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Rapid Responses: Rapid Responses published:
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Prevention is better than cure: there’s no other way
- G.N Malavige (2 April 2004)
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Mental health neglected malady in South Asia
- Anil Pandit (2 April 2004)
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Coronary Heart Disease in India: Absolute Numbers and Economic Burden
- Rajeev Gupta (6 April 2004)
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Heart of the problem
- Binoy Skaria, Nija Jacob (7 April 2004)
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Managerment of acute myocardial infarction in rural setting
- Himmatrao Saluba Bawaskar (22 April 2004)
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Tackling infectious disease in South Asia: solutions on the horizon
- Sanjay Bhattacharya, Dr. Timothy M.A. Weller (27 April 2004)
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Evidence for epidemic of coronary heart disease in India is weak
- Naseer Ahmad, Raj Bhopal, Professor of Public Health, University of Edinburgh (6 May 2004)
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Doing something about the burden
- Dr M Justin S Zaman BSc MBBS MRCP (4 June 2004)
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Newly detected provisional diabetics in the rural South India.
- Tarun Sharma, Swati Agarwal, Pradeep G Paul,Sheshadri Mahajan, Padmaja Kumari Rani, Rajiv Raman, Govindasamy Kumaramanickavel, Tarun Sharma (13 May 2005)
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G.N Malavige, lecturer in Microbiology Faculty of Medical Sciences, University of Sri Jayawardanapura.
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Ischemic heart disease (IHD) is the leading cause of death in Sri Lanka while stroke is the third cause of death (1). Although coronary revascularization procedures are carried out in Sri Lanka it is not available to most patients due to the cost. For instance, a coronary by pass grafting surgery costs around $2000 whereas the average income of a Sri Lankan in around $3362 per annum. Pharmacotherapy is equally expensive with an average cost of a prescription of a patient with diabetes and IHD (containing a cocktail of drugs including statins, oral hypoglycemic agents and an ACE inhibitor) being around $2000 per annum. Moreover, thrombolytic drugs such as streptokinase are not available in most hospitals in Sri Lanka, expect for the teaching hospitals and general hospitals. However, the coronary risk factors seem to be increasing and in 2000 the overall prevalence’s in a sub urban population were diabetes 6.5%, hypertension 27%, hypercholesteroleamia 17.4%, obesity 18.4% and central obesity 50.2% (2). There is a significant increase in all coronary risk factors when compared to the prevalence 10 years ago. This difference is seen mainly in the prevalence of central obesity and hypertension which was 16.9% and 16.11% in the year 1990 (2). Therefore, it is evident that diabetes and IHD will continue to be the leading cause of morbidity and mortality in the coming years. Especially since the demographic transition in Sri Lanka will lead to a rapid increase in numbers of older people. What can be done to curb this epidemic of non communicable diseases? Treatment and secondary prevention is obviously very expensive. Therefore, it is impetrative that preventive measures should be implemented as soon as possible. Although, Sri Lanka is a developing country plagued by a civil war and scanty resources we have made a remarkable progress in reducing the burden of infectious diseases. Only Sri Lanka has been able to sustain high levels of immunization coverage among its children. All these achievements could be attributed to the primary health care system in Sri Lanka. Unfortunately, prevention of non communicable diseases has not been given much emphasis in the primary health care system. Therefore, it is vital that a program of prevention of non communicable diseases be included in the primary health care system emphasizing the importance of regular exercise, healthy eating habits and most importantly cessation of smoking. Reference: 1. Annual health bulletin 2000: 23 2. Malavige GN, de Alwis NM, Weerasooriya N, Fernando DJ, Siribaddana SH. Increasing diabetes and vascular risk factors in a sub-urban Sri Lankan population. Diabetes Res Clin Pract. 2002 Aug; 57(2):143-5. Competing interests: None declared |
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Anil Pandit, Resident-Physician Patan Hospital, Lalitpur, Nepal , GPO 252, Kathmandu
