By: Irene Calimlim
Once seen as diseases of affluent nations, chronic diseases such as hypertension and diabetes are on the rise in developing nations such as India. This is known as the “demographic transition,” wherein a country transitions away from communicable diseases to noncommunicable diseases as its GDP rises. This transition has occurred rapidly in India: within the past two decades, India has risen up to become the nation with the highest number of diabetes cases. It is estimated that by 2020, 66.7% of all deaths in India will be due to chronic diseases. These conditions are not only confined to the urban wealthy, but have also been increasing across all demographics throughout rural India. A current intern who has been working with the Mobile Health Team shares some insights into the village situation with cardiovascular diseases.
Within the past decade, cardiovascular diseases have become the leading cause of death among the project villages in which the Comprehensive Rural Health Project works. Over the past three years, various campus staff and fellows have been investigating both the prevalence and cause of hypertension and diabetes in our villages. Additionally, Village Health Workers and members of the Mobile Health Team have been trained on how to diagnose, counsel, and prevent various noncommunicable, chronic diseases.
Yet, even though cardiovascular diseases are now the leading cause of death among CRHP project villages, focus group discussions have shown that awareness of hypertension and diabetes continues to remain low among the villagers.[i]
In September 2013, interviews were conducted with 20 Village Health Workers; the same questions were used for focus group discussions in four villages to check hypertension awareness.
Given that very recently, these same communities faced problems such as malnutrition, leprosy, and water-borne infections, chronic diseases comparatively does not seem like a pressing health concern. The symptoms are not readily noticeable: it could manifest as a headache, blurred vision, or there may not even be any symptoms, hence, why it is often called the “silent killer.” Additionally, there are no easy cures: treatment is long-lasting and involves either taking medicine for an extended period of time and/or making changes to lifestyle, which can be very difficult to do. In discussions about hypertension prevention, our Village Health Workers frequently discuss how difficult it is to get patients to make lifestyle changes and to convince them that the condition is serious and life-threatening. However, because village communities are small, these patients can also serve as examples for others, as explained in a quote from one of our Village Health Workers: “I would tell this man to quit his tobacco habit, to eat a low-salt diet. He would dismiss me. Then one day, he got a heart attack and died. I was then able to use him as an example to others of what will happen if they didn’t make a change.”
CRHP’s Mobile Health Team regularly visits project villages. The main goals of these visits are to provide on-site support to Village Health Workers, to advise and mentor village groups in development activities, and to check up on health cases referred by the Village Health Worker through Mobile Health Clinics. The clinics provide opportunities for patients with more serious or chronic conditions to be seen. They can receive medication and be referred to a hospital, if needed, through the Mobile Health Team. These clinics also provide a good opportunity to conduct blood pressure screenings and to provide health education.
In January and February of 2014, I tagged along on these visits to investigate hypertension in 10 villages. With the general understanding from the Mobile Health Team that a majority of hypertension patients choose to use medication rather than make lifestyle modifications, I wanted to investigate health risk behaviors and their barriers. These yielded a number of interesting insights into the village situation, related to addictions, exercise, nutrition, and stress.
With regard to tobacco use, 52% of the 55 villagers surveyed said that they currently use tobacco. Out of tobacco users, an overwhelming majority chose to take gutkha, a form of chew tobacco made of crushed betel nut and nicotine that is laced with thousands of chemicals.[i] Despite being banned in the state of Maharashtra, gutkha is widely available, sold at the corner shops that pepper the villages for as little as three rupees for a packet.[ii] Alcoholism is another risk factor for cardiovascular diseases, and it is also a serious social problem that leads to violence, particularly against women, in our villages. In two of the villages, Rajuri and Naigaon, Women’s Self Help Groups were able to successfully ban the sale of alcohol in the village shops. It is both ironic and devastating that products such as gutkha are so widely accessible because, inversely, fresh vegetables and fruits are not. In all the villages I visited, nearly everyone talked about the difficulties of getting fresh produce and needing to take a rickshaw to Jamkhed on market days if they wanted to buy fruits and vegetables. Although the majority of villagers are farmers, most of what is grown consists of cash crops such as sorghum, cotton, chick peas, pulses, and wheat, plus the villages are frequently drought-stricken, making produce inaccessible and expensive.
Recreational exercise is also a very low priority in the villages. It is only young children, particularly, young males that are seen exercising in public. For women, there is a stigma attached to exercising in public. This goes with the belief that women that exercise are seeking male attention and trying to look good. So there is a social stigma attached to trying to be physically fit. Again, CRHP Women’s Self Help Groups have been integral in the efforts to increase physical activity among village women by forming community walking groups and teaching easy yoga and stretching routines that can be done in a home.
Cardiovascular diseases are a formidable hurdle to overcome, especially when living in an environment that doesn’t facilitate healthy living, be it easy access to gutkha, lack of nutritious food, and many other factors that simultaneously influence an individual. While behavior change is a key step to reducing cardiovascular disease incidence, it is often more effective to try to create community- and systemic- level change. Some key steps that CRHP has been pursuing are to create healthier communities through the action of our community groups (Women’s Self-Help Groups, Adolescent Girls’/ Boys’ Program, Farmers’ Club) as well as creating visual aid materials such as cardiovascular disease flashcards for the Village Health Workers to use to raise awareness among the villagers.
[i] Banerji, Annie. “India ‘gutka’ chewing tobacco habit a tough nut to crack.” Reuters. http://www.reuters.com/article/2012/09/06/us-india-tobacco-idUSBRE88508420120906
[ii] “Cancer epidemic on the way.” BBC WorldService: India. http://www.bbc.co.uk/worldservice/sci_tech/features/health/tobaccotrial/india.htm