Global Burden of Disease study: Here are the top 10 killers in India

The Global Burden of Disease study, released last month, provides shocking insights into what is causing deaths and disabilities among people — as many as 328 diseases in 195 countries continue to kill and cripple. India, one of the most populous nations, figures starkly in the study, which also measures injuries and risk factors. The top 10 killers in India range from Ischemic Heart Disease (IHD), or a simple heart attack, to tuberculosis.

If India has to realistically move towards achieving the World Health Organisation (WHO)-recommended Universal Health Coverage (UHC) guidelines, it will have to provide much better preventive, clinical and financial services to reduce the number of deaths and disabilities.

1. Ischemic Heart Disease (IHD) causes 17.8% of all deaths

Heart attacks killed more people in India than any other cause in 2005, and it remained the biggest killer in 2016. It has been a decade since the disturbing trend of heart attacks striking people below 40 started in India. The Outpatient Department (OPD) in Gurugram’s Medanta, one of India’s largest private hospitals, is teeming with patients. Dr Ravi Kasliwal’s clinic is busy as ever. He heads the clinical and preventive cardiology departments there. Only a few weeks ago, a 28-year-old man showed up in the emergency department, complaining of a shooting pain in his chest. It was a heart attack. “His major artery was 100 per cent blocked. The heart attack must have taken place a few hours ago that day, but the thickening of the artery happens over 7-10 years. He had started smoking 12 years ago, and had up to 15 cigarettes a day,” Dr Kasliwal told DNA. 

One in four patients that Dr Kasliwal examines has a blocked heart artery, and up to 30 per cent of this patient group is young. “Diabetes and high blood pressure ring alarm bells for impending heart attacks, and these warning signs should not be ignored. Smoking, physical inactivity and psycho-social stress will inevitably lead to a heart attack,” he said.

2. Chronic Obstructive Pulmonary Disease (COPD) causes 8.66% of all deaths

Last week, 77-year-old Ramswaroop Goyal of Delhi’s Bhola Nagar came heaving to the OPD of Dr Randeep Guleria, a pulmonologist and director of All India Institute of Medical Sciences (AIIMS). Goyal has had difficulty in breathing over the past decade. But a few days ago, it got exacerbated, largely due to Delhi’s worsening air quality. “He suffers from COPD of the lungs. It leads to the weakening of lung capacity. He is largely bed-ridden and requires intermittent oxygen support to breathe,” said his son Banshi Dhar, as Goyal looked on from behind a mask that was releasing steroid gases into his lungs to help him widen his airway, and ease breathing. 

Meanwhile in Mumbai, Dr Amita Athavale, head of department, respiratory medicine at King Edward Memorial Hospital, is planning a long-term research on COPD exacerbation cases in rural areas. “It is largely caused due to indoor air pollution… in village kitchens, due to burning of biomass,” said Dr Athavale. 

Human lungs have a holding capacity of 3.5 litres. After 30 years of age, it declines by 10-30 ml per year, if a person does not exercise. In COPD patients, it declines faster, almost 100 ml per year. “The lungs enlarge, they lose elasticity, remain ballooned and oxygen holding capacity drops. Oxygen is heart fuel. The organ has to work more. This causes heart failures in COPD patients,” said Dr Athavale. 

Dr Athavale saw three women with COPD, who had come from Uttar Pradesh and Bihar, in her Mumbai clinic. “They said that they have now received LPG connection under the Pradhan Mantri Ujjwala Yojana. We get about 1,000 indoor admissions for COPD every year. We are collecting data for a longitudinal study to see if mass shift to LPG usage will reduce COPD cases. Three patients is too less a number to conduct a study, but it is a start,” she said.

3. Diarrhoeal diseases cause 7.94% of all deaths  

Diarrhoea kills just a little less than COPD. In all age groups, it is the third largest killer in India. But when we consider percentage deaths from diarrhoea in children below five, the figure swells up to 13 per cent. We are losing three lakh children to diarrhoea every year. 

One such case emerged at Lady Hardinge Medical College and Kalawati Children’s Hospital a few weeks ago. A two-month-old from Haryana’s Mewat was wheeled into the hospital. “Ideally the infant should have weighed four kilos, but he weighed a measly two kilos. He was 2.5 kilos when he was born, a normal weight for a newborn, and shed 500 grams in two months, instead of gaining weight,” said Dr Varinder Singh, a senior paediatrician. 

