A ‘Harm Reduction’ Approach to Bolster Public Health in India

Cancer continues to be the second most common disease, and the largest cause of fatality, with cancer-led deaths accounting for over 8% of overall mortality across the world.

(L-R) Dr Anoop Misra, Dr KK Aggarwal

Serving the world’s second-largest population, the Indian healthcare system has faced a myriad of challenges. Over the years, the development of the healthcare sector has become a political commitment. Since the launch of Ayushman Bharat, the world’s largest healthcare scheme, in 2018, over 12 lakh people have been treated and 14,856 hospitals have been empanelled. The Government-initiated National Health Protection Mission aims to provide health protection to 10.74 crores poor, deprived rural families and certain occupational categories of urban workers’ families. Further, the Union Government has also increased the allocation for the healthcare scheme to Rs 6,400 crore for 2019-2020. By 2025, the Government is also planning to increase public health spending to 2.5% of India’s Gross Domestic Product by 2025. But this raises a number of questions: Is this adequate? Do we have a better healthcare environment? And, are we moving in the right direction?

There is a substantial scope to enhance the healthcare system exponentially across the country. Our ultimate goal needs to be developing a well-functioning healthcare system for 1.3 billion people (and increasing) in India. In order to create a strong backbone for a better healthcare industry, the Government, civil society and doctors along with public health specialists ought to have a comprehensive strategy to address the challenges of public health.

While access to affordable treatment options is undeniably the most important tenet of public health, a robust public health system also endeavours to prevent illness in the first place. In this context, the National Health Policy 2017 rightly emphasizes preventive health as a policy thrust area. Emphasis on prevention can reduce the burden on the public health system, and through judicious use of precious healthcare resources, can lower overall public health expenditure and improve quality of care.

India bears a particularly high non-communicable disease (NCD) burden. As per WHO estimates (September 2017), nearly 61% of all deaths in India can be attributed to NCDs, including heart diseases, cancer and diabetes. Cancer continues to be the second most common disease, and the largest cause of fatality, with cancer-led deaths accounting for over 8% of overall mortality across the world. Lung cancer is one of the most common types of cancer in India and accounts for 5.9% of all new cancer cases diagnosed in the country. Increase in cancer is directly correlated with unhealthy lifestyles, including tobacco consumption, alcohol intake and obesity. Tobacco consumption is a major contributory factor in nearly 95% of lung cancer cases and causes other serious health complications. Studies by the American Cancer Society have conclusively proven that combustible tobacco products are the single largest cause of cancer.

As per a study by the WHO and the US National Cancer Institute, global tobacco-led deaths are estimated to increase from 6 million to nearly 8 million annually by 2030. India is the second-largest consumer of tobacco in the world (Source) and in 2018, around 28.6% of adults and 15% of children consumed tobacco in India, according to the WHO, and over 1.35 million people die of tobacco-related illness in the country each year. Needless to say, refraining from tobacco consumption can be a significant action to reduce the risk of cancer.

People should be sensitized about the harmful effects of tobacco consumption and encouraged to abstain from the use of cigarettes and other forms of tobacco. In the case of long-term smokers, where there is a dependency on nicotine and quitting is not always a viable option, harm reduction alternatives can be explored. Various progressive nations such as the United Kingdom, New Zealand, Norway and Canada are offering lesser harmful alternatives to smoking, to reduce the harm caused by consuming tobacco.

In India, the immediate need is to follow a harm reduction strategy to reduce the incidence of diseases such as cancer. Medical health practitioners should advise patients to quit smoking with the support of approved nicotine replacement therapy products and if smokers are unable to quit the habit completely, they should be advised to shift to less harmful alternatives that may support their transition. Electronic Nicotine Delivery Systems or ENDS provide an alternative source of nicotine and reduces the user’s exposure to tar, carcinogens and toxins that are found in cigarette smoke. There is mounting evidence to show that ENDS are substantially less harmful than cigarettes. A report by Public Health England has stated that vaping is at least 95% less harmful than tobacco and has the potential to help smokers quit smoking. Another study published in the New England Journal of Medicine shows that vaping can be a viable alternative to help smokers transition and helps them stay away from combustible cigarettes. A group of 80 medical practitioners had recently written to the Prime Minister of India seeking regulations for ENDS, with the objective of ensuring that adult smokers have access to these reduced harm alternatives, while at the same time, restricting the use of these products by non-smokers.

The concept of ‘harm reduction’ acknowledges that safeguarding public health often requires significant behavioural and lifestyle changes on part of the patient, and sometimes inculcating these – especially in cases of dependency to an addictant - requires more than mere will power. Offering reduced harm alternatives to adult smokers gives them a third alternative besides quitting or dying.

NITI Aayog’s recent strategy document for a New India @ 75 recognizes that a sound public health system emphasizes on prevention of NCDs. To achieve this vision, we have for a better, healthier India, existing efforts such as upgradation of health infrastructure, strengthening healthcare manpower, and providing universal access to healthcare might not be sufficient. These need to be greatly supplemented with practices and technologies that have been successfully used in other countries to reduce the health and economic burden of tobacco, in order to ensure better public health outcomes for the people of this country.


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