The Burden of Non-Communicable Diseases (NCDs) – Part 1

A crisis of catastrophic proportion emerging in India currently is the rising burden of non-communicable diseases, labelled briefly as NCDs. These do not cause havoc in the lives of people all at once but kill them one by one. Gradually sapping the vital energy of persons, such diseases cause much pain, misery, disability and premature deaths, leaving in their wake unbearable suffering and penury for all the near and dear ones – children and mothers in particular.

According to the data released by the World Health Organization in Sep 2017, NCDs together are responsible for 61 per cent of deaths in India and more than 70 per cent of the deaths worldwide. There is a noteworthy reduction in deaths (infant, child and maternal) because of eradicating various infectious diseases more or less fully or partially in India. Since last 7 decades since Independence, the life expectancy of Indians has gone up by 36 years (from 32 years in 1947 to 68 years in 2017). However such gains, though very significant, are not getting transformed into improved health (defined by World Health Organization (WHO) as a “State of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” with a proposed addition of spiritual dimension in later years). This is largely because of the wide prevalence of nutrition-deficient health hazards (i.e. anaemia, stunting, wasting and related lifecycle disabilities), the persistence of some old and emergence of some new infectious diseases and particularly because of the rising burden of NCDs. Children and women bear the worst effects of the disease burden either directly (because they are affected by the disease) or indirectly (because their parents, partners, siblings or elders are affected). The focus of this article is on NCDs – the biggest mind-body disease burden of the modern era – the age of unprecedented economic growth, scientific/technological progress and lifestyle transformation.

Non-communicable diseases (NCDs) – meaning: As the very name suggests NCDs are those that are not caused by infectious agents or are not transmitted from one infected source to another. Whereas communicable diseases (CDs) such as malaria, cholera, tuberculosis, polio, leprosy, worm diseases (soil-transmitted), influenza and other types of infections (i.e. HINI, chicken guinea, dengue, Nipah) are spread by either viruses, bacteria and parasites from one infected source to another. NCDs cover a wide range of interrelated physical, neurological and mental diseases. These include physical (body related) illnesses such as blood pressure, heart attacks, stroke, diabetes, cancers, asthma, cataract, osteoporosis in other words many chronic diseases of the heart, blood vessels, throat, lungs, liver, kidney, joints and many other organs of the human body, neurological (brain/nerves) disorders such as Parkinson’s, dementias (predominantly Alzheimer’s) and mental (mind) diseases such as depression, anxiety disorders, phobias (fears), schizophrenia and bipolar disorder. Suicidal tendencies (which lead to suicide attempts and suicide deaths), other forms of self-inflicted harms and injuries, inclusive of various types of addictions to alcohol, drugs, tobacco, social media, selfie and so on are also covered under the label of NCDs as they are manifestations of poor mental health.

Numbers speak: There is perhaps not a single person who has not seen a close relative, friend, colleague or neighbour suffer from or die due to one or more of the NCDs, even though they themselves are not directly affected. There is evidence to highlight the gravity of the problem (see box – estimates of major NCDs). It is important to remember that behind every number cited, there is a human person – child, woman or man (alive or dead), and a family.

Estimates of major NCDsHeart disease: Cardiovascular disease (CVD) is the term used to refer to all types of diseases that affect the heart or blood vessels, including coronary heart disease or ischemic heart disease (clogged arteries), which can cause heart attacks, stroke, congenital heart defects and peripheral artery disease. The death rate due to cardiovascular disease in India rose by around 34 per cent from 155.7 in 1990 to 209.1 in 2016 for every one lakh population. As many as 23.8 million prevalent cases of ischemic heart disease were estimated in India in 2016, and 6·5 million prevalent cases of stroke, a 2.3 times increase in both disorders from 1990. (GBDS, 2018) ¹.

· Cancer: India recorded an estimated 3.9 million cancer cases in 2016, as per the data available with the National Cancer Registry Programme of the Indian Council of Medical Research, (ICMR)(cancerindia.org.in,11-10-2018). Cancer cases in the country have increased to 14,51,417 in 2016 from 12,70,781 in 2013 as per Indian Council of Medical Research (ICMR) cancer registry data as cited in the Lok Sabha (Central Government, 2016)². According to a recent report, 2.5 million new cancer cases are reported each year in India with one death every 8 minutes (Balasubranian, D, 2018)³. According to the National Institute of Cancer Prevention and Research ( NICPR, 2018), an estimated number of people living with the disease is around 2.25 million in 2018, new cancer patients registered every year are over 11,57,294 lakh, and cancer-related deaths are 7,84,821persons (Men: 4,13,519, Women: 3,71,302). ICMR estimates India is likely to have over 17.3 Lakh new cases of cancer and over 8.8 lakh deaths due to the disease by 2020.

