health infrastructure. Obviously there are gaps. We need to change that.
Roychowdhury: Dr Ratna Devi, you could be in some way part of the change because you been bridge between political will and the patient will and other stakeholders as part of it so you’ve been the unifying structure there to implement what the government wants to do with the help of other stakeholders. So can you share with us your experience, what kind of projects are being done in India and what more needs to be done.
Dr Ratna Devi: Unfortunately in India, culturally, we do not consider healthcare as a priority. Even when we are healthy and there is an incident, we try to postpone a visit to the doctor or to manage our healthcare on our own till it becomes a crisis situation where we can no longer postpone it. That’s one of the reasons for the high costs of healthcare which could have been prevented had some intervention taken place at the primary level itself.
There are several reasons for that. I think traditionally we are stoic population who like to put off things, saying it will correct itself over a period of time. There have been traditional ways of managing small incidences and when those things do not work, then we seek care at a hospital or healthcare facility.
As Dr Joshi mentioned, there has been lot of migration. People moving from rural to urban areas bringing massive changes in lifestyles and consequently no time to seek healthcare. Even if a person wanted to, daily life is so grueling that it is impossible to seek healthcare without losing your daily wages or without losing your job opportunities. So the whole concept of managing your own health, that ‘I’m the person responsible for my own good health’ does not exist.
Also, there is low health literacy. Whether it is the so-called rural population or the urban educated population, you don’t see behaviour change happening in spite of good messaging, in spite of reading the right stuff, in spite of people being told by their physicians. Or even inspite of people having other members in the family suffering from the same disease.
Prevention just does not happen. I think that is because people live in denial. Most often people think, ‘It’s not going to happen to me’. And one of the reasons could be the cost of healthcare. The general understanding of people is that if you go to a hospital, you end up with something that you did not know existed and that could result in a lot more spending that you had not expected.
For good examples (of existing healthcare delivery projects), the best one that I can relate to is the HIV movement, where the patients themselves formed peer groups and the stigma that was associated with the diseases was removed. There was lot of awareness generation because people talked among themselves. The movement was successful because people came out from their homes, got themselves tested and those who were positive, were then directed towards healthcare facilities.
In the NCD segment, that kind of moment is yet to start. There are a few organisations working in that particular area, specially the cancer groups, where there has been a lot of advocacy and awareness generation. Enrollment has happened so people are coming forward to seek treatment. It is still in a very very nascent stage and lot of work needs to be done to get people mobilised to work together, to become aware that what we are talking about, actually affects everybody and then start working towards prevention so that they are the managers of their own health.
Lakshmipriya Nair: Dr Thorpe, can you give us some examples of successful programmes that have been implemented in other countries and can be implemented in India so that NCDs can be controlled.
Dr Thorpe: On the prevention side, I can think of two things that happened in US. One, is that smoking rates declined from about 50-55 per cent of the population in the 1960ties to 20-21 per cent of the population today. So if you look at that big decline in smoking, combined with the more extensive use of statins, and other types of cholesterol-lowering drugs, anti-hypertensives etc, cardiovascular mortality rates in deaths due to strokes have dropped dramatically. There’s been some important successes there. There are lot of reasons why smoking rates went down. A part of it is the high taxes we imposed, both at the state and federal level, on buying of tobacco products. But there is also a shift in social perception of smoking that happened over a long period of time.
On the obesity side, we have lot of good data now from a intense lifestyle intervention programme called the diabetes prevention programme. Very similar programmes like that have been operated in very diverse countries: Finland, China, the US. We have 10 years of data from the US randomised trial that shows that that programme targeting overweight pre-diabetic adults has resulted in cumulative reduction in the incidence of diabetes. There are elements of that programme (diet, exercise, nutrition, physical activity and exercise goals) that could be and have been adapted in a variety of different settings.
On the treatment side, where all the money is, in terms of expenditure associated with chronic disease, one of the things I think we’ve learnt from looking at data over the last decades, is that we will need to use interdisciplinary health teams. And they don’t have to all be primary healthcare physicians. Managing and working with patients and engaging with patients to be compliant in terms of taking their medication, having the right combinations of medicines and dosage of them, can be done with community health workers, home health aides, nurses, nurse practitioners working with primary care physicians that are doing the basic and fundamental diagnosis of the disease. Going by the data we have, those health teams have resulted in the dramatic reductions in rate of hospitalisations, the rate of re-admissions to hospitals, the number of emergency room and clinic visits. So that is one of the very good success stories we could look at in a variety of different countries to find ways to scale those teams and replicate their success.
A lot of what we are talking about here is not necessarily health insurance benefit designed but is related to population and public health interventions that need to be more widely diffused in countries like India as well as in the US, in order to combat these problems.
| About the panelists |
Usha Sharma: Dr Joshi, as a doctor, how are you increasing awareness about NCDs as well as creating better platforms to access medication?
