Kerala has made significant progress against several leading causes of death and disease. Life expectancy has increased dramatically, infant and maternal mortality rates have declined, the under-five mortality rate has decreased significantly. But, has Kerala solved all its healthcare issues?
The Nipah outbreak or the Covid-19 pandemic may not test Kerala’s healthcare infrastructure, but the state is facing a health crisis that is rooted in its social transformation. Kerala society needs to develop a bipartisan vision and an appropriate praxis to ensure healthy lives and promote wellbeing for people of all ages. Kerala’s electorate will soon head to the polling booths to select their legislative assembly members. Perhaps, this is the right time to present a people’s manifesto on health to political parties, as health is not on top of their agenda.
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A vision for health in Kerala
A broad-based political discourse involving bipartisan political leaders and all population segments is essential to achieve a vision for health in Kerala. A detailed analysis of Kerala’s determinants of health and wellbeing is an essential step towards developing a comprehensive action. There is a consensus on the need for good health as an essential component of sustainable development. A healthy population is an essential infrastructure for development. That reflects the complexity and interconnectedness of health and development.
The demographic, epidemiological, migratory, and environmental transition presents new challenges to Kerala’s health sector. Kerala’s demographic change can alter disease burdens, the health care system, its costs, family and social structure, economies, trade, and human migration patterns. Dr Nithya NR (2013) from the Department of Political Science, University of Kerala, India, listed some of the critical aspects of the present health scenario in Kerala as:
- The privatization of medical care
- Over hospitalisation
- Over administration of medicines
- Increasing number of specialists
- Escalation of the health care cost
- Marginalization of the poor
- Large number of ill-qualified doctors
- Decline in professional ethics in the health sector
- Increase in medicine’s price
- Lack of political commitment
- Bureaucratic inefficiency
- Corruption and
- Lack of proper planning
It appears that Kerala’s political discourse is oblivious of the gravity of the present and imminent challenges to its citizens’ health and wellbeing. The structural changes needed to address these challenges are not in the political manifesto of any political parties or the popular discourse. Also, there is propaganda to project Kerala as a global leader.
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Social determinants of health in Kerala
Reimagining health and wellbeing in Kerala needs to consider widening economic and social inequalities, rapid urbanisation, threats to the climate and the environment, the increasing burden of infectious diseases, and emerging challenges of noncommunicable diseases. Unwavering support for affordable Universal health coverage must be integral to achieving a healthy population in Kerala. The health and wellbeing of the population cannot be achieved without ending poverty and reducing inequalities.
The challenges of a high prevalence of comorbidity are yet another characteristic of Health in Kerala. There is a link between chronic diseases such as diabetes, CVD and TB. A 2012 study supported by the Kerala government found that 44% of TB patients had diabetes. Moreover, 21% of TB patients were found to have undiagnosed diabetes.
Kerala’s health gains are uneven in a closer analysis between districts, population groups, and age groups. The apparent impressive gains of overall averages hide that many are being left behind. One of the significant reasons for the perception of health in Kerala is a model derives from the hegemonical patterns of health policymaking. Health policymaking in Kerala is mainly done from biomedical models of health and practised by a few medical elites of the state.
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Lifestyle diseases major threat in Kerala
High prevalence of heart diseases, cancer, geriatric care challenges, the prevalence of high-risk factors, and an unacceptably high percentage of malnourished and underweight children cannot be wished away. The economic burden of ill health is high in Kerala, which could eat away some of the overall development gains. Catastrophic health expenditure requiring distress financing and out-of-pocket health expenditures will have severe long-term health and economics consequences. Uncontrolled Rapid privatisation of healthcare will make affordable healthcare a luxury.
All this should be read in the context of the government’s failure to agree on a comprehensive health policy for Kerala. Written policies do act as a tool for accountability and monitoring. The health policies in Kerala, influenced mainly by the biomedical models of health and wellbeing, has consistently rejected social-structural models of health which derives knowledge from a structural analysis of health and an enquiry into the social production of health and wellness.
Kerala is the most urgent candidate to explore the structural determinants of health and wellbeing and integrate health into its policies. A range of structural determinants of health, which can influence health equity in positive and negative ways:
- Adequate housing, basic amenities and a healthy environment.
- Access to Social support networks.
- Decent Income, social status and social protection.
- Education and literacy.
- Employment status, working conditions and Job security.
- Social environments.
- Physical environments.