· Diabetes: The number of people with diabetes in India increased from 26.0 million in 1990 to 65.0 million in 2016 (GBDS 2018). Out of 100 persons nearly – 9 women and 12 men, are affected by high and chronically high levels of blood sugar in India (NFHS, 2015-16)⁴. According to the International Diabetes Federation, the number of persons with diabetes in India reached 74 million in 2017 and is estimated to reach 134.3 million people by 2045. Diabetes prevalence has increased by 64% across India over the quarter-century (Dey, Sushma 2018)⁵. The most important risk factor for diabetes in India was overweight, the prevalence of which among adults in India increased from 9·0% in 1990 to 20.4% in 2016. For every 100 overweight adults aged 20 years or older in India, there were 38 adults with diabetes, compared with the global average of 19 adults in 2016 (GBDS, 2018)⁶. Nearly 21 per cent women and 19 per cent men are suffering from obesity which makes them highly prone to many NCDs including diabetes (NFHS, 2015-16)⁷.

Chronic respiratory diseases: Incidence of persons suffering from Chronic Obstructive Pulmonary Diseases (COPD) in India increased from 28.1 million people in 1990 to 55.3 million in 2016. The number of asthma cases in India increased from 22·9 million in 1990 to 37·9 million in 2016. (GBDS, 2018)⁸.

Mental Illness: The number of persons who are suffering from mental illness is estimated at 10 per cent of the Indian population. More males (13.9 per cent) than females (7.5 per cent) are affected by mental illness. Nearly 9.8 million young Indians aged between 13-17 years require active interventions for mental disorders (NIMHANS, 2016)⁹. The total cases of depressive disorders in 2015 in India were nearly 57 million people (18 per cent of the global estimates), which was 4.5% of population in 2015 while total cases of anxiety disorders were over 38 million which was 3% of the population – together 7.5 per cent of Indians suffered from both these major mental health diseases, making India world’s most depressed country (WHO, 2017)^{10 and 13}. An Indian Council of Medical Research Report states that 12 per cent of children between the ages of 4 to 16 suffers from psychiatric disorders in India (India Today, 2017)¹². According to a study by the All India Institute of Medical Sciences (AIMS) among school (primary and secondary) children in rural areas of 4^th stage in India, 23 per cent had high blood pressure (BP), exhibiting various degrees of hypertension (Pasha, Ashwath, 2018)¹³. It is estimated that 4 million Indians suffer from some form of dementia. While Alzheimer’s disease is one such neural disorder (1.6 million out of 4 million cases), there are other disorders contributing to dementia too (Balasubramanian, 2018)¹⁴.

Suicides: Suicidal tendencies leading to suicide attempts and suicide deaths are primarily a symptom of the mental health disease burden, sometimes combined with physical diseases. As per available evidence India accounted for more than a quarter of all suicide deaths globally in 2016 – the reported suicide death cases were totally 2,30,314 persons in India – 94,380 women (nearly 37 per cent of the 2,57,624 suicide deaths among women worldwide) and 1,35,934 men (slightly above 24 per cent of the 5,59,523 global suicide death among men). The suicide death rate (SDR) for women in India is 15 per every one lakh women, double than that of the global suicide rate for women (7 per every one lakh women) in 2016. There was an increase of 40 per cent in the number of suicide deaths between 1990 and 2016. As many as 63 per cent of all suicide deaths reported in India were in the 15-39 years age group – 71.2 per cent of the suicide deaths among women (in most cases married women) and 57.7 per cent among men were in this age group (GBDS, 2018)^{15 and 16}. Although more women make suicide attempts than men, more men are likely to die in their suicide attempts than women – an often hidden issue on the subject. An alarming difference is noted in GBDS, 2018 and NCRB, India data¹⁷.

Effects of NCDs: Effects of NCDs are on individuals, families, communities and wider societies inclusive of the economic system. Non-communicable diseases – both physical and mental are a threat to personal well-being as they bring much pain to the affected persons and much suffering and loss to the other members of the family. As there is no complete cure in chronic cases (i.e. heart, blood pressure, diabetes, cancer, certain chronic mental illness cases), continuous use of medication and frequent hospitalization is required. Many of those affected suffer disability which affects their day to day functioning – making her/him more dependent on others for care and support. Caregivers often women members of the family and in some cases men without required competencies for the job, often burdened with excessive work and extra demands on their time, and experiencing high-stress levels may not always succeed in meeting the needs for physical and emotional care essential for such patients. This situation further intensifies for the affected – the loneliness, emotional turmoil and physical pain/discomfort associated with the disease. Institutional care facilities can only reach a minuscule of such patients and often not a desirable alternative for home and community-based care.

