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Hitting at the Heart of Asia's Development

A gathering pandemic of chronic disease is impoverishing millions of families and threatening the health care systems of developing countries.

SUPER SIZE RISK A mother helps her son, a patient in the obesity treatment section of a Shanghai hospital. Obesity-related ailments have skyrocketed in the People’s Republic of China as wealth has grown.
Photo by AFP

As Dr. Devi Shetty delicately stitches a new valve into the heart of a poor laborer on an operating table at Bangalore’s Narayana Hrudayalaya Heart Hospital, the renowned cardiac surgeon ponders an impending epidemic of heart disease in his country and other developing nations of the Asia and Pacific region.

Millions of Asians and Pacific islanders now have a deadly cluster of risk factors for the biggest chronic disease killers, cardiovascular diseases (CVD)—heart disease and stroke. Overweight from inactivity, fastfood diets, high blood pressure from excess salt, and tobacco use, they have the same risk factors that clogged arteries in Western countries decades ago.

In the World Health Organization’s (WHO) Western Pacific region, which encompasses 37 countries and areas, an estimated 25,000 people die everyday from chronic noncommunicable diseases (NCD), with over 20,000 of these deaths in developing countries.

The impact on economic and human development in the region is staggering. WHO estimates that in the decade up to 2015, preventable CVD, diabetes, and other illnesses like lung cancer from smoking will cost the People’s Republic of China (PRC) a staggering $558 billion. India’s loss for the same period is estimated at $236 billion.

“It is disastrous when a breadwinner is afflicted,” says Dr. Shetty, who serves some of India’s neediest heart patients. “The costs and loss of income throw the entire family into poverty.”

According to WHO, chronic diseases are by far the world’s biggest killers, and their impact is steadily growing with approximately 17 million premature deaths yearly as a result of a global epidemic. One billion people worldwide are overweight, and that figure is expected to balloon to 1.5 billion by 2015 without immediate action.

Contrary to the myth that these diseases are more common in wealthier nations, this epidemic causes more casualties in low- and middle-income countries, where 80% of all chronic disease deaths occur, says WHO. Health experts and doctors who deal with this issue everyday do not need to know the numbers to see that chronic diseases are having a devastating impact on the development of Asia’s people and economies.

“When I operated in England, the average age of patients was 65,” explains Dr. Shetty. He now commonly sees Indians 20 years younger crippled by the same heart disease, stroke, and diabetes.

Dr. Cherian Varghese, a NCD expert with WHO, says in his home state of Kerala, India, time and again he has seen families driven into poverty by the death or crippling of wage earners through heart attack or stroke.

WHO estimates, by 2010, 60% of the world’s heart patients will be Indians. This is partly because South Asians are more genetically prone to heart disease, stroke, and diabetes than Europeans, say physicians who deal with the issue.

South Asia, not North America or European Union countries, now has the highest level of CVD globally. An insidious ailment that develops over a lifetime, it often goes undetected, culminating in a devastating heart attack or stroke. According to WHO, a similar health disaster is playing out from Fiji Islands to Pakistan, the Maldives to Bhutan.

A small number of preventable risk factors cause the vast majority of cases of chronic diseases. Three of the most important are unhealthy diet, physical inactivity, and tobacco use.

One in every three smokers in the world is a Chinese male. The majority of these smokers are of working age, and highly vulnerable to tobacco-related sickness and death, which will rob untold tens of millions of Chinese families of their only wage earner.

Just two decades ago, it was unimaginable that the leading cause of death among urban Chinese today would be CVD, with stroke rates higher than those of western countries. The National Nutrition and Health Survey 2002 discovered that around one in six Chinese has high blood pressure with only one quarter of them aware of their condition.

Although these grim statistics are partly due to an aging population, the main driving force behind Asia’s epidemic of chronic disease is as easy to see as the expanding waistlines across the region.

Coronary artery disease is now the number one killer in countries such as the Philippines and Indonesia, according to WHO. In these countries, scarce public health care funds are spread even thinner by the double burden of battling communicable diseases in tandem with these chronic illnesses. The prematurity of NCD deaths is an economic and development issue, as the age of breadwinners dying from CVD falls every year in the Asia and Pacific region.

A global epidemic of diabetes is also hitting Asia and the Pacific harder than anywhere else, according to WHO, which estimates cases in Asia will skyrocket by 90% in the next 20 years, with an expected 330 million ffected. If these rising rates of diabetes are left unchecked, the region will soon be home to 61% of the world’s diabetics, with 100 million cases in the PRC and India alone.

