India’s Prevention Paradox
Photo: Patrick Beznoska on Unsplash
COVID-19 has again put the failures of our health care system in the spotlight. Shefali Saldanha argues that an overhaul should bring to the forefront the conversation about preventing sickness, before treating the survivors of our failed health policy.
For my mother—who grew up in the 60s and 70s—a bottle of Coca Cola was a special treat, permitted about once a month. I imagine that this was true of many Indians of her generation. Today, for most Indians, a Coke is no longer a rare treat; the soft-drink is easily available in every corner of the country, often easier to find than fresh vegetables.
Unchanged from my mother’s childhood, however, for the Dharavi dwellers in my hometown of Mumbai is the question of water. For many, even water remains unaffordable now at Rs.25 per gallon. These seemingly-innocent attributes of our food environment, and water and sanitation systems, have a devastating impact on our health and well-being.
The shortcomings of India’s approach to keeping its citizens healthy have been brought to light during the COVID-19 pandemic. Though no country sufficiently prepared for coronavirus, India’s failure is remarkable. India has one doctor for every 1,456 citizens, much below the WHO recommended ratio of one doctor for every 1000 citizens. Government healthcare spending at 1.25% of GDP in 2017-18 is substantially less than the OECD average of 8.8%. The pandemic has revealed how overburdened our medical system is with patients with all sorts of illnesses not getting sufficient attention. Doctors, activists, citizens have all rightfully called for an overhaul of our medical system beginning with significantly more overall government spending.
However, what good does it do to have doctors to treat COVID-19, but not running water so that people can wash their hands enough to not catch the virus? What good does it do to provide insulin for diabetics, when the Indian food environment causes diabetes?
While improving health care is absolutely necessary, equal attention should also be paid to the environment that is causing Indians to become sick, as well as to employing population-level prevention strategies that would allow citizens to lead healthier lifestyles. These goals would help reduce the overall burden on the medical system. Even in the year 2020, millions of Indians continue to die from preventable illnesses. Neonatal diseases still make up the top cause of death and disability in the country.
In my earlier essay, I examined how the majority of Indians do not have sufficient defences against COVID-19 because they do not have access to clean water and sanitation, a basic human right that should be afforded to all citizens, making minimum regular hand-washing nearly impossible. The simple act of hand washing could prevent not just COVID-19, but the seasonal flu which kills millions, and other diseases. What’s more, having access to clean water can prevent diarrhoea, cholera, typhoid, E. Coli, dysentery, and more. Yet often when discussing the issue of diarrhoea, the entirely preventable disease that is the fourth leading cause of death in the country, the lack of oral rehydration solution (ORS), and rotavirus vaccine is highlighted as the problem, rather than the contaminated water that caused it.
Poor water and sanitation is estimated to have caused over one in ten deaths of children under five in India in 2015, and cost 5.2% of GDP in 2015. Whereas, the World Health Organisation estimates that every 1.00 USD invested in Water, Sanitation and Hygiene reaps a return of 4.30 USD in medical cost savings and greater productivity. Fixing this is a no-brainer, and the current Government has demonstrated political will with the Swachh Bharat initiative. Despite criticisms, Swachh Bharat has increased rural access to toilets by 31% (40 to 71%) since 2012, a true success despite missing the ambitious target of 100%. Along with improving access to toilets, we also need to improve access to clean water for handwashing to prevent water-borne diseases.
Giving all citizens access to water and sanitation is just one example of a population-level prevention strategy that the Government could employ to stop millions from dying from preventable illnesses. Examining and regulating the food environment that is causing the growing incidence of diabetes in our country, earning it the title of ‘Diabetes Capital of the World’, would be another. There were 72 million victims of our toxic food environment suffering from diabetes cases in 2017, and this number is set to almost double by 2050 with the greater availability of processed, unhealthy foods at prices affordable to all income brackets. Rather than develop the army of health professionals and insulin stock that would be required to manage type-2 diabetes and all the medical complications associated with the disease, the Government would be better off implementing evidence-based regulations on our food environment such as soda taxes, bans on the sale of junk food in and around hospitals and government buildings, and more effectively, stop spending USD 1.7Bn annually (Rs.124Bn) to subsidise sugar, the leading cause of diabetes.
What good does it do to have doctors to treat COVID-19, but not running water so that people can wash their hands enough to not catch the virus? What good does it do to provide insulin for diabetics, when the Indian food environment causes diabetes?
There is precedent for this kind of policy intervention. In Chile, where diabetes and obesity is also a huge problem, within 18 months of enforcing regulations that ban junk food 100 meters from schools, the consumption of sugary drinks declined by 25%. A similar government policy is showing results in Mexico. India too is taking a step in the right direction by proposing to ban the sale of junk food within 50 meters of schools. Many more such preventative regulations are needed to restrict the growth of type-2 diabetes by improving our food environment.
Hence, when thinking of overhauling the health system in India, greater investment should be in population-level prevention strategies, not just care. We are aware of the top ten risk factors that drive the most death and disability in India in 2017 include unhealthy food, undernutrition, air pollution, tobacco, and access to clean water and toilets. Simon Fraser University’s Professor Bruce Lanphear highlights, “Once we know the causes, we can prevent disease. Yet we spend most of our health dollars on treatment, and a never-ending, ever-elusive search for cures.” Only five of the last thirty years gained in life expectancy in the past century is due to medical care, the rest is due to improved environments that prevent people from getting sick. Yet, typically around the world, 95% of spending is on clinical treatment strategies, 5% on population-level prevention strategies.
Our current Government has correctly identified these problems and has policies such as Swachh Bharat which at least, on paper, show political will to implement interventions, which would ensure not just improvement of health care infrastructure, but prevent illness, to begin with. For example, the National Health Policy 2017 lists targets such as increasing spending on health to 2.5% of GDP by 2025, also includes seven priority areas for improving the health environment such as water and sanitation (under Swachh Bharat), food environment (under Eat Right India), air pollution, tobacco consumption, and road injuries. These policies will only be as good as its implementation. Swachh Bharat has highlighted the challenges of rolling out such a programme in our country, and the importance of proper legislated procedures detailing implementation, maintenance, and monitoring.
COVID-19 has shifted the focus on health, and the importance of prevention. A recent Lancet journal article titled the Cost of Preventable Disease in the USA highlights, “Can we not extend the lessons learned in the past year to bring about a permanent doubling down on prevention, putting it at the heart of our conversations on health, well beyond the COVID-19 pandemic? This would require us to embrace the notion that no amount of preventable illness or death is acceptable.”
In the context of India, this means we need to see every death from poor water and sanitation as plainly unacceptable, and every death from diabetes as the result of policy decisions benefiting the food industry over health.
We have no time to waste. Lives are on the line. We must take concrete steps to provide reliable clean running water to our citizens, to tax unhealthy foods (not to forget to stop subsidising them first), and ban their sale around key facilities such as school and hospitals, and make sure that the policies that we legislate are actually implemented on the ground before more lives are lost. When discussing how to overhaul the health care system, let’s bring to the forefront the conversation about preventing sickness, before treating the survivors of our failed health policy.
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Shefali Saldanha is Singapore-based working for an Impact Investing firm managing the India portfolio. Previously she worked for a social enterprise based in Mumbai. She has an MBA from Oxford, a BA from the University of Virginia and over a decade of experience working in the social sector space in India and regionally. You can find her at linkedin.com/in/shefalisaldanha.