The baby was admitted in a state of shock. He had been passing water in stools rapidly, and was severely malnourished. “The mother was  not breastfeeding the child. Breastfeeding awareness in India is extremely poor. On top of that, diluted milk or plain water is fed to the child,” said Dr Singh. The result is infection, severe dehydration, loss of body fluids causing electrolyte imbalance and acidosis, which leads to multi-organ failure. It is a gruesome death caused due to poor hygiene and ignorance among the parents.

4. Cerebrovascular diseases cause 7.09% of all deaths

They are essentially brain strokes or internal bleeds, and have moved up from the sixth position in 2005 to the fourth in 2016.

A 11-year-old girl in Mumbai was admitted to KEM Hospital’s neurosurgery department after a vessel that carries blood to the brain burst and she had profuse internal bleeding. Doctors were baffled with the case as there was no blockage, and ruled out junk food or obesity to be the cause. “It was rather stress. She may have been facing a lot of psychosocial stress at school, which had caused inflammation of the vessel. Such internal bleeding is a silent killer,” said professor Aadil Chagla, neurosurgeon at KEM Hospital. 

When Dr Chagla started his practice in 1989, cerebrovascular diseases were prevalent in patients who were in their 60s or 70s. Three decades later, he says, more young patients have these phenomenon. 

“Pollution, stress and junk food are in general lowering resistance levels. If vessels are not strong enough to carry the blood load, they will burst and bleed,” he said.

5. Lower Respiratory Tract Infections (LRI) cause 5.06% of all deaths 

These include pneumonia and influenza infections. Antibiotics often prove ineffective in today’s drug-resistant strains, including the infamous super-bugs. They include a battery of parasites, viruses and bacterial infections that strike the old and young alike. They mostly kill the elderly and children below five. Pneumonia is known to kill one in every four people that it infects.

6. Tuberculosis (TB) causes 4.45% of all deaths 

After an eight-year fight against TB, Rahima Bi (44) of Uttar Pradesh died a lonely death earlier this year. She was one of the 12 documented cases of extremely drug-resistant (XXDR) TB cited by Dr Zarir Udwadia of private-run Hinduja Hospital, a research study that shook the world. The Indian government woke up to the ticking time bomb of drug-resistant TB, an ailment in which no medicine works. 

She was deemed cured of XXDR-TB before she died. She later had developed COPD and anaemia, which  depilated her further, as after-effects of TB. Last when DNA met her, she was beaming and showed this correspondent her chest X-Ray report. Her lungs were clear of infection. She was still weak and spat blood at times. She was living alone in her shanty when she breathed her last. Her sons were away for work. Her husband had abandoned her. While India has records of close to 17 lakh TB patients, an additional 10 lakh patients have been undetected. According to WHO reports, up to  four lakh Indians die of TB annually. 

“Sadly it’s a man-made problem caused by decades of a poorly functioning, underfunded and inefficient government TB programme, coupled with a dysfunctional and untrained private sector that is responsible for our present plight,” said Dr Zarir Udwadia, chest physician, Hinduja Hospital in Mumbai. “At my clinic, we see an endless stream of drug-resistant patients from all parts of the country, infected with highly resistant strains and denied access to the drugs that could save them. They are the young bread earners of their families, struggling to overcome a deadly disease and crippled by its social and economic ramifications. Each is a study in desperation. Sadly, each patient will infect 10-20 close contacts at home, in schools, colleges and work places ensuring that the problem will only amplify over the decades ahead.” 

New drugs like Bedaqualine and Delamanid could save thousands of lives but sadly the government sees it fit to control their use in such a draconian fashion that they are inaccessible to all except a tiny minority of those who would benefit from them, he said.

7. Diabetes causes 3.11% of all deaths

In 2005, it was the least of our concerns. It ranked 13. In 2016, it is the seventh largest cause for deaths in India. 

Dr Shashank Joshi is treating a 16-year-old girl with Diabetes Mellitus or Type II diabetes after she recorded a fasting blood sugar level of 180 milligrams per deciliter (mg/dL) as opposed to the normal 100 mg/dL. She had a post-lunch reading of 300 mg/dL, up from a normal of 140. 

India has an estimated 6.5 crore diabetics. Joshi, a Mumbai-based endocrinologist says diabetes is equal to a heart disease. “Blood sugar sticks to vessels, retina, kidneys, nerves and damages arteries. A diabetic lives 7-8 years less than a normal person,” Joshi said. “Ten to 15 years later, diabetics face strokes or heart attacks.”

8. Road injuries cause 2.59% of all deaths 

Deaths due to road injuries have spiked over the last decade, moving from the ninth position to the eighth in 2016. According to the government’s own admission, fatalities in road accidents have increased by 3.2 per cent between 2015 and 2016. A total of 1,50,785 persons were killed in over 4.8 lakh road accidents in 2016. 

