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PHFI-IHME-led Lancet paper examines fatal and non-fatal health loss across in India

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Even as life expectancy increases in India, tuberculosis and neonatal preterm birth complications continue to take a high toll on health

People in India are living longer, but healthy life expectancy has increased more slowly and a complex mix of fatal and non-fatal ailments cause a tremendous amount of health loss, according to a new analysis of 306 diseases and injuries in 188 countries.

Thanks to marked declines in death and illness caused by HIV/AIDS and malaria in the past decade and advances made in addressing communicable, maternal, neonatal, and nutritional disorders, health has improved significantly around the world. Global life expectancy at birth for both sexes rose by 6.2 years (from 65.3 in 1990 to 71.5 in 2013), while healthy life expectancy at birth rose by 5.4 years (from 56.9 in 1990 to 62.3 in 2013).

Healthy life expectancy takes into account not just mortality but the impact of nonfatal conditions and summarises years lived with disability and years lost due to premature mortality. The increase in healthy life expectancy has not been as dramatic as the growth of life expectancy, and as a result, people are living more years with illness and disability.

This is also true in India. Life expectancy increased by 6.9 years for men between 1990 and 2013 and 10.3 years for women in the same period. But healthy life expectancy increased by less: men gained 6.4 years and women gained 8.9 years. Life expectancy for women in India still outpaces that of men, 68.5 years compared to 64.2 years.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition” examines fatal and nonfatal health loss across countries. Published in The Lancet on August 27, the study was conducted by an international consortium of researchers working on the Global Burden of Disease (GBD) study, including from the Public Health Foundation of India (PHFI), and led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.

For most countries, changes in healthy life expectancy for males and females between 1990 and 2013 were significant and positive, but in dozens of countries, including Botswana, Belize, and Syria, healthy life expectancy in 2013 was not significantly higher than in 1990.

The study’s researchers use DALYs, or disability-adjusted life years, to compare the health of different populations and health conditions across time. One DALY equals one lost year of healthy life. DALYs are measured as the sum of years of life lost due to early death and years of healthy life lost due to disability.

In India, the leading causes of health loss, as measured by DALYs, in 2013 were ischemic heart disease (IHD), chronic obstructive pulmonary disease (COPD), lower respiratory infections, tuberculosis, neonatal pre-term birth complications, neonatal encephalopathy, diarrhoeal diseases, cerebrovascular disease, road injury, and low back and neck pain. Neonatal encephalopathy and tuberculosis were not among the leading causes of health loss globally.

Causes of health loss differed by gender in India as well. For Indian men, the top-five causes of DALYs in 2013 were IHD, tuberculosis, COPD, neonatal encephalopathy, and neonatal pre-term birth complications. For women, the top five were IHD, lower respiratory infections, diarrhoeal diseases, COPD, and neonatal pre-term birth complications. For Indian men, the fastest-growing leading causes of health loss between 1990 and 2013 were self-harm, IHD, and cerebrovascular disease, which increased at rates of 149.9 per cent, 79.9 per cent, and 59.8 per cent, respectively. Only IHD was in the top-10 causes of male DALYs in 1990. For women, the largest increases among the leading causes of DALYs occurred for IHD (69 per cent), depressive disorders (66.1 per cent), and cerebrovascular disease (36.8 per cent). Only IHD was among the 10 leading causes of health loss for women in 1990.

Healthy life expectancy in India is 12 years lower for women and eight years lower for men than in neighbouring Sri Lanka,” said study co-author Dr Lalit Dandona who is Professor at PHFI and IHME and led the work of this study in India. “This difference indicates that substantial health improvements in India are possible and that public policy should make this a top priority in order to enable India reach its optimal development potential.”

The relative contribution of Ischemic heart disease to the disease burden in India has doubled over the past 25 years, making it the leading cause of health loss among both men and women in India presently,” said Dr K Srinath Reddy, President, PHFI and member of the GBD Scientific Council. “Major health system and policy shifts for more effective preventive and curative approaches for heart disease are needed in India to curtail this trend.”

It is unacceptable that tuberculosis continues to be among the top five leading causes of disease burden in India in 2013, as it was a quarter century ago,” said Dr Soumya Swaminathan, Director-General, Indian Council of Medical Research. “Systematic evidence-based approaches for tuberculosis control and ultimate elimination have to be rapidly implemented in India to improve the situation.”

In the current epidemiological transition, road injuries is a major concern and one that predominantly affects men in the working and productive age group,” said Dr Nobhojit Roy, Professor, BARC Hospital and a co-author of the study. “Though preventable, road injuries have increased rank since 2005. Between 1990 and 2013, worldwide DALYs per 100,000 from communicable, maternal, neonatal and nutritional ailments declined by 42.4 per cent but only by 30.9 per cent from injuries.”

The study also examines the role that socio-demographic status – a combination of per capita income, population age, fertility rates, and average years of schooling – plays in determining health loss. Researchers’ findings underscore that this accounts for more than half of the differences seen across countries and over time for certain leading causes of DALYs, including maternal and neonatal disorders. But the study notes that socio-demographic status is much less responsible for the variation seen for ailments including cardiovascular disease and diabetes.

Factors including income and education have an important impact on health but don’t tell the full story,” said Dr Christopher Murray, Director, IHME who leads the GBD study globally. “Looking at healthy life expectancy and health loss at the country level can help guide policies to ensure that people everywhere can have long and healthy lives no matter where they live.”

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