- Food security and safe food.
- Social support and social inclusion.
- Personal health practices and coping skill.
- Support for healthy early child development.
- Exposure to conflict and violence, including domestic abuse.
- Access to affordable health services of decent quality.
- Gender norms in accessing health services.
- Culture and health-seeking behaviour.
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Global healthcare commitments
Kerala also needs to meet the global commitment by 2030 to end the epidemics of AIDS, tuberculosis, malaria, neglected tropical diseases, combat hepatitis, water-borne diseases, and other communicable diseases. Kerala has a natural leadership opportunity to implement Health-related Sustainable Development Goals
TB is still an unfinished agenda in Kerala. It affects primarily young adults the world over. In Kerala, however, proportionally more people over 45 years have TB, data collected by the state TB cell shows. Between 2004 and 2014, the proportion of TB cases among those above 45 years increased by more than 10%.
To align with the National Sustainable Development Goals, Kerala needs to reduce, by 2030, one-third of premature mortality from noncommunicable diseases through prevention and treatment and promoting mental health. The state needs to strengthen substance abuse prevention and treatment, including narcotic drug abuse and harmful alcohol use.
Kerala is increasingly called the diabetes capital of India, with a prevalence of diabetes as high as 20% ─ double the national average of 8%. In a large multi-centre study involving nearly 20,000 subjects, the prevalence of diabetes in Thiruvananthapuram (Kerala’s capital city) was 17% compared with 15% in Hyderabad and New Delhi, 4% in Nagpur and 3% in Dibrugarh.
Alcohol abuse causes an increased level of the disease burden in youth in the state. The Kerala alcohol policy is motivated by revenue considerations rather than public health considerations or a balance between two. Support and treatment programs for alcohol abuse is far farm adequate.
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Need to curb road accidents
In 2019, Kerala had the fourth-highest number of road accidents in the country, adding to the state’s fragile trauma care system. The state was ranked fifth from 2015 to 2018 regarding the number of road accidents in 2019. The Kerala road safety authorities have identified a high number of 238 accident black spots in the state.
As per the Union ministry of road transport and highways protocol, an accident blackspot is identified when five accidents or 10 fatalities have been reported within an area of 500 m in length in three years. To achieve the UN Sustainable Development Goal related to health, by 2020, the state has to halve the deaths and injuries from road traffic accidents.
The state needs to ensure universal access to sexual and reproductive healthcare services, including family planning, information and education, by 2030. During NFHS- 5, The Total Fertility Rate (TFR) in Kerala stood at 1.8. Whereas at the National level, the TFR is 2.2, slightly above the replacement level of 2.1. Like many other states, In Kerala also, Family planning is the responsibility of women.
About 50 per cent of married women used some modern contraception method across the State of Kerala in India in 2016. Tubal ligation, the surgical removal or blocking of fallopian tubes, was the most common method used by women in Kerala, at around 46 per cent. Male sterilization remains 0.01% though it is a simple procedure than the surgical procedure of Tubal ligation.
Kerala is far away from achieving universal health coverage, including financial risk protection from ‘Catastrophic health expenditure’, access to essential healthcare services, access to safe, effective, quality and affordable essential medicines and vaccines for all.
Catastrophic out-of-pocket expenditure on health has become a critical element of the State’s health system. According to a 2011 KSSP’s study, on average, a person spends almost Rs Six thousand a year out of his pocket to seek medical care in Kerala.
By 2030, Kerala has to substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination. As a first health risk assessment on the burden of outdoor air pollution in Kerala by Prof Myriam Tobollik and colleagues (2015) from the Department of Environment and Health, School of Public Health, Bielefeld University in Germany, and the Federal Environment Agency of Germany shows that many deaths attributed to ambient air pollution by PM2.5 are due to cardiovascular causes. In the baseline scenario (Cardiovascular Deaths (CD)_Baseline (6)), 51% of the male and 49% of the female cardiovascular deaths can be attributed to air pollution in Kerala.
Some of the comprehensive epidemiological data on the disease burden in Kerala is very sobering. Kerala is reporting diabetes 20%, high blood pressure 42%, high cholesterol (>200mg/dl) 72%, smoking (42% in men), obesity (body mass index >25) 40%, physical inactivity 41%, alcohol abuse 13%. Kerala also has a high per cent of malnourished children. 19% of Kerala children are underweight, every fifth child has stunted growth, and 15.3 per cent of children are underweight in Kerala.