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Every day 2 people commit suicide in the capital city of Nepal, Kathmandu valley. Police sources say that the rate of suicide is increasing day by day. In year 2000/2001, there were 210 cases in Kathmandu valley and 2000 cases in Nepal. This figure nearly doubled in 2001/2002, with suicides raising to 380 in Kathmandu valley and 3033 in Nepal. The Central Bureau of Statistics of Nepal conducted a census of the population in July 2001. It reported 1492 suicides in the year preceding the census. Suicide is seventh most common cause of death in Nepal. Asthma and COPD related causes being at the top. Accidents and accident related causes, are less common than suicide. The typhoid, malaria, measles, jaundice and HIV are down below in the list2. Suicide has never been considered as a disease of public health importance, though mortality from suicide exceeds other causes. It has drawn considerable attention in the West while it remains largely neglected in developing countries. It is surprising that this edition of BMJ doesn't mention suicide at all. 1. Kantipur Daily. 16th May 2003 2. His Majesty’s Government/Nepal. Population Census 2001. National Planning commission. Central Bureau of Statistics Competing interests: None declared |
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Rajeev Gupta, Consultant Physician and Professor of Medicine Monilek Hospital and Mahatma Gandhi National Institute of Medical Sciences, Jaipur 302004 India
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For calculating the absolute number of patients with coronary heart disease in India, extrapolation from mortality figures available from the various Global Burden of Diseases studies can be used. According to the Global Burden of Diseases study published by the International Institute of Health, in 1990 coronary heart disease caused 0.62 million deaths in men and 0.56 million deaths in women in India. In 2000 this increased to 0.85 million in men and 0.74 million in women, a sum of 1.59 million deaths. Clinical studies show that untreated these patients die at rate of 7-8% per year. Addition of appropriate medical therapies can reduce this death rate to 2% per year. If we consider an average mortality of 5-6% per year, then the absolute number of heart disease patients will be 20 times the persons dying from it. This would extrapolate to a burden of 31.8 million patients in India. This compares with 16.5 million patients in USA and 2.7 million in the UK. Further extrapolation of this data would suggest that there would be 1.27 million acute coronary events per year in India at the rate of 4% events per year in the total coronary population. Compare this with 0.63 million acute coronary events in the European union and 0.275 million heart attacks annually in UK. For estimation of the disease burden, the Global Burden of Diseases Studies reported the disability adjusted life years (DALYs) lost by various diseases in India. Perinatal conditions top the list followed by lower respiratory infections, diarrhoeal diseases, ischaemic heart disease, and unipolar depression. Coronary risk factors such as high blood pressure, tobacco and cholesterol are in the top ten. This shows that cardiovascular diseases are a major burden in this region. The World Bank has concluded that in India DALYs lost due to ischaemic heart diseases are projected to more than double in the next 20 years. In 1990 coronary heart disease was responsible for 5.6 million DALYs lost in men and 4.5 million in women. This is projected to increase to 10.5 in men and 7.7 million in women by year 2010. In India and many developing countries in the absence of reliable mortality data estimates of the burden of disease have mostly been based on population based cross-sectional surveys. Morbidity surveys involve problems of sample design, sample size, standardization, and measurement errors. Indian coronary disease epidemiological studies have been reviewed earlier. In the urban population the prevalence increased from 1.05% (Agra, 1962) and 1.04% (Delhi, 1962) to 6.60% (Chandigarh, 1968). In recent years a consistent high prevalence of coronary heart disease has been reported from Delhi (9.67%, 1990), Jaipur (7.8%, 1995), and Chennai (9.0%, 2001). In semi-urban populations of Haryana and Kerala the prevalence has increased from 3.6% (1975) to 7.4% (1993). In rural populations the prevalence increased from 2.06% (Haryana, 1974) and 1.69% (Vidarbha, 1988) to 2.71% (Haryana, 1989), 3.09% (Punjab, 1994), 3.46% (Rajasthan, 1994) and 5.00% (Himachal, 2002). Rural-urban comparison shows that while prevalence has increased two-fold in rural areas (2.06% in the 1970s to 4.14% in the 1990s) the prevalence in urban areas has increased nine-fold (1.04% in the early 1960s to 9.45% in the mid 1990s). There is evidence of coronary heart disease growth from rural to semi-urban and urban areas with the highest prevalence reported from metropolitan Delhi and Chennai. This clearly shows the importance of socio-economic factors associated with societal transition explaining the coronary heart disease epidemic in India. Analyses of prevalence studies in various decades in India provide significant information regarding the absolute number of coronary heart disease cases. Decadal variations indicate that the prevalence has increased in urban areas from about 2% in 1960 to 6.5% in 1970, 7.0% in 1980, 9.7% in 1990 and 10.5% in 2000 while in rural areas it increased from 2% in 1970 to 2.5% in 1980, 4% in 1990 and 4.5% in 2000. In terms of absolute numbers there is a very steep increase in coronary heart disease cases in both urban and rural areas. In