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Rapid Changes in Asia Alter Health Landscape

K. Srinath Reddy

 

Many of the highly populous nations of the world are located in Asia. China, India, Indonesia, Bangladesh and Pakistan together add up to 45 percent of the world’s population. The health status of these countries, therefore, has a major bearing on global health indicators. Most of the countries of this large continent fall into the low- and middle-income categories. Their health profile is similar to that of developing countries across the world, with some regional variations. The rapid changes in the developmental and demographic profiles of these countries over the past two decades are reflected in an altered mix of the major public health challenges that they now face.

Until about 30 years ago, the developing countries of Asia were mainly threatened by infectious diseases, nutritional deficiencies and unsafe pregnancies, resulting in a huge burden of death and disability in childhood and early adulthood. This pattern has now changed, swiftly and substantively. While some of these health problems do remain a concern and call for continued action, new threats to health have emerged, not only in the form of HIV/AIDS but also in terms of chronic illnesses, such as cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. We can examine how chronic diseases have evolved in Asia, using China and India as the main case studies and cardiovascular disease (CVD) as the primary chronic disease of interest.

Delayed, but determined, industrialization and recent, but relentless, urbanization have initiated the socio-economic and demographic transitions that propel the health and nutrition transitions in Asia. Globalization, which constituted the tail wind of the 20th century, greatly accelerated the progression of the chronic diseases by altering tradition as well as trade. Marked alteration of living habits, within a single generation, has seen risk behaviors lead to biological risk factors and then on to chronic disease-related clinical events at steeply spiraling rates.

The age standardized death rates for cardiovascular disease were 365 per million for the Southeast Asia region of the World Health Organization, as compared to 202 per million for the Americas, in 2005. In China, the proportion of deaths attributable to CVD, chronic obstructive pulmonary disease and cancers rose from 41.7 percent in 1973 to 74.1 percent in 2005. Even in the rural areas of Andhra Pradesh, India, CVD accounted for 32 percent of all deaths in 2004.

Many of the chronic disease-related deaths, in the low- and middle-income countries of Asia, occur at a much younger age than in the high-income countries of the world. In 1990, India was estimated to have lost 9.2 million potentially productive years of life, due to CVD-related deaths occurring in people 35-64 years old (570 percent more than the U.S.). The projected loss of productive life years from premature deaths caused by CVD will reach 17.9 million in 2030 (940 percent more than the U.S.). The corresponding losses for China were estimated to be 6.7 million years in 2000 and 10.9 million years in 2030.

According to estimates by WHO, economic losses that result from CVD, diabetes and cancer, are expected to be US$558 billion for China and US$237 billion for India, during the period 2005-2014. For families, the economic consequences can be disastrous. Among the survivors of a stroke in China, for example, 71 percent experienced catastrophic health expenditures. In the south Indian state of Kerala, of families with people who had cardiovascular disease, 73 percent suffered catastrophic expenditures, 50 percent resorted to distress financing, and 40 percent lost sources of income. As the CVD epidemics advance globally, the poor are becoming increasingly vulnerable, among countries and within countries.

Policy Implications

Though policy responses to these epidemics were initially slow and hesitant, they have begun to take shape and gain traction over the past few years. These responses have to be examined in terms of their approach to the control of risk factors, as well as the development of national programs for providing preventive and clinical services.

India and China are major producers of tobacco, both in terms of agriculture and manufacture. India overcame its reluctance to curb the tobacco epidemic about a decade ago. Strident advocacy by civil society groups, judicial activism to uphold the rights of non-smokers, the persuasive impact of growing global scientific evidence on the health effects of tobacco, the catalytic effect of the global inter-governmental negotiations on the Framework Convention on Tobacco Control (FCTC), the changing attitude of the media, and growing political support for tobacco control measures combined to decisively swing the balance in favor of a comprehensive tobacco control legislation that was initiated in 2001 and secured parliamentary approval in April 2003.

India’s tobacco control law calls for a ban on most forms of advertising (other than at point of sale), prohibition of smoking in public places, prominent (pictorial) health warnings on tobacco products, a ban on the sale of tobacco to people under 18 years of age, and testing of tobacco products for their emissions and ingredients. The enforcement of these provisions, however, needs to gather strength across the country.

