Tackling cardiovascular diseases: What lessons India can learn from US

India needs to strengthen and integrate local, regional, and national health systems

heart-disease-medical-care-doctor-hospital According to reports, the physician/population ratio in India is much lower than the WHO recommendation.

Very recently, actor Mandira Bedi's filmmaker husband Raj Kaushal died of a cardiac arrest in Mumbai at the age of 49. A month or so before Kaushal's death, actor Amit Mistry died of a heart attack, minutes after he finished his breakfast. At the time of death, he was 47. Three years back, well-known industrialist Anant Bajaj, the only son of Bajaj Electricals Chairman Shekhar Bajaj, died due to heart attack at the age of 41 and the same year, actor Inder Kumar, too, lost his life to cardiac arrest. He, too, was in his 40s, no more than 44 when he died.

This is deeply worrying. The young in India are losing their lives to heart diseases in the prime of their age, when they should be living and working to their fullest capacities and contributing towards the growth of the nation. That cardiovascular diseases (CVDs) are the leading causes of death in India is known, going by the number of people we are losing to heart diseases each year. 

According to the World Health Organization, in the year 2016, India reported 63 per cent of the total deaths due to non-communicable diseases, of which 27 per cent were attributed to cardiovascular diseases (CVDs). As per the ICMR India State-level Disease Burden initiative, cardiovascular diseases ranked number one in the list of diseases that led to the deaths among both men and women, across age groups. But what is deeply concerning is that 45 per cent of deaths due to CVDs occur in the working age group of 30-69 years in the country. In India, mortality due to ischemic heart disease—a condition of recurring chest pain or discomfort that occurs when a part of the heart does not receive enough blood—is found to be highest in this working age group.

As per the WHO, “cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels, including coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis and pulmonary embolism”. Covid has only further complicated matters of the heart: As per experts, patients with pre-existing cardiovascular disease and risk factors are more likely to experience adverse outcomes associated with the novel coronavirus disease (COVID-19).

“Although SARS-CoV-2 infects people of all age groups, elderly people with underlying cardiovascular diseases and those with conventional cardiovascular risk factors including male sex, diabetes, obesity and hypertension are particularly vulnerable with high morbidity and mortality,” writes Dr Ankur Gupta, from the department of cardiology at Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh in the March 2021 issue of Indian journal of Medical Research.

In the past two years, as nations have struggled with Covid management, what has come to fore is the underlying preparedness in the areas of Non Communicable Diseases (NCDs) most notably cardiovascular diseases as they form one of the foremost risk factors for COVID-19. With global bodies such as the UN and the WHO setting the goal of reducing the risk of premature mortality (that is death in the age group of 30 to 69 due to preventable cause) from NCDs, including CVDs, by 25 per cent by 2025, cardiovascular disease prevention and control are firmly on the global agenda. Yet, it is the developing world which faces an ever increasing number of patients with CVDs as the burden shifts from the first world countries to low and middle income countries largely because of population growth and aging. India is no exception as it continues to undergo an epidemiological transition from predominantly infectious diseases to NCDs. Here a comparative study between India, an LMIC, and the USA, a developed country, in the area of cardiovascular diseases becomes pertinent as it throws a light on how the latter went through the same situations as we are going through now, and how it reached a point where its CVD numbers began declining; what were the policy frameworks that contributed to the same and how its health system responded to growing challenges.

In his 2018 paper, 'Cardiovascular Diseases in India Compared With the United States', Prabhakaran Dorairaj, associated with the Public Health Foundation of India, writes that even as the prevalence of CVD in India has risen over the past two decades due to population growth, aging, and a stable age-adjusted CVD mortality rate, the United States has experienced an overall decline in age-adjusted CVD mortality, over the same time period. These improvements in CVD mortality in the United States, he says, are largely due to its management of risk factors associated with heart diseases such as tobacco use, cholesterol, and blood pressure, and improvements in acute care. If India, too, were to experience similar gains in reducing premature death and disability from CVD, it would have to implement population-level policies while strengthening and integrating its local, regional, and national health systems, Dorairaj points out.