urban populations, the numbers have increased from 0.5 million in 1960 to 4.5 million in 1970, 5.6 million in 1980, 9.7 million in 1990 and 14.1 million in the year 2000. In rural populations the numbers have increased from 4.1 million in 1970 to 6.4 million in 1980, 11.8 million in 1990 and 15.7 million in 2000. Thus epidemiological studies show that there are at present 29.8 million coronary heart disease patients in this country. This number is similar to derived from global burden of disease studies. As epidemiological studies exclude many patients with silent and asymptomatic coronary heart disease, the actual numbers may be much greater. From the year 1995 to 2000, India has been spending about 5% of its gross domestic product on health. Of this private expenditure on health is about 82-83% and the general government expenditure is 17-18%.Therefore any disease that is as widespread as coronary heart disease would entail substantial economic burden on the population. Considering the data in the global burden of disease study mortality statistics the number of patients with coronary heart disease in the country is about 32 million (vide supra). Of this about a fourth would be aware of their disease status and therefore at any given point of time about 8 million coronary heart disease patients would be under some form of medical care. For all these patients, a minimum basic prescription following the ‘polypill approach’ should include a beta-blocker, ACE inhibitor, statin, aspirin, vitamin and occasional nitrate tablets. Many patients are on more complex pharmacotherapy. The average cost of generic forms of these drugs in India amounts to Rs 5500 (£ 69) per year. If we consider that 8 million patients are on this form of therapy, the total burden in terms of cost of such therapy to the patient population would be 44 billion rupees a year (£ 0.55 billion). Add a similar amount for ancillary services such as costs of investigations and hospital visits (44 billion rupees, £ 0.55 billion). We have determined the cost of a single acute coronary event to the patient as Rs 5000 per event (£ 63) in terms of costs of medicines. For 1.27 million acute coronary events, the cost would be 6.5 billion rupees (£ 80 million). About 20,000 coronary bypass surgeries and 30,000 coronary angioplasty procedures are performed in the country every year. At the minimum cost of Rs 100,000 per procedure (£1250), many hospitals charge the patient more than 5-times this amount, this would add burden of another 5 billion rupees (£ 625 million). All this adds up to 100 billion rupees (£1.25 billion) in direct cost of therapy to the patient. A similar amount could be spent by the healthcare system in caring for these patients in outpatient clinics, hospitals and other institutions. Therefore at an underestimate the economic burden of coronary heart disease in India could be 200 billion rupees (£ 2.5 billion, $ 4.4 billion). Indirect costs should be added. Economists would consider that this disease is contributing this much to the national product, but we conclude that this is a waste as more than 80% of the heart attacks can be prevented by appropriate management and prevention strategies. REFERENCES World Health Report 2002. Reducing risks promoting healthy life. Geneva. WHO. 2002. Beaglehole R, Yach D. Globalisation and the prevention and control of non- communicable disease: the neglected chronic diseases of adults. Lancet 2003; 362:903-8. Gupta R, Rastogi P. Burden of coronary heart disease in India. In: Manjuran RJ. Cardiology Update. Cardiological Society of India 2003; 142- 51. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003; 326:1419-23. Competing interests: None declared |
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Binoy Skaria, Cardiology Research Registrar Fellow, University of Southampton Human Genetics Division, SO16 6YD, Nija Jacob
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We read with interest the excellent clinical review ‘Burden of non communicable diseases in South Asia’ by Abdul Ghaffar etal, BMJ Volume 328 3April 2004-04-07 Till about a century ago, the people of South Asia did hard physical labour (fishing or farming) and ate a healthy mix of rice, vegetables and fish. Today, regardless of age, they sit in a shop or an office six days (and sometimes seven days) a week with hardly any exercise and mostly have an unhealthy diet, with everything fried in ghee and oil, for the best taste. Physical fitness activities are a ‘waste of time and money’. All this contributes to the ‘metabolic syndrome epidemic’ with glucose intolerance, dyslipidemia and central obesity. To add to the picture is hypertension and smoking caused by physical inactivity, alcohol & stress. Stress in turn is contributed heavily by the long hours and hard work ( there are no ‘weekends’ here ; you are lucky to get a Sunday off), poor pay and diminishing morale. The diminishing role of family support doesn’t help in coping with stress. We hold a personal view that, people from South Asia have smaller coronary arteries than their Western counterparts, which puts them at a major disadvantage. These form the short cuts to