Dr Joshi: The situation is extremely critical in India. I would say that it is a danger zone because NCDs are driving two things. One is they are killing people. The average life span of a Mumbaikar is eight years less than an average Indian. And why does he die early compared to rest of the population in India? Because seven out of 10 causes of death are NCDs. I.e diabetes, chronic heart disease, respiratory disease, hypertension, COPD, pollution related asthma etc. We all are living here but we all are going to die eight years before rest of the people in India. This is hardcore data from our own city.
Let us look at causes of death at a national level. Just 10-20 years back, (the highest deaths) were from diseases like tuberculosis and communicable diseases. HIV gets more media publicity but its intervention programme is in place. Today it is NCDs that are killing (patients). Even mortality indicators are clearly showing that these diseases kill.
But the bigger problem than mortality is that these diseases are affecting the productive years of people’s lives, which are the years between 25 to 55 years. We know that all the NCDs in India occur a decade or so earlier than in the Causacian population. We have lower BMI, our body structure is smaller but our body composition has more fat and therefore we are ‘thin fat Indians’.
We are actually abdominally obese, with high insulin resistance which is driving the epidemic. When somebody (is diagnosed with) diabetes or blood pressure, it is not the disease that kills, it is the burden of the disease which comes due to the complications of the disease. The disease is diagnosed almost a decade late, it comes almost a decade earlier and as Dr Ratna Devi rightly said, people in India get diagnosed late and only go to a doctor in a crisis. Indian diabetic patients do not take their diabetes as seriously as this: they will exercise a bit, change some dietary habits, take alternative medicines and then dismiss it as a ‘mild sugar problem’. Till he has a heart attack, or his kidneys fail or he becomes blind or his legs are amputated.
Whereas in the US, in 2003, the American Diabetic Association and American Heart Association had said, that if you have a simple diagnosis of diabetes, it is equivalent to a heart attack. Here, the rates of deadly retinopathies, renal failures, amputations and heart problems have reduced because their prevention programmes are in place. Of course, they have a reimbursement system in place as well … of course there are problems with Obamacare, but they do have some systems in place.
So firstly, NCDs kill. Secondly, they cripple and maim. And the economic costs of complications arising due to NCDs is very very large. These complications put fear into patients and they go into denial mode. So we have got into a vicious cycle which needs to be broken.
We need to recognise that NCDs are epidemical in India, they are killing Indians and we are clearly in a danger zone. The average life of any Indian or an urbanite Indian residing in any city of the country is lesser than that of an average person living in the world.
We also have a double burden of a large paediatric population as well as a very large geriatric population. One fourth of the geriatric population of the world lives in India. So we need to have things in place and not be in NCD denial mode. Our healthcare professionals, particularly from the Health Ministry, need to recognise that.
Our tobacco control and smoking cessation programmes have just come into place via some legislations and taxations. Also, fast foods are breaking our ancestral food habits and diets. Our Government should ban or tax these products heavily so that they are unsustainable in India because they are damaging our health and economy.
So we should not deny that we have an NCD problem; we need to tackle it aggressively at every stage, be it pre disease or end stage and we need to ensure that we empower our patients.
Currently our healthcare infrastructure is over burdened so healthcare providers do not have the time. So therefore we need to have more nutritionists, counselors and patient support systems in place. We need to have peer groups, as Dr Ratna Devi was saying, Unless you take drastic steps there will be no change. Otherwise it will be too late to manage it. NCDs have clearly overtaken the communicable diseases.
Sanjiv Das: Do certain dietary habits predipose us to diabetes? For instance, I am from the state of West Bengal and all Bengalis love their sweets. Rice is also a staple of our diet. And many of our relatives have been diagnosed with diabetes. What advice can you give for such populations?
Dr Joshi: Eating sweets and rice does not mean that you will develop diabetes as long as you are physically active. Physical activities can reduce the chances of having diabetes. If there’s a family history of diabetes then this can increase the chances of diabetes.
There are two major risk factors for diabetics in India. One is family history and the other is abdominal circumference. Men with an abdominal circumference of more than 90 cm and women with more than 80 cm are at a greater risk to develop any of the NCDs or metabolic syndrome cluster of disease conditions like increased blood pressure, a high blood sugar level, and abnormal cholesterol levels.
My advice is very simple: eat moderately and exercise. Prevention is all about motivation and empowerment. Walk at least 1000 steps a day, and you can walk away from diabetes and other NCDs. A community movement is necessary for general awareness and I don’t think it is impossible.
Roychowdhury: Dr Ratna Devi, what are your key recommendations for the government?