As per data from the Institute for Health Metrics and Evaluation (IHME), in 2016, there were an estimated 62.5 and 12.7 million years of life lost prematurely due to CVD in India and the United States, respectively. Because of India’s large population, the absolute estimated prevalence of CVD in India (54.6 million) is more than 60 per cent of that in the United States (33.6 million). The very first aspect in which the two countries differ significantly is the area of expenditure on healthcare. In 2014, India’s total per capita health spending represented 4.5 per cent of its GDP as against the 16.6 per cent of GDP involving healthcare spending in the United States. This means that the Indian government spends less than one third on public health, while the American government spends 49.8 per cent of its GDP on public health, writes Dorairaj in his research paper.

"In the United States, the focus is on healthcare insurance coverage, while in India, health spending is largely out-of-pocket, with low insurance coverage. Indians with lower socio-economic positions often depend on the public health system, which has limited capacity for acute and chronic CVD care and may have high out-of-pocket costs in private or non-profit settings. This is not the case in the USA," says Dorairaj, in a telephonic interview to THE WEEK. 

The experiences of India-based Sareeta Diwan and US-based Karina Stalekar best sum this up: When a private school teacher Diwan had to get her aunt treated for a coronary artery blockage, she was forced to shell out close to a lakh rupees for the entire treatment for the lack of medical insurance. It was hard on Diwan who could not afford the high cost and had to take a personal loan to see her aunt through the crisis. Around the same time, Karina Sthalekar, an Indian IT professional based in the US had a smooth run when her brother-in-law required urgent treatment for ischemic heart disease. The entire treatment was paid for. Experts emphasise that the universal health coverage proposed by the central government needs to include care for cardiovascular diseases.

Digital maintenance of health records across the spectrum of health institutions is one aspect which has helped physicians in the States give better care for their patients. This is not the case in India. In rural areas, at the level of primary healthcare centres, this often becomes a problem, say activists. 

"Take for instance a farmer who visits the PHC close to her village once in a month or two and they do not carry the file or the follow-up documents in each visit. At such a time, both the doctor and the patient are in a quandary and many a time patients delay visiting health centres because they've either lost or misplaced documents," says a student of public health from Tata Institute of Social Sciences, requesting anonymity. Health information data in India is gathered by numerous agencies, and most often there is little coordination between these agencies in managing health information and data in their systems. The National Rural Health Mission has taken a step forward in this regard by establishing an integrated nationwide health management information system portal, yet, on the ground things still seem to be running with pen and paper.

Then there is the issue of an acute shortage in the healthcare workforce in India, which is entirely absent in the US. According to reports, the physician/population ratio in India is much lower than the WHO recommendation, that is, two-thirds of health workers operate in urban areas, leaving the rural PHCs, CHCs and more, without as much as one attending doctor at all times. If we were to focus on the shortage in the area of paediatric cardiac care alone, the shortage is acute. 

"The sad part in India is that in most hospitals, the same surgeon who operates on adults, also operates on neonates, despite the fact that the specialty in both cases is entirely different. We hardly have about 20 surgeons across the country who are dedicated pediatric cardiac surgeons. But we need about 10-20 times the number of cardiologists, 20-50 times the number of surgeons than what exists at present," says Dr. Krishna Kumar, clinical professor and head of the department of paediatric cardiology at Amrita Institute of Medical Sciences. There's a requirement of at least a thousand pediatric heart centers for all of India, says Kumar. As of now, there are hardly 50 that operate and of them, the majority are a part of “for-profit institutions” and less than 10 of them are in the government sector spread across India, which means that a very large chunk of population is left with no access to affordable cardiac care for children. 