having the first coronary event. The lucky survivor often carries on the same lifestyle. To the best of my knowledge there are less than 10 smoking cessation clinics for the whole of the region, which are mostly privately run. In a place where private practice is everything, if you advise patients strictly, you run the risk of losing the patient to the neighbouring physician .Cardiac rehabilitation programmes are mostly unheard of. Percutaneous intervention and bypass grafting are mainly for the few who can afford it privately. What are the solutions? Reforms should take place at all levels. Education should not stop after just teaching people to write and sign their names. Only then, they will be able to NOT vote for a health minister who doesn’t know reading and writing. English, as a medium of instruction, should be given more importance, as, from personal experience, we feel that is the only way to access the wide world outside. Local systems of medicine should be given due importance , but should also be reminded to observe the limits. I have seen many end stage rheumatic valve disease patients, who were treated for joint pains by Ayurvedic physicians at the age of 6 and ‘completely cured’. Yoga and naturopathy are effective forms of alternative medicine, to reduce stress and weight gain. Finally, money is important, and politicians in the developed countries, should get more funds across for basic improvements, health education and research. Competing interests: None declared |
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Himmatrao Saluba Bawaskar, cliniciaC Mahad Dist Raigad Maharashtra 402301
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Management of Acute myocardial infarction in a rural setting. Ghaffar A et al enlightened the important subject which is most concerned to developing country like India (1). The prevalence of coronary heart disease (CAD) has progressively increased in India during the last half century. Illiteracy, smoking , tobacco chewing in additions to these risk factors rural population are unaware of hypertension and diabetes resulting in reporting CAD cases in acute stage ( 2). Observation of unexpected sudden death preceded by chest pain together with information and news coming from urban areas has caused villagers to become more aware of chest pain in young males (2). In one year 69 patients of AMI reported within three hours of chest pain at general hospital Mahad. All received 1.5 million units intravenous streptokinase(STK) by intravenous drip over one hour, the hospital to needle time was 10-30(average 19) minutes. Reperfusion i.e. regression of elevated ST segment in electrocardiograph (ECG) achieved within 30-60 ( average 38) minutes in 52(75.5%) and within 90 minutes in 12 cases. 5 ( 7.2%) cases showed no improvement. these five cases underwent rescue angioplasty at Mumbai. 22 cases took discharge after STK therapy and were admitted to tertiary care hospital at Mumbai were discharged after 7 days. Remaining 40 cases had uneventful recovery with T wave inversion in corresponding AMI leads and were discharged at request on 4th day of admission. All 40 cases were followed for six months without any cardiovascular events. Other 71 cases reported with chest pain and chronic breathlessness. Their (ECG) showed old myocardial infarction ( deep Q waves with T wave inversion). All of them gave history of had severe chest pain 2-6(average 3.5) months before, were treated by family doctors at village with analgesic. No body received STK. In India medical professional is commercialized. Specialists are flourished in big cities like Mumbai, Pune, Chennai, Delhi and Kalkatta. There are many small intensive care units opened by converting residential blocks. Even multistoried tertiary care hospitals registered as public trust just to get tax free grants and import license. These hospitals behave like a commercial health industry. At times payment capacity decides the hospital admission and duration of stay and not the severity of illness. In such situation patient behaves like parked taxi with meter on. Specialists attached to tertiary care hospitals are given target for admissions if their post is to be continued. Because of easy availability of transport due to privatization of auto riksha (three wheeler) in rural India. Majority of AMI patients reach hospital in golden hours. Since the advent of thrombolysis morbidity and mortality due to AMI has been reduced in Mahad (2). Traffic jam in big cities delays the hospitalization , in such situation, pre-hospital thrombolysis by paramedics or physician may salvage the heart in golden hours and prevent subsequent morbidity and mortality( 3). Thus a day is not away to take needle to patient rather patient to hospital. Diabetes, hypertension, hyerlipidemia, raised homocysteine level, lack of exercise and cut throat competition and struggle for survival are major risk factors resulting in high incidence of CAD in young Indians(4). Many patients sold their piece of land, jewelry or pay heavy interest to moneylender to reimburse the hospital payment, thus heart attack is earth- quake for villagers and their family. Government