The Jan Swasthya Sahyog hosted the Forty-Third Annual Meeting of the Medico Friend Circle at its campus in Ganiyari last month, from January 27 to 29, 2017. One hundred and nineteen delegates from a variety of backgrounds and across India discussed the challenges around providing equitable and accessible healthcare to all. Featuring talks by doctors, community workers, researchers, and activists, the meeting focused on chronic diseases of the poor.
A keynote address by Dr. Yogesh Jain argued that the early chronic disease agenda focused on individual lifestyle factors and behaviors as risk factors for chronic disease. A new wave of research indicates that social factors such as undernutrition, chronic stress, environmental pollution, occupational hazards, and violence, may be the more important risk factors for chronic diseases. We must shift from an individual to a structural lens if we are to adequately address these risk factors and reduce disease incidence and burden.
From Kerala to Kashmir, varying experiences proved that within the broad category of chronic diseases, local health profiles differ. Dr. Yogesh Kalkonde made a fascinating presentation about how, surprisingly, stroke has come to be the leading cause of death in rural Gadchiroli. Reducing stroke mortality requires prevention and screening. This means ensuring that hypertension is screened for and treated. The government should also promote communities’ own lifestyle modification efforts and ensure high-quality, local acute care if it wants to reduce stroke mortality.
Speakers from a variety of settings clearly portrayed how mental health must not be viewed only through the lens of illness. Chronic stress and chronic disease go hand in hand. Dr. Srivatsan’s paper lists eight carefully analyzed chronic stresses in Indian life, including catastrophic medical expenses, hunger, and lack of a secure daily wage. All health promotion efforts should include robust mental health emphasises and address local needs.
Another key determinant of health is nutrition, and across the board, hunger is a source of chronic stress. It is well known that hunger makes people vulnerable to infectious diseases like TB, but even a short nine months of antenatal stress in an undernourished mother leave lifetime impacts. Antenatal and early childhood stress, especially hunger, pre-dispose the body to lean diabetes, in which insulin control is hampered not by excess but deprivation. In utero stresses are compounded by inadequate food and protein intake later in life, since the Indian public distribution system favors carbohydrates over protein. This type of diabetes transcends the Type 1 and 2 divide and often oral treatments do not work, requiring injectable insulin. It is urgent that we address hunger when we discuss diabetes yet so far the research agenda has focused almost entirely problems of excess rather than deprivation.
Forty-three years ago, when the Medico Friend Circle first met in Ujjain, a far-away Finnish town was also gearing up to re-build itself for a healthy future. The people of North Karelia were disturbed to find that coronary artery disease was the leading killer in their coastal town. Together, they reduced risk factors using a community intervention model. They re-tooled their economy and diets away from high fat foods, banned smoking, and ensured active lifestyles through healthy community planning. In response to Dr. Zachariah’s forty-third birthday tribute to friends in North Karelia, Dr. Shaheen asked whether and how Ganiyari too could go on a diet?
Health care should be communitized rather than commercialized, argued speakers from a number of backgrounds. They discussed how they used low-cost, community based interventions for health promotion. Such interventions ranged from the 38 chronic disease support groups at JSS, to once-monthly community-based physiotherapy in areas where there are no physiotherapists, to CorStone’s emotional health- and resilience-building curricula that equip people to proactively respond to a variety of challenges, including chronic disease and violence. These interventions are not simply aimed at cutting costs: rather they aim to provide healthcare that empowers patients to live full lives.
Chronic diseases yield long-term profits for drug companies. While the few rupees required for a daily dose of a maintenance drug may seem inexpensive next to expensive antibiotics, lifetime costs mean that chronic diseases provide big–and reliable–profits to pharmaceutical companies. Cancers require a huge outlay from patients for chemotherapy drugs, many of which are priced so high as to be out of the reach of all but a few Indians. The meeting featured a lively session specifically devoted to strategies for regulating pharmaceutical companies, ensuring low-cost drugs, and blocking hazardous and ineffective drugs from the market.
Members also discussed health care in conflict zones in India. One member visited Kashmir and interviewed doctors and others. She shared the devastating impact of the Indian army’s use of rubber bullets that have blinded, maimed, and killed young people. Restrictions on movement and communication have restricted health care and will surely leave lingering impacts on physical, mental, and community health.
As delegates arrived on the afternoon before the conference, JSS was bustling. Three separate sickle cell patient support groups from different areas in northern Chhattisgarh met each other for the first time. Together, they founded a Sickle Cell Disease Mahasangh (Federation) and signed a letter to Chhattisgarh state health officials about their needs.
Food and fellowship were also important at the Friend Meet. Two long and rich sharing sessions allowed members to ask questions about how handling the ethical, political, and personal challenges facing those who work in community health. The menu featured local vegetables, dals, snacks, and the famous tivra bhaji. JSS School of Nursing students performed dances to Chhattisgarhi folk songs.