Another pertinent aspect that led to the decline in deaths resulting from coronary heart diseases in the United States, has been the primary intervention model, which means to treat the risk factors responsible for cardiovascular diseases; because by treating the risk factors CVDs can be prevented. But this 'preventive' model is almost absent in India. Take for example, hypertension or high blood pressure is one of the leading risk factors for CVDs. In India, less than 40 per cent of those diagnosed with hypertension in urban areas are receiving treatment for it while close to 80 per cent of those with hypertension in the United States are receiving treatment with at least one blood pressure lowering drug. Our risk for developing CVDs increases with raised blood pressure and glucose levels, higher consumption of salt, tobacco, increased weight etc. While the US is now managing these risk factors and nipping them in the bud with timely intervention at the initial stages itself, it has been able to prevent deaths occurring due to CVDs. As India goes on from being an LMIC to a developed country, it needs to strengthen its focus on containing the risk factors and preventing them from converting into a full-blown cardiac disease.

Dr Praveen Devarsetty, a public health expert, wrote about the comparison of different strategies for blood pressure management in rural India as a way to tackle risk associated with cardiovascular diseases. In a cross-sectional study involving close to 63,000 individuals over the age of 40 years from across 54 villages in a South Indian district, he found that a substantial proportion of the rural population had elevated CVD risk.

"Despite the fact that most of its population is concentrated in the rural areas, India's healthcare system remains largely focussed in the urban sections only. Our study found that most people in the rural settings remain unaware about their conditions related to hypertension. As of now, the government has begun door-to-door screenings in various villages for diagnosis of CVD risk factors including tobacco consumption, hypertension, diabetes, obesity, smoking, etc. but the challenges still remain. Once the screening is done and the patient is asked to go and visit the doctor, things begin to get murky. Until and unless the ailment prevents the person from doing work, he or she will not consider it to be a disease and hence would not approach a facility. As time passes, complications arising out of CVDs become difficult to manage. So as of now in India's villages, there is a big gap between the diagnosis and the patient actually seeking help in time by visiting the doctor. This needs to be addressed," says Dr Devarsetty from The George Institute for Global Health in Hyderabad.

The policy level focus in India has to be on preventable mortality in order to achieve the kind of success rate that is evident in the US, says Chandrakant Lahariya, a public health policy expert who served in the World Health Organization until recently. "Nobody should die for a cause which is preventable or which could have been avoided by public health interventions such as behaviour and lifestyle factors, socioeconomic status and environmental factors," he said. In 2010, the Ministry of Health & Family Welfare launched the national programme for prevention and control of cancer, diabetes, CVD and stroke (NPCDCS) which was initially limited to 100 districts across 21 states. Thereafter, under the Ayushman Bharat, health and wellness centres (HCWs) were established at the level of primary and community health centres in villages as a way to reach more and more people in remote areas for diagnosis of NCDs.

As per Dr Harsh Vardhan, ex-Union health minister, “The Ayushman Bharat programme has so far screened 838.39 lakh people for hypertension, 683.34 lakh for diabetes and 806.4 lakh for the three common forms of cancer through the HWCs”. Along with the focus of ‘Eat Right India’ and ‘Fit India Movement’, the entire vision of the government is to move from Diagnostic Cure to Preventive Health, he stated. Yet, on the ground, loopholes remain. When this journalist visited a PHC in Chhattisgarh, the HWC was non-existent in practice. The PHC itself was in a decrepit condition, with just a wooden table and a broken plastic chair on the patio outside. The door to the PHC had been locked for almost a fortnight, the villagers informed.

Experts concur that all the challenges which India as a nation faces at present, have been faced by America in the past and have dealt with them in a way that they no longer pose a healthcare risk for the country. Over the years, the United States has managed to bring about substantial declines in age-adjusted CVD mortality due to basic healthcare prevention measures across the country, coupled with improvements in secondary and tertiary care. "To achieve similar gains, India needs to strengthen and integrate its local, regional, and national health systems. Achieving universal health coverage, including financial risk protection, remains an aspirational goal to help all Indians realize their right to health," says Dorairaj.