The Health of the Nation

An old adage observes that knowledge is power and that information can be liberating. Indeed, the collection, analysis, and dissemination of information should not only be seen as an exercise in scientific inquiry but instead as a critical tool for guiding the formulation and implementation of policies to address complex societal problems. This is particularly true for understanding, and even predicting, the dynamics of health transitions of populations so that targeted and multifactorial interventions can be implemented to protect and promote health.

The Global Burden of Disease Study, initiated 26 years ago, does just that. The study reports are published periodically, and chart the change in health transitions and patterns of disease-related deaths across eight regions of the world. Estimates of years of life lost to premature death as well as the years of disease-related disability that is weighted for severity, expressed as a combined metric of Disability Adjusted Life Years (DALYs), provides greater focus for action within countries. The first-of-its-kind Indian State-Burden Initiative report was released last week by the Vice President of India, and a technical report published in the journal Lancet. This report describes such health related trends for every state from 1990 to 2016, and allows comparisons of health loss between diseases, risk factors, sexes, age groups, and over time. While the results of the study can be gleamed with an online interactive tool, following are the study highlights.

The highest risk factors

Determining and addressing risk factors for major diseases may lead to a reduction of the overall disease burden. The study raised alarms of the potential of 3 categories of diseases - undernutrition, air pollution, and noncommunicable diseases - to become national epidemics.

Despite a decline from 1990 levels, child and maternal malnutrition remains the single largest risk factor, contributing to 15% of the disease burden in 2016. Undernutrition increases the risk of common infections as well as neonatal disorders, nutritional deficiencies, diarrhoeal diseases, and respiratory disorders. With the under-five mortality six times higher than Sri Lanka and burden of child and maternal malnutrition 12 times higher than in China, India has wide gaps to bridge.


Fig. 1. Child and Maternal malnutrition risk factor attribution to population DALYs. (original data can be found here.)

Second, air pollution levels in India are amongst the highest in the world, making it responsible for 10% of the total disease burden in the country. Outdoor air pollution levels have steadily increased since the 1990s, leading to increases in risk of cardiovascular diseases, chronic respiratory diseases, respiratory infections, and cancer.

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Fig. 2. Air pollution risk factor attribution to population DALYs. (original data can be found here.)

Third, a group of risks including unhealthy diet, high blood pressure, high blood sugar, high cholesterol, and being overweight, which mainly contribute to ischaemic heart disease, stroke and diabetes, caused about 25% of the total disease burden in India in 2016, up from about 10% in 1990.

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Figure 3. Dietary risk factor attribution to population DALYs. (Original data can be found here.)

Inequalities among States

The report found some encouraging results in that life expectancy at birth improved in India from 59.7 years in 1990 to 70.3 years in 2016 for females, and from 58.3 years to 66.9 years for males. Additionally, the per person disease burden, from all causes, dropped by 36% in the same period. However, the report highlighted stark inequalities among states with the per person DALY rate varying widely between them. For instance, the life expectancy of women in Uttar Pradesh is 12 years lower than that of women in Kerala, while the life expectancy of men in Assam is 10 years lower than that of men in Kerala. The under-five mortality rate has reduced substantially in all states over 25 years. But there was a four-fold difference in this rate between the highest, in Assam and Uttar Pradesh, as compared with the lowest in Kerala in 2016. These interstate differences underpin the inherent inequalities still present in  21st Century India where states in early stages of the health transition are not only coping with the persisting challenges of infectious, nutritional and pregnancy-related health threats but are also coping with the rising magnitude of non-communicable diseases faced by the whole nation. The WHO asserts that equal access to the highest attainable standards of health is a fundamental and inalienable right of every human being. Bridging the gap between disabilities and years of life lost due to disease across states should therefore be an agenda of national importance.

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Fig 4. State level distribution of population DALYs for all causes. (Original data can be found here.)

Recent reports indicate that the Modi government has approved a three-year budget for its public health program almost 20% lower than what the health ministry said is required. The GBD-India data highlight the need to develop customised, state-level responses to address the major contributors to diseases and, thus, help the National Health Policy as well as the government’s flagship National Mental Health Policy to set and track the progress towards country-level targets. The unacceptably high disease burden of undernutrition and air pollution needs to be addressed by large-scale, systematic interventions implemented at a national and regional scale. Results of research done in regional settings show promise of scaling up, such as the results of the innovative pollution auditing intervention in Gujarat or the lay health worker led interventions for combating alcohol abuse in Goa. Similarly, addressing the dangers of non-communicable diseases through massive public health programs in the food, agriculture and urban development (since NCDs are significantly more prevalent in urban areas) sectors can prevent deterioration of health statuses across state and socioeconomic boundaries. Achieving the overall health targets for India and reducing health inequalities among states are pressing needs, and cannot be addressed in the face of budget cuts. If left unattended, we risk impeding the rapid economic and social progress to which India aspires.

Aneree Parekh