Falling through the Cracks.

Hello! A few years ago, I took a Harvard Pre-collegiate course titled “AIDS, Earthquakes, and Ebola: The Fight to Save the World.” This introductory global health course was my first motivation to pursue public health. At the end of this course, I developed a short thesis titled “ A Biosocial Perspective on CVD Amongst Lower-income Households in India”, and I have adapted that thesis in this article. I hope you enjoy!

India is the second most populous country and cardiovascular disease (CVD) is one of the leading causes of death; over 60% of all heart disease cases occur in India. (1) In 2010, approximately 37 million Indians died prematurely due to CVD. (2) However, Indians from “lower socioeconomic backgrounds” are disproportionately affected as CVD most often goes undiagnosed.

Ischemic heart diseases (where blood flow is obstructed) and strokes represent the majority of CVD cases and the largest risk factors for CVD in India include diabetes, hypertension, and obesity (which are also expected to become even more prevalent in the future). (3,4) A BMJ study finds that CVDs account for roughly one-third of all deaths in rural South India. In a study assessing the effectiveness of long-term medication in treating CVD in India, 123 out of 260 patients eventually stopped taking medications, with the majority of these patients unable to afford it. (5)

Clearly an example of spatial mismatch (scarce resources allocated to those who have less need), health care is only affordable to the rich and affluent in India, even though those who are at the most risk for developing CVD live below the poverty line. (6)

By looking at CVD in India from a biosocial perspective, we can understand how structural violence and spatial mismatch affect which people get treated and how to implement an effective intervention at the governmental and societal level. In North India, the lowest-income households had the highest rates of morbidity and hospitalization due to CVD. (7) These households are more likely to spend large sums of money on health care and they are more likely to go to less-funded public hospitals which may not offer the most cost-effective treatment plan.

Treatment options for low-income patients are indeed few and far between; public hospitals are so crowded that in the city of Kolkata, patients have to wait on average 90 minutes just to enter a public hospital. (8) This is because the Indian healthcare system puts a vast majority of medical expense on the patient, with the government only paying 17% of total expenditure; this system dissuades people from seeking care due to high cost and results in poor quality care in many public hospitals. (9) Because government expenditure controls public hospitals, low-income Indians with severe illnesses are turned away; these profit-driven organizations find it wasteful to invest in the healthcare of low-income individuals. (10)

Structural violence also prevents low-income households from gaining wealth and seeking proper care; since societal inequalities often appear simultaneously, low-income Indians are stuck in endless cycles of lack of education, lack of income, and lack of health care.

The Indian government has made some productive steps to increase healthcare affordability, namely the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana program. (11) The Indian government aims to provide over 500 million individuals with free healthcare through public and private hospitals. While this is not a complete solution, it is a step in the right direction; the government has recognized the problem and must now work to address the structural issues that prevent lower-income individuals from accessing quality care.

While India’s medical schools have been graduating more doctors recently, the health care system lacks the infrastructure to support the country’s rapidly growing population. India has been graduating roughly 67 thousand doctors a year in a system where there are only half as many new posts available. This shortage of jobs for doctors limits the amount of specialized care patients can receive. India has the staff, stuff, and space; its healthcare system merely lacks the systems for it to function in the most efficient way possible.

A vast majority of low-income individuals in India live in rural communities. In these communities, physician care teams not only lack the infrastructure to effectively treat patients…

…but they also lack the appropriate training to diagnose severe cases that are more prevalent amongst rural and low-income populations. (12)

To ensure that low-income individuals are aware of treatment options, many interventions have been researched, including affordable CVD testing using frontline medical officials, yoga programs to rehabilitate CVD patients, and mobile applications to provide patients with the proper treatment plan. (13) Participants in these tests had significantly lower mortality rates due to CVD. The problem remains that these interventions would be a major expenditure for the Indian government and are hard to scale.

Another issue faced by low-income and rural Indians is their inability to quickly contact their medical care team:

The National Rural Health Mission (NRHM) was built in 2005 with the goal of reducing this issue. (14) The NRHM has strengthened rural healthcare infrastructure with the creation of sub-centers, primary health centers, and community health centers. (15) In this way, the highly centralized Indian healthcare system can provide equipment as well as physicians to low-income communities, broadening access and improving quality.

The Indian government has made remarkable strides to improve CVD outcomes for underserved individuals. The government has promised to devote roughly 2.5% of GDP to Indian healthcare with 70% of this amount for primary care. (16) However, since risk factors that increase the prevalence of cardiovascular disease have been becoming more common in India over the past several decades, this problem is timely and needs to be addressed in the very near term. Furthermore, income disparities are predicted to rise in the future with 71% of the world’s population living in nations with growing inequality. (17) Thus, it is incredibly important for policymakers to broaden access to care and identify structural issues that may prevent underserved individuals from receiving the medical attention they need.

Over the past couple months, I have been developing the Health in Perspective platform. Now, I am inviting you to share your health policy perspectives. If you are interested in co-authoring a Health in Perspective article and researching a health policy topic that matters to you, fill out this short form! (Click Me)