hospitals are ill-equipped. Often patients are diverted to private hospitals as instruments and gadgets of intensive care is under repair. Tortoise pace attempt to revive intensive care unit in a public hospital. Poor patients with acute life threatening medical emergency admitted to government hospitals. Doctors get varied experience inform of invasive and non-invasive procedures and response to treatment, after getting enough practical experience and qualification majority left the government institutes and utilized their experience to earn and treat patients admitted in a five star commercial health institutes. Similar to Malaria, tuberculosis, filarial and dengue fever, in India CAD is an epidemic form. It is high time that Government of India should form a task force to combat this life threatening disease affecting young and earning members of society. H.S.Bawaskar
Reference 1-Ghaffar A, Reddy KS and Singhi M. Burden of non-communicable diseases in South Asia. BMJ 2004;328:807-10. 2- Bawaskar HS, Bawaskar PH. Thrombolytic therapy in acute myocardial infarction in a rural setting. Tropical Doctor 2002,32:66-70. 3-Keeling P, Debbie H, Price L, Shaw S, and Barton A. Safety and feasibility of prehospital thrombolysis carried out by paramedics. BMJ 2003; 327:27-28. 4- Enas AE, Yusuf S and Mehta JL. Prevalance of coronary artery disease in Asian Indians. (Editorial). American J. Cardiology 1992;70:945-49. Competing interests: None declared |
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Sanjay Bhattacharya, Specialist Registrar, Department of Microbiology City Hospital Birmingham. Dudley Road. Birmingham. B18 7QH., Dr. Timothy M.A. Weller
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EDITOR--The clinical review on the infectious disease burden in South Asia makes for informative but disturbing reading.1 The scope, priority, and goals of a microbiology department in a developing country is different from that of the developed world. One of the authors of this letter (SB) has had the opportunity to work in both settings (India and the UK). This makes it possible to suggest realistic measures that can bring about significant changes in the way infectious disease is managed in the developing world. Indian (practically throughout South Asia) microbiologists offer a service based primarily within the laboratory with minimal patient contact. The emphasis is low cost, low technology, labour-intensive diagnosis. The expensive, high technology microbiology practised in the Western world would not be appropriate considering the limited resources available. However, cost-effective measures involving a change in basic attitude and procedure could be introduced. The current UK practice of close liaison between medical microbiologists and the clinical team is rarely encountered in South Asia. The resulting poor communication can lead to laboratory services that do not reflect the clinical priorities. Provision of medical microbiology that combines a diagnostic service with continuous clinical input with regards to optimal specimen collection, choice of antibiotics and further management would ensure the most effective use of limited resources. In order to provide this service there is a need to reorient microbiology training at the medical level as well as the technical level in the developing world. Preventative measures via a proactive Infection Control service could also improve cost effectiveness. Introduction of infection control nurses, development of a comprehensive infection control policy, continuous surveillance and feedback to clinical team and nursing staff, compulsory notification to national surveillance centres, and close liaison with public health would provide value for money in resource deficient developing world. The Sri Lankan approach based on periodic in-service training programmes of medical laboratory technologists and infection control nurses together with establishment of a Task Force in microbiology to identify priority areas in microbiology services2 could be adopted by other South Asian countries. It is important that political parties who govern the nations are conscious of the changes that need to be brought about to ensure public health. The challenge before the microbiologist is essentially managerial, political and economic. It is about influencing and convincing the people at the top so that policy changes are not just cosmetic but are viable tools in bringing genuine socio-economic and health benefits to all concerned. References: 1. Zaidi AKM, Awasthi S, deSilva HJ. Burden of infectious diseases in South Asia. BMJ 2004; 7443: 811-815. 2. Thevanesam V, Corea E. Infection control in Sri Lanka. J Hosp Infect. 2002; 52: 231-3. Contributors: SB and TMAW were involved in writing the paper. TMAW critically reviewed the paper suggested necessary changes in the original manuscript. TMAW is the guarantor of the paper. Funding: None Competing interests: SB received his initial microbiology training in India between 1997 and 2002. |
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Naseer Ahmad, House Officer c/o 89 Clitheroe Road,Manchester, Raj Bhopal, Professor of Public Health, University of Edinburgh