NCDs push many families into economic crisis: The heavy costs of long-term treatment despite insurance cover or government support available wipes out lifelong savings and assets of many affected individuals/families, pushing them into debts and penury. The loss of work/labour, productivity and capital from NCDs has serious economic implications at all levels from the local to the global. According to a study released by the World Economic Forum (Nordqvist, C., 2011)¹⁸, the global cost of just 5 NCDs (cardiovascular, diabetes, mental illness, chronic respiratory and cancer) is anticipated to reach $47 trillion over the next 20 years. Mental illness accounts for one-third of the amount ($ 16 trillion). The costs could be much higher in 2018. The rising disease burden of NCDs is already posing a serious economic challenge to India and its states. India is turning out to be a capital for some of the major NCDs such as diabetes, strokes, cancer and depression. This will no doubt place a heavy demand on public resources, as higher per cent of limited public finances has to be provided to address this challenge. According to a more gloomy prediction – the rising NCD disease burden may bankrupt health systems and affect the national and global economics adversely if not addressed immediately on a war footing.

People especially children are caught in the complex web of NCDs: Both the physical body (inclusive of the brain) and the mind constitute one whole, in other words, they are inseparable. In the same vein all the NCDs, whether physical, neurological and mental cannot be delinked from each other. On the one hand, the mental state of a human person generates diseases which are expressed in the physical body brain of the person and on the other hand the physical diseases contribute to the deterioration of mental health condition. For instance, high stress/anxiety levels result in diseases such as high blood pressure, stroke and diabetes just to name a few and in turn heart, lung and stomach related diseases raise the anxiety and hypertension levels in affected persons. In other words, the genesis (factors or causes that lead to) and effects (outcomes or results) of physiological, neurological and mental diseases constitute an inseparable and complex web. It is a matter of deep concern that larger and larger number of adults, adolescents and children are caught in this complex web of causes and effects, resulting in immense physical pain and emotional suffering. Research breakthroughs and advanced medical therapies to address specific NCDs is a part of the challenge. The concerted participatory effort which brings together all stakeholders inclusive of communities/collectives of people in health promotion and disease prevention processes is another very crucial dimension of the challenge.

The second part of this article will deal with various factors leading to NCDs and ways and means available for people to promote their own health and prevent them from succumbing to these diseases

References:

Global Burden of Disease Study – 1990-2016, 2018, “The changing patterns of cardiovascular diseases and their risk factors in the states of India”, Lancet Public Health Journal, 2018
Central Government, 2016, “Number Of Cancer Cases Have Increased Over Last 3 Years”: NDTV, Dec, 02
Balasubramanian D, 2018, “Conquering the Emperor of Maladies”, The Hindu, 10-06-2018.
NFHS (National Family Health Survey, India), 2015-16
Dey Sushma, 2018, “Diabetes Bleeding India Dry”, Times of India, 5^th of October
Global Burden of Disease Study 1990–2016, 2018, “The increasing burden of diabetes and variations among the states of India”, The Lancet Global Health, September, 12th
NFHS (National Family Health Survey, India), 2015-16
Global Burden of Disease Study 1990–2016, 2018, “The changing patterns of cardiovascular diseases and their risk factors in the states of India”: The Lancet Global Health, September
NIMHANS (National Institute of Mental Health and Neuro Sciences), 2018, National Mental Health Survey of India, 2015-16
WHO (World Health Organization, 2017, “Over 5 crore people suffer from depression in India”: Live Mint, Feb 24^th, 2017,
Meenu Katariya, 2018, “India Is The World’s Most Depressed Country With Every 6th Indian Suffering From Mental Illness”, October 10th
WHO, 2017, “9 types of mental disorders among children: Symptoms and warning signs”, New Delhi, India Today, April, 18th
Pasha, Ashwath 2018, “AIMS Study finds 23 per cent prevalence of hypertension among rural school children”, The Hindu, Sep, 29^th
Balasubramanian D, 2018, “Neuro degeneration to neuro regeneration, Exercise helps”, The Hindu, October, 6^th, 2018
The Global Burden of Disease Study, 1990 -2016, 2018, Gender differentials and state variations in suicide deaths in India: https://www.thelancet.com/action/showPdf?pii=S2468-2667%2818%2930138-5, Sep. 11th
Archana Jyoti, 2018 “India accounts for 37% women suicides globally”, The Pioneer, September, 13^th, (https://www.dailypioneer.com/2018/page1/india-accounts-for-37–women-suicides-globally.html),
Economic Times Bureau, 2018, “Alarming Gap between Lancet and NCRB suicide data”, Sep 14 (https://economictimes.indiatimes.com/news/politics-and-nation/alarming-gap-between -lancet-ncrb-suicide-data/articleshow/65803575.cms),
Nordqvist, Christian, 2011, “Five Non-communicable Diseases, $47 Trillion Global Burden Over Next Two Decades, Medical News Today, 18^th September