Richard Doll was a famous British epidemiologist. Along with Richard Peto, a brilliant Oxford statistician, he led a long-term study of thousands of British doctors to identify factors which impacted their health. The study, which started in 1951, carefully documented deaths and analysed them by cause and age. It showed that half of all regular smokers were killed by their tobacco habit. Half of those deaths occurred in middle age. On average, regular smokers lost about 10 years of their life expectancy compared to non-smokers. Deaths occurred mainly from cardiovascular disease and a variety of cancers. Stopping smoking before the age of 30 years averted a majority of these premature deaths.
This study catalysed public policy interventions for tobacco control worldwide. The World Health Organization’s Framework Convention on Tobacco Control and India’s own tobacco control legislation emerged in 2003. Craving for nicotine, which is as addictive as heroin or cocaine, requires a determined effort for cessation. Such efforts are countered by the tobacco industry, which attempts to retain nicotine addicts in its grasp by luring them with novel products such as e-cigarettes and nicotine pouches.
Reducing the risk of avoidable mid-life mortality became a major goal of public health experts, who directed their attention to modifiable risk factors like tobacco consumption (in any form), unhealthy diets, physical inactivity, uncontrolled hypertension and poorly managed diabetes. Doll made the case for impactful public health and clinical interventions which reduce the risk of premature death by succinctly stating, “In old age death is inevitable, but death before old age is not.” He lived to be 92, proving his point.
Delaying death should not be the only goal of public health. Death may come late but disease, damage and disability should not come long before. It is, therefore, necessary to adopt a life course approach to promote policies which prevent acquisition of risk at a young age (childhood and adolescence), early detection of risk factors and their effective control in young and middle-aged adults, coupled with clinical care of manifest disease to avert fatal outcomes and reduce disability at all ages.
Cardio-metabolic diseases (CMDs) are presently the leading cause of death, globally and in India. They encompass a cluster of diseases characterised by disordered glucose and lipid metabolism, resulting in damage to blood vessels in different parts of the body and multiple organ dysfunction which can manifest as acute life-threatening emergencies or chronic prolonged deterioration of health. Coronary heart disease (heart attacks) and stroke (paralytic brain attacks) are the most prominent disorders in this group along with diabetes. Peripheral vascular disease (which can lead to gangrene of limbs), fatty-liver disease and vascular dementia are among others now featuring in the expanding cluster of CMDs.
For a variety of reasons, Indians are especially vulnerable to such diseases. Physiological adaptation to poor intrauterine and early-childhood malnutrition makes them vulnerable to ‘rebound adiposity’, as they gain access to more food in later years. Low skeletal muscle mass makes them more insulin resistant and glucose intolerant, leading to many millions affected by diabetes and pre-diabetes.
Fat accumulation in and around abdominal organs (visceral adiposity) is especially dangerous, as it stokes rampant inflammation, scorching blood vessels and scarring many organs. Lack of physical activity ensures that the muscles remain insulin resistant. Smoking too increases insulin resistance, as do unhealthy fats in the diet. Stress, whether from emotional distress or sleep deficiency, also stokes the inflammatory embers of CMDs.
The burden of such diseases will grow rapidly in India, unless multi-sector public policies and responsive health systems reduce their risk at various stages of life. An ageing population, increasing urbanisation and lifestyles that unwittingly embrace risk are propelling these diseases of maladapted modernity. These diseases are affecting all social classes and are no longer restricted to urban areas.
As the Covid-19 pandemic showed, it is not just the virus that kills. Many lives were lost due to co-morbid conditions which greatly increased the risk of severe illness, hospitalisation and death. These are mostly related to CMDs. This is also true of other respiratory virus outbreaks like influenza. In extreme hot weather—increasingly common as global warming heats the planet—CMD increases the risk of death and disability from acute cerebrovascular and cardiovascular events.
Apart from premature death, there is an adverse economic impact due to lost or diminished productivity. Even among the survivors of acute events, productivity is reduced due to ‘absenteeism’ and ‘presenteeism’. Not only patients but also their care-givers lose working time. Healthcare expenditure proves expensive for families and employers. The health system comes under great strain due to escalating demands, even as it strives to address the unfinished agenda of overcoming threats to maternal and child health, nutritional disorders and infectious diseases.
If we wish to add years to life and life to years, as the Indian population moves towards Viksit Bharat, we have to thwart the threat posed by CMDs. This is only possible if we implement multi-sectoral policies which are conducive to people making and maintaining healthy living choices across the life course. The health system too must gear up services which promote health, prevent disease, detect disorders early and treat them effectively before serious damage occurs. National and state programmes designed to advance universal health coverage must position CMD prominently at all levels of healthcare to provide quality health services which do not impose financial burdens which may lead to ‘forgone care’.
There is also a great need to prepare the required health workforce, capable of addressing the needs of long-term care. From technology-enabled frontline workers to nurses and primary care physicians, there is a need to reorient healthcare teams to the needs of CMD. Their learning has to include use of point of care diagnostics, decision support systems on hand held devices, telemedicine, AI-enabled clinical and socioeconomic data integration, management of multi-morbidity and support for selfcare.
K Srinath Reddy | Chancellor, PHFI University of Public Health Sciences; and Chair, Centre for Universal Health Assurance, Indian School of Public Policy
(Views are personal)
(ksrinath.reddy@phfi.org)