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Dear Editor, It is widely believed that India is on the verge of an epidemic of coronary heart disease (CHD)(1). We believe this assumption to be based on weak evidence. We found one meta-analysis, reporting a nine fold increase in urban India (1 to 9%) and two fold increase (2 to 4%) in rural India between the 1960s and 1990s (2). We believe these results to be inaccurate because of the poor quality of underlying data and because comparisons were based on studies defining CHD differently. CHD was measured using either Minnesota coded electrocardiograms or clinically defined using non validated translations of the Rose angina questionnaire. The latter tends to give greater positive results and is less valid in women (3) and South Asian populations (4). Our review, which is currently undergoing peer review, focused on Minnesota coded ECGs to provide an objective measure. We reviewed 31 studies published between 1974 and 2002. The quality of the data was generally poor as many did not fulfill basic criteria for epidemiological research (5). Further, research was generally concentrated on a small area around the capital, Delhi. We found the prevalence in urban India to be higher than rural areas in males and females. We found no clear rise in prevalence, including age specific rates, in males over a 27 year period with some modest evidence of a rise in females. A major expansion of research and surveillance is urgently needed with new studies following more rigorous and standardised methods to permit comparison over time, between locations and between and within populations. Only then will the true extent and impact of the disease in South Asia be known. In the meantime, claims of a massive epidemic need to be interpreted with caution. 1. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular disease. Part II. Variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation 2001;104:2855-64 2. Gupta R, Gupta VP. Meta-analysis of coronary heart disease prevalence in India. Indian Heart Journal 1996;48:241-5 3. Harris RB, Weissfield LA. Gender differences in the reliability of reporting symptoms of angina pectoris. J Clinical Epidemiol 1991;44:1071-8. 4. Fischbacher CM, Bhopal R, Unwin N, White M, Alberti KGMM. The performance of the Rose angina questionnaire in South Asian and European origin populations: a comparative study in Newcastle, UK. International Journal of Epidemiology 2001;30:1009-16. 5 Bhopal R. Concepts of Epidemiology. Oxford: Oxford University Press, 2003.p 290 Competing interests: None declared |
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Dr M Justin S Zaman BSc MBBS MRCP, Specialist Registrar Papworth Hospital, Cambridge, UK
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Reading your thorough clinical review on the “Burden of communicable diseases in South Asia” was mildly depressing as there were no answers suggested (though I appreciate it was an article on all forms of non- communicable disease, and management was beyond its remit). You say that "even at the current state of knowledge, however, the magnitude of the problem is large enough to demand urgent attention and action". As a United Kingdom-based trainee cardiologist, my interest in cardiovascular disease in South Asia stemmed from an article by Thomas Pearson in the late 1990s. The message from that piece is not greatly diferent from yours. Since I do not practice in South Asia, I have no real feel as to whether or not attention/action is already being taken. I ask this in self-confessed ignorance, having read this special issue of the BMJ from cover to cover, and not found any potential ongoing solutions to the impending crisis (i.e., any good news). I suppose one should blame the Editors for that? Even way back in 1990, infectious/parasitic disorders and cardiovascular disease were nearly equivalent as the leading causes of death, with 9.2 million and 9.1 million deaths attributed to each category respectively. Cardiovascular disease has of course since moved ahead. If one believes in the "epidemiologic transition", then South Asia is surely moving from the Age of Receding Pandemics to the Age of Degenerative and Man-made Diseases. With the suggestion that South Asian populations may be at especially high risk, the projected estimates of cardiovascular disease rates in the developing world are most likely conservative. But you at the WHO know all this already, stretching as far back as the 1996 "Report of the Ad Hoc Committee on Health Research Relating to Future Intervention Options. The neglected epidemics of noncommunicable diseases and injuries. Investing in Health Research and Development". In the UK, we continue to have problems in controlling the pandemic. Obesity and type II diabetes mellitus are on the rise. The UK Government has only recently focussed on this and its relation to inactivity. It is still usually more expensive to buy healthy foods and drinks, though government campaigns have led to less salt being used in manufactured foods in the UK. This does not surely bode well for South Asia. A different approach