Underfunded public health care systems are ill-prepared to deal with millions of new diabetics, a disease that affects every organ in the body, is a leading cause of CVD, and whose complications can include blindness and kidney failure. Diabetes is now the leading cause of limb amputation in Singapore.

Government health programs will be overwhelmed as untold millions of Asian children—overweight from junk food, sugary soft drinks, and inactivity—make the epidemic multigenerational. The disease usually shows no symptoms until the damage has been done with catastrophic future consequences for the four out of five diabetics in many Asian countries that go undiagnosed.

The only good news is that although chronic diseases are the most common and costly health problems, they are also highly preventable. In the past, funding for major CVD prevention and control has been neglected say experts. But that must change as campaigns against chronic diseases will require the same marshaling of both financial and human resources that have been employed to combat communicable diseases such as malaria, polio, and HIV/AIDS, in order to prevail over this new threat to the region’s health and development goals.

Mobilizing support for the prevention and control of chronic diseases in Asia’s developing countries will contribute to poverty reduction by improving the health and productivity of millions.

According to WHO, governments need to invest in better disease surveillance and broad public health campaigns to encourage healthier living, and has proposed a bold new global goal: to reduce the projected trend of chronic disease death rates by 2% each year According to WHO, governments need to invest in better disease surveillance and broad public health campaigns to encourage healthier living, and has proposed a bold new global goal: to reduce the projected trend of chronic disease death rates by 2% each years.

WHO’s Dr. Gauden Galea points to a group of 7,000 residents of Da Quing, PRC, at high risk for diabetes, who cut their risk in half with a healthy diet and exercise program. A Finnish study showed that a modest loss of only 5 kilos over 4 years and regular exercise bestowed an impressive 58% risk reduction in 7,000 men.

Innovation will play a key role. Dr. Shetty and his colleagues have started the Yeshasvini Health Scheme, a health insurance plan for a few rupees a month that puts international quality care within reach of millions of farmers in the southern Indian state of Karnataka, sparing them catastrophic health costs.

Dr. Shetty and his team also set up the Integrated Telecardiology and Telehealth Project, with the help of the Indian Space Research Organization, a telemedicine system that has enabled hundreds of thousands of poor, rural Indians to consult cardiologists hundreds of kilometers away, saving them what is often a futile trip of several days.

As Dr. Shetty points out, 95% of patients do not require surgery but treatment with medicines. He hopes to see the system eventually used as a preventative and educational tool and a model for the rest of Asia.

In the past, countries such as the PRC and India have spent too little on health care; the former spends less than 1% of gross domestic product. Dr. Varghese and others see the current financial crisis as an opportunity to curb chronic diseases.

As Asian governments plan to spend billions on infrastructure projects to stimulate spending, some of those resources could go to creating open spaces in densely populated areas—green spaces where people can exercise—as well as improving local food production, processing, and labeling, especially encouraging farmers to grow locally better and more affordable produce.

In addition, money could be invested in public education about disease risks and how to avoid them; screening programs; and updated, more accessible local health clinics offering affordable combination drug treatments. Any public information program would likely go hand-in-hand with a campaign to prohibit smoking in public places to curb secondhand smoke exposure. While some steps would require only modest funding, all would be helpful weapons in the battle against chronic diseases.

A WHO World Health Report examined the vast evidence-based knowledge about inexpensive and cost-effective measures to produce rapid health gains and for which the benefits far outweigh the costs. Examples include salt reduction in processed foods; improved school meals; and taxation of tobacco products, which is not only cost effective but also raises revenues for governments for chronic diseaseprevention campaigns.

Countries in the region can also learn from each other’s successes in the war against chronic diseases and support region-wide initiatives. Thailand enacted a model tobacco control program with effective law enforcement, bans on promotion and smoking in public places, vending machines, health warnings on cigarette packages, and taxes from tobacco products devoted to anti-tobacco efforts and health promotion.

The Ministry of Health of the PRC, with the support of WHO, developed medium- and long-term, high-level national plans for chronic disease prevention and control; many other countries have done the same. To achieve the WHO goal of saving 36 million lives from chronic diseases in the next 10 years, all sectors— from government and private enterprises to civil societies and community-based organizations—must work together, explains Dr. Shigeru Omi, former WHO regional director for the Western Pacific.

“This has to be a joint effort,” says Dr. Omi. “We know what to do, and we must do it now.” •