The wayward tax policy needs to be rectified. While cigarettes could certainly do with higher taxes, other smoked tobacco products (“Beedis”) and smokeless tobacco continue to be very minimally taxed. However, a National Programme for Tobacco Control has been launched in 2008 and is being scaled up.

China has been more hesitant in enacting similar tobacco control measures, since tobacco manufacturing industries in China are owned by the government. However, China has begun to implement smoke-free policies for public places, spurred on by the smoke-free Olympics of 2008. But the absence of an organized civil society movement for tobacco control is a contributor to China’s slow progress in this arena. Recently reported declines in male smoking rates, though small, are a welcome sign.

Lifestyle Changes

Nutrition and physical activity, too, demand attention at the policy level in both countries. Edible oil consumption has risen sharply in both countries, as has the consumption of salt, fat and sugar-rich processed foods and beverages. In India, the per capita consumption of edible oil has nearly doubled in recent years, up from 128Kcal/per capita/day in 1983 to 240Kcal/per capita/day in 2003. Even within the very short time window between 1989-1993, the proportion of Chinese people consuming more than 30 percent of their daily calories in the form of fat rose twofold in the low-income group (from 19.1 percent to 36.4 percent) and threefold in the high-income group (from 22.8 percent to 66.6 percent).

Salt is an important risk factor for hypertension in both countries, especially in China which has a high incidence of strokes. Reduction of salt in processed foods requires high priority, along with public education to reduce salt during cooking and at the table. Increase in the production and domestic consumption of vegetables and fruits will not only provide many protective phytonutrients, but also act as a channel for supply of dietary potassium which counters the effect of dietary salt on blood pressure. Policies are also needed to counter the growing consumption of meat and to encourage the consumption of fish. As obesity levels rise sharply in adults and children in both countries, policies must address the aggressive marketing of high-calorie but low-nutrient beverages and fast foods. Availability of healthy edible oils at affordable prices is needed, while the removal of trans-fats from processed foods has become a public health priority.

Urban design polices for enabling safe and pleasurable physical activity, as part of the daily routine of all citizens, are imperative to counter the ill effects of unplanned growth wherein pedestrian pathways are shrinking, protected cycle lanes are disappearing, and open spaces are becoming a rarity.

Integrations into Health Systems

Health services, too, need to be reconfigured to integrate health promotion, risk factor detection and management, cost-effective acute care and chronic care services for periodic re-evaluation. The needs of the health workforce also must be addressed, with non-physician health-care providers recruited to strengthen prevention and early risk detection in primary care settings.

India introduced a pilot component of the National Program for Prevention and Control of Diabetes, Cardiovascular Diseases and Stroke, in 2008. Based on the evaluation of this program, conducted in 10 districts, it is proposed to be scaled up to a national program in mid-2010. But this vertical program needs to be integrated into the national flagship health programs like the National Rural Health Mission (launched in 2005) and the soon to be initiated National Urban Health Mission.

China has been working on a framework for a national program for prevention and control of non-communicable diseases for more than six years. It should be ready to launch sometime soon. There have been several large-scale pilot programs for cardiovascular disease prevention in major cities (Beijing, Shanghai and Changsha) and at individual worksites. A community-based diabetes prevention trial has also validated the effectiveness of diet and physical activity in reducing the incidence of diabetes in high-risk individuals. China has strong surveillance systems for diseases and risk factors. Its Centers for Disease Control are well developed and capable of providing strong leadership to the national program when it is launched.

Other Asian countries are gearing up to respond to the expanding threat of cardiovascular disease also. Pakistan has developed a national action plan for non-communicable diseases (NCDs). Thailand, with its strong public health system, is developing a primary health-care approach to NCD prevention and control. All of these developments in Asia would need to be closely monitored over the next decade to evaluate the impact of multi-sectoral policies and programs on CVD. It would be equally important to ensure that these programs are well integrated into the overall health system rather than function as isolated vertical programs, which lack resources, penetration and impact. This space clearly needs to be watched closely.

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Resources

• Preventing Chronic Diseases: A Vital Investment, WHO Global Report.
• Oxford Health Alliance
• Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the Threat of Chronic Diseases in India. The Lancet, 2005;366: 1744-1749.
• Health Systems Reform in China, Lancet Series, Oct. 20, 2008.
• Heartfile

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K. Srinath Reddy is president of the Public Health Foundation of India.