Professor Aadil Chagla, neurosurgeon at KEM Hospital in Mumbai, was a victim of one such bus accident himself, years ago. “While most of us survived, the bus conductor succumbed because there was no first aid to salvage him,” said Chagla. 

Chagla has started building a trauma centre along National Highway-66 at Mahad in Raigad district neighbouring Mumbai and Pune. “There should be a trauma centre every 50-100 km on highways. Victims die due to non-receipt of care in the golden hour. It takes at least 3-4 hours to take them to a tertiary centre to Mumbai, and by the time they are admitted, they die,” said Chagla. “While the government has announced various new road projects, it has done nothing to ensure road safety. About 90 per cent of head injury victims do not need surgery. They need conservative treatment to stabilise breathing, regulate blood pressure and intravenous fluids.” We are also trying to arrange for a mobile CT scanner to be put in place to ply through 3-4 trauma centres along the highway, as also an ambulance. This is just a drop in the ocean but it has to start from somewhere,” said Chagla.

9. Chronic Kidney Disease (CKD) causes 2.39% of all deaths 

It ranked 15 in 2005. It’s the ninth most probable cause of deaths in the 2016 rankings.

“The reason CKD is such a huge problem is that there is a very high incidence of diabesity and hypertension in our country. These are major risk factors for CKD,” said Dr Bharat Shah, leading nephrologist at private-run Global Hospital in Mumbai’s Parel area. 
Heart attacks, cerebrovascular diseases, diabetes and CKD are all related to each other. One can lead to another or occur independently, even in younger age groups. 

A small percentage progress of CKD graduates to kidney failure. Other patients may have a higher risk of developing heart diseases. Some also have co-morbid condition of diabetes.

Those who develop kidney failure have only two options — dialysis and transplant — most Indians cannot afford. It is estimated that only 15-20 per cent of patients get dialysis and transplant. This means 80 per cent do not survive, said Dr Shah. 

He advises, “The best way is to educate the masses about preventing and controlling diabetes and hypertension and avoiding unnecessary use of unknown alternative drugs and pain killers. The best way to detect early is to do two simple tests: urine routine and serum creatinine.”

10. Self harm causes 2.35% of all deaths

There have been less deaths due to self harm in 2016 than in 2005. Of eight lakh suicides across the world annually, 1,35,000 are from India, which means one in every eight persons that ends her life is an Indian. Psychiatrists say that the overwhelming proliferation of romantic relationships on social media is a new cause for self harm. 

A 17-year-old girl was rushed into the emergency department of KEM Hospital after she consumed poison. She had befriended a man who had made a fake Facebook profile and masked his age online. He later blocked her. Dejected, she decided to take her life. She was later salvaged, said Dr Sagar Mundada, senior resident doctor, psychiatry. 

Every week, the Wednesday OPD in KEM deals only with self-harm patients. “We get at least three patients every week who have tried to harm themselves in someway or the other — poisoning or slashing of wrist. They fall in the age group of 15-25,” Dr Mundada said. 

WHAT ABOUT CANCER?

Cancer does not make it to the top 10 causes of death in India because the family of the variety of cancers is huge. If all types of cancers are summed up, they result in over 8 per cent deaths. That is like being in the top five killers. However, cancer is not seen as a single ailment. For example, oral cancer is separate from prostate cancer. Patients of blood cancer are considered a different group from those suffering from breast cancer. Eighty people in a population of one lakh suffer from cancer. Two-third cancers are lifestyle related. This means those pre-disposed to risks like diabetes, hypertension, alcohol, drug use, tobacco consumption are at greater risks. Sixty per cent of deaths in cancer can be attributed to tobacco.

NOT DOING ENOUGH

• According to the GBD study, India is not spending enough to salvage the death and disability situation.
   
• 1990: Healthcare Access and Quality (HAQ) Index for India was 30.7 against best possible 48.8 with a gap of 18.1 units
   
• 2015: HAQ Index 44.8 against best possible 68.4 with a gap of 23.6 units

WHAT IS DISABLING INDIA?

1 Iron-deficiency anemia

2 Sense organ disease

3 Low back and neck pain

4 Migraine

5 Skin diseases

6 Depressive disorders

7 Other musculoskeletal disorders

8 COPD

9 Diabetes

10 Anxiety disorders

(Maitri Porecha is a health correspondent with DNA, and is currently pursuing the Universal Health Coverage Fellowship supported by the World Health Organisation and the Centre for Media Studies)