in South Asia is needed and we all realise this. As S M M Hossain et al say on page 830 of the same issue of the BMJ, "Most South Asian governments have concentrated on emulating a Western style of healthcare service, with the result that an elite few are overmedicalised whereas the majority are neglected. However, community participation in the development of local health services could provide a solution". We need to involve people (before they become patients) via their communities. We need new approaches. "Cricket has suddenly acquired huge public health significance in South Asia", say Shafqat and Bharucha on page 843, but how many women go to the matches? Most articles on this subject bemoan the void of physical activity in South Asian cultures, but is physical activity being encouraged for women in an environment and form that is acceptable? You say "More accurate estimation of these burdens, their risk factors, and time trends would help to better inform policy and to monitor change in response to public health interventions". Ahmad et al in a rapid response to your article say that "Evidence for epidemic of coronary heart disease in India is weak" (they obviously do not believe in the epidemiologic transition theory). This may all be true if we are going to be perfectionists and provide an evidence-based health policy for 1 billion people, but by the time you instigate it, you may have missed the boat. I know that WHO has published a great deal about this. More information on its successes so far would be interesting, such as the pick -up rate of your "CVD-Risk Management Package" (though I appreciate this was designed for people who ALREADY have hypetension, or another risk factor such as diabetes or smoking). As someone who is due to commence a Doctorate shortly focusing on UK South Asians, and who harbours a desire to join you in this fight, I fear I will be entering the battlefield with the battle already lost. Give me some hope! Competing interests: None declared |
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Tarun Sharma, Director, Shri Bhagwan Mahavir Vitreoretinal services Sankara Nethralaya, 18, College Road, Chennai - 600006, Swati Agarwal, Pradeep G Paul,Sheshadri Mahajan, Padmaja Kumari Rani, Rajiv Raman, Govindasamy Kumaramanickavel, Tarun Sharma
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In developing countries like India, diabetes mellitus is emerging as a major cause of increase in morbidity and mortality through its microvascular complications. About half of the patients develop complications even before their diabetes is diagnosed.1, 2 The actual onset of type II diabetes may occur about 9 to 12 years before its clinical diagnosis and this asymptomatic phase of hyperglycemia induced microvascular complications is estimated to last for about 4-7 years.3 Therefore, efforts are needed to identify asymptomatic diabetic patients from the general population. This report describes how common are newly- detected provisional diabetics (defined as individuals with random blood sugar > 200 mg/dl) in the rural settings. Community based targeted screening for diabetes was carried out in the 2 rural districts of India. All inhabitants, aged > 30 years, were invited. Random blood glucose was measured with a glucometer (Accutrend Alfa) by finger-prick capillary method. In 73 diabetic screening camps, 23,472 individuals were examined. Of these 23,472 subjects, known diabetics were 4111 (17.5%; 95% CI – 17.0 – 18.0), and newly detected provisional diabetics, 1076 (4.6%; 95% CI – 4.3 – 4.9). Random blood glucose between > 140-199 mg% was estimated in 1157 (4.9%) and less than 140 mg% in the remaining 17,128 (73%). This study data shows that around ten percent of the individuals in the rural settings are potential diabetics (RBS > 140 mg/dl). Identifying this high-risk group is important as patients in the undiagnosed asymptomatic phase with impaired levels have a higher mortality rate due to myocardial infarction, stroke and large-vessel occlusive disease than known diabetics or normoglycemics.4 These potential diabetics are also found to be independently associated with microvascular complications of diabetes such as retinopathy, renal disease, and polyneuropathy.5 References 1.United Kingdom Prospective Diabetes Study. Complications in newly diagnosed type 2 diabetic patients and their association with different clinical and biochemical risk factors. Diabetes Res 1990;13:1-11. 2.Harris MI. Non-insulin dependent diabetes mellitus in black and white Americans. Diabetes Metab Rev 1990;6:71-90. 3.Harris MI, Klein R, Welborn TA, Knuiman MW Onset of NIDDM occurs at least 4–7 yr before clinical diagnosis. Diabetes Care 15:815–819, 1992. 4.Guillermo E. Umpierrez, Scott D. Isaacs, Niloofar Bazargan, et al. Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes The Journal of Clinical Endocrinology & Metabolism Vol. 87, No. 3 978-982 5.J. Robinson Singleton, A. Gordon Smith, James W. Russell, and Eva L. Feldman Microvascular Complications of Impaired Glucose Tolerance. Diabetes 52:2867-2873, 2003. Competing interests: None declared |
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