Dr Ratna Devi: My first recommendation is to recognise patients as a very strong voice that can contribute very positively at different levels, whether it is at the prevention, management or a service delivery platform. In all these platforms they (the patients) have a definite role. If it is a large enough group, they can be a very strong voice to bring about changes at the policy level as to what is the most conducive way to reach out to populations that need those kind of services. For prevention strategies, since we are such a diverse country, it is very important that patients are involved in message dissemination, message construction, as well as converting those messages into behaviour change. In terms of service delivery, there have been excellent examples where people who have come out of a situation have been able to convince other people to adopt healthy means and these could be expert patients who are then trained so that they can manage situations at the community level or at the home level. This is the first recommendation I have, to be able to recognise them as a very strong voice that can contribute very positively at different levels.
The second one is to empower them with the right amount of knowledge and the tools. There is a lot of information available but how to understand that at an individual level to be able to connect or correlate to the disease condition or the disease syndrome that the patient has, is very difficult. That is the reason why we hear a lot of stuff but we do not really imbibe or understand what exactly it is trying to convey to us. So, empower them with the right knowledge and the right tools. When we say tools, there are lot of diagnostic kits and home made kits available in the market but how easy are they to use, how comfortable are people really with these kits? Patients may buy an instrument but the paraphernalia that goes with it is sometimes not available. So empower the patients so that they are able to use the tools with the right knowledge and the right information.
Thirdly, make the patients responsible for their own disease outcomes, manage their own disease in a way that they feel happy at the end of a certain period that they have achieved the targets they set for themselves. It is very difficult in the current situation because as we said, our health system is so over burdened so that kind of space just does not exist. But what we can do is have counselors from amongst the patients or caregivers who can then come forward and do this work for them.
Roychowdhury: Dr Thorpe, we do see certain policy initiatives with a health focus like the recent increased tax on tobacco products. What would be your recommendations?
Dr Thorpe: I will start in a couple of places. One of the things that I have mentioned in the beginning is to develop a national framework, a national road-map for driving the reforms we’ve been talking about, that will prevent the growth in NCDs, do a better job of early detection and then manage and work with patients to do that.
If you have to be successful then a couple of things have to happen with the blueprint. One recommendation is to recognise the power of partnerships. The magnitude of this problem, be it any country, be it India, Indonesia, US, etc is quite substantial. The government is not going to be able solve this by itself. So, patients, providers, employers and those whom they employ, should work collaboratively so that it is part of a process.
Secondly, we have to find new ways to unleash the extraordinary amount of entrepreneurship and innovation, which is already here in India. In so many sectors of the Indian economy there has been a lot of innovation in international leadership going on, innovation in entrepreneurship. We have to harness that in some way in order to make it a part of the reform process, for coming up with innovative ways for preventing disease or doing delivery system reforms. For instance, take the role of electronics, the role of some of the new monitoring devices that are available and are being developed. We can look at more innovative and effective ways of preventing and managing these diseases,
Finally, to lay this blueprint down, you must see what the requirements are and have a discussion on how are you going to get to pay for it, to decide what is fair and what makes sense. I was really struck by how low India’s spend on healthcare is as a percentage of its GDP. The bulk of it, over 60 per cent, is paid-out-of-pocket. So I think as part of the framework discussion, they should have a debate, a discussion on what role is expanding private insurance going to play. Does the type of private insurance that currently exists in the market make any sense in terms of treatment needs of chronically ill patients? I think that probably there is a big gap between what the insurance covers and what you really need to provide healthcare services that are clinically effective to chronically ill patients. If you can get more money from the private sector to do this then is there an opportunity for the government sector, over a period of time, to increase their commitment towards those at the lower end of income distribution, for those who are living in poverty, and for coming up with a national framework for public health infrastructure that would be adopted obviously at the state-level?
So that would be a starting point. If we have a road-map that engages a wide variety of stakeholders and takes the best of the best – there is a lot of good thinking out there in terms of provider groups, insurance groups, patient advocacy groups, employers and so on – then we will have all of these people sitting at the table trying to solve the problem.
Roychowdhury: What will be the role of PFCD in this scenario?
Dr Thorpe: We’d love to serve as a resource to work with different groups that are interested in putting this framework together. We have found, at least in the US, that is increasingly working in a variety of different countries, that having a stakeholder approach, that ‘we pull together’, we have around 100 different organisations working together collaboratively, with policy makers, who are putting together policies to solve the NCD problem. We started out by highlighting the problem, (like we did here today), in recognising the problem. We need to make a quick transition into implementing a best practice solution to solving these problems. A starting point in terms of the framework is cataloging what are the effective interventions out there that we’ve seen internationally or in India through existing pilot projects that work. How can we scale and replicate those successful models so that they are available throughout India and not in some limited pilots?