Epidemic of Chronic Ailments.

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thehindu wrote: Mon, 19 Dec 2005 16:47:56 +0530thehinduSubject: Article from The Hindu: Sent to you by JagannathEpidemic of Chronic Ailments.=============================================================This article has been sent to you by Jagannath ( jagchat01 )=============================================================Source: The Hindu (http://www.hinduonnet.com/2005/12/19/stories/2005121905271100.htm)Opinion- News Analysis Responding to a public health challengeG. AnanthakrishnanThere are nearly 70 million people with kidney disease of varying severity levels in India. Hypertension and diabetes, the main causative factors, need to be targeted. IN A paper he

co-authored in a recent issue of The Lancet, Union Health Minister Anbumani Ramadoss argues that a comprehensive prevention and control strategy is needed to check the growing national prevalence of diabetes, respiratory and cardiovascular diseases, which, together with cancer, cause an estimated 53 per cent of all deaths and 44 per cent loss of Disability-Adjusted Life Years (DALY). The Minister's call will certainly resonate with health professionals who have been campaigning for the inclusion of prevention and control measures in the public health system. Many life-threatening complications resulting from diabetes and hypertension are widely discussed but kidney disease does not get the same visibility. End Stage Renal Disease (ESRD), which requires therapy in the form of dialysis or kidney transplant, is invariably financially ruinous for the patient and his family. Prevention, therefore, has to be the focus both of health policy and medical education.

There are nearly 70 million people with kidney disease of varying severity levels in the country; the figure could be higher but more accurate data is not available because of inadequate testing and reporting.Maintenance dialysis for those with ESRD merely to stay alive is prohibitively expensive in the Indian context in the absence of a state-funded programme. It has to be financed almost entirely out-of-pocket. One study found that nearly 70 per cent of patients starting on dialysis in a sample area died within twelve months because they could not sustain the treatment beyond six months. Even if it were to be economically feasible, dialysis is considered by many medical professionals to be less effective compared to transplants, since it may not provide a satisfactory quality of life. Again, transplants are even more difficult to obtain for the majority of patients for a variety of reasons, starting with costs. Given such a challenging background,

aggressive prevention and control strategies against chronic diseases gain importance. The two major factors causing kidney disease are type 2 diabetes and hypertension and the need to get a grip on these is emphasised by A. Vishnu Moorthy, a nephrologist and university faculty member in the United States, who was recently on a lecture tour of medical colleges in India. Chronic renal failure has reached "epidemic proportions" and it could take a turn for the worse, he warns, referring to the World Health Organization forecast of a diabetic population of 57 million in India in 2025. Such a high prevalence would portend serious consequences for public health and economic productivity. In their paper in The Lancet, K. Srinath Reddy, Bela Shah, Cherian Varghese and Dr. Ramadoss give the national prevalence of diabetes and hypertension, the two major causes of renal failure, as follows: 11.8 per cent for diabetes in the urban areas and 3.8 per cent in rural areas, and in

the case of hypertension, an equally worrying 20 to 40 per cent in urban adults and 12 to 17 per cent among rural adults.The benefits of early diagnosis of diabetes and hypertension at the community level became internationally known when the ten-year project of the Kidney Help Trust (KHT) in Sriperumbudur taluk of Tamil Nadu produced remarkable results. The validated programme pioneered by M. K. Mani, chief nephrologist, Apollo Hospitals, Chennai and managing trustee of KHT won recognition for preserving good renal function among people at risk. Prevalence of renal function impairment among the population not covered by the project was 27.51 per 1000 and in the area where it had been working, it stood at 10.79 per 1000. Kidney failure was therefore prevented or the onset delayed in 17 persons per 1000. Rewarding programmeSuch a rewarding programme can be scaled up effectively, Dr. Moorthy believes, if the primary health care personnel are trained

to follow the prescribed protocol: to identify diabetes and hypertension early and manage these conditions in the general population. Good drugs to prevent the progression of kidney disease must find a place in treatment regimens. The growing burden of chronic diseases is expected to inevitably strain the resources of the medical community. The United States expects to have a dearth of nephrologists in about ten years because of higher patient load. India has programmes to train doctors in nephrology, but there would still be a shortage because a significant number migrate to the Middle East, Australia, and other countries where demand is increasing. The medical curriculum is not designed to teach students about the importance of early detection of conditions that threaten kidney function. The situation demands that nephrologists (and not general physicians) must train students; they must also be examined in the subject adequately, suggests Georgi Abraham, council

member of the International Society of Nephrology.Strategies for prevention are particularly relevant to India because of the weaknesses in the healthcare system. Government hospitals do not provide free maintenance dialysis; in many instances, patients with chronic renal failure waiting for dialysis in Government institutions must give way to those with acute renal failure caused by factors such as snakebite or other poisoning. The United States by comparison spends about 13 billion tax dollars annually on dialysis; the cost of treating a patient with ESRD runs to $46,500 a year in the U.S. Japan has more patients on dialysis than the rest of Asia and fewer patients with a transplant than all other Asian countries combined. The two most powerful economies — the U.S. (which has 19.2 million adults living with kidney disease) and Japan — have begun to accord high priority to prevention and control, considering the rising budgetary costs involved in treating

renal failure."The Government has to realise that it cannot have economic growth without health. You cannot have prosperity and an IT boom if 25 to 30 per cent of your population is going to develop hypertension and diabetes," says Dr. Moorthy. A preventive effort led by p7hysicians, public health personnel, private practitioners and non-governmental organisations holds the key.There is also an urgent need for more research on health outcomes. Public registries modelled on the U.S. can provide an accurate picture of the prevalence of kidney disease in the general population. Maternal nutrition is also believed to play a key role in developing chronic disease. The nutrition link is postulated by the Barker hypothesis, which states that malnutrition before birth and during infancy predisposes individuals to chronic diseases — diabetes, hypertension and by extension kidney problems — in adult life. Providing adequate nutrition to women and children is

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