About 14% of all deaths in Kerala are caused by coronary heart/artery disease (CHD/CAD). Approximately 60% of CAD deaths in men and 40% of CAD deaths in women occur before the age of 65, a young age as CAD in Kerala is premature and malignant. The high rates of premature heart disease in Kerala also results in a high economic burden as high as 20% of its state domestic product.
More than 60% of the high income and more than 80% of low-income people hospitalized for heart attack result in catastrophic health spending, with 50% of these requiring distresses financing in Kerala.
The Prevalence of premature CAD in Kerala is because of increasing modifiable risk factors in teenagers. The contributing factors are high consumption of alcohol, unhealthy diet along with very high intake of saturated fat as part and parcel of cultural, lack of physical activity, sedentary lifestyle and air-pollution.
There are 974 female cancer and 913 male cancer patients per million in Kerala as per cancer registry data. In one year, Kerala has roughly 35,000 new cancer cases occurs. In this, 50% of cancers are in the throat, mouth and lungs in male & 15% in women caused by tobacco and alcohol habits. Actually, in Kerala overall, tobacco is responsible for 50% and diet for 10-20% of cancers.
Breast cancer is the most common malignancy among women in Kerala; about 30 to 35% is accounted for by breast cancer. According to the data available with the Thiruvananthapuram Cancer Registry, the prevalence rate in rural areas is 19.8 per 100,000, while in urban areas, it is 30.5 per 100,000.
The incidence of colorectal cancer in Kerala is about 5.5/ 100,000. Also, the incidence of thyroid and ovarian cancers is up among women in Kerala. Prostate cancer, the most common malignancy among men worldwide, is among the ten leading cancers in Kerala. Cardiovascular disease is the foremost killer of people with diabetes. 80% of diabetic patients die from heart disease.
People from Kerala have the highest cholesterol level in India, ranging from 197 to 229mg/dl than 157 to 180mg/dl nationally. Fat intake in Kerala is 30% of the energy, with 70% of that (20% of daily energy) coming from saturated fat. As a right step, Kerala Government has imposed a 14.5 per cent “fat tax” on foods such as burgers and pizza sold in specific locations such as cultural complexes and indoor stadiums.
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Privatisation of healthcare escalates costs
One of the significant consequences of the unregulated rapid privatization of health care in Kerala is over-medicalization and escalation of healthcare costs. Kerala has the country’s highest caesarian rate of 30.5 per cent, which is three times higher than the national average. The World Health Organization’s recommended rate is (15 %).
Kerala needs to substantially increase health financing and the recruitment, development, training, and retention of Kerala’s health workforce, particularly nurses and community health workers. Nursing training in Kerala needs to reform, keeping in mind the nursing profession’s dual role in Kerala. Nursing professionals contribute to the local health care needs and the international health care needs of developed countries.
In the context of emerging and re-emerging diseases, there is a need to strengthen the State-specific capacity for early warning, risk reduction, and health risk management. Rajeev Sadanadan and his colleagues (2018) alerted us to the need for developing a global health security perspective while addressing the 2018 Nipah virus outbreak linked to Pteropus bats in Kerala.
Health is a public commodity, and it is a fundamental human right. The Covid-19 pandemic has robbed the civil society space in health response, and the governments gladly usurped space to a law and order frame of response. Criminalising health and disease is a disturbing trend.
A transparent health financing policy based on a cost budget should be mandatory from Kerala’s elected government. Lack of a costed health policy should be considered as criminal negligence of the government. Citizens’ right to life is compromised when a government fails to present a written, cost health policy. An annual report of the State of Health in Kerala must be a mandatory report from the next elected government.
A transdisciplinary, multisectoral, rights-based, gender- and eco-sensitive approach is essential to address Kerala’s health inequalities and to build good health and wellbeing. Investing in health do make solid economic sense as well. Health is a pressing issue in Kerala. Commitment to Kerala’s real health issues is the litmus test to the social commitment of political leaders of Kerala.
(Dr Joe Thomas is associate dean, faculty of sustainability studies, and head, School of Public Health, MIT World Peace University, Pune.)
References:
Nithya N.R. (2013), ‘Kerala Model of Health’: Crisis in the Neo-liberal Era, International Journal of Science and Research, ISSN No. 2319-7064, Volume 2 Issue 8, August 2013, pp.201-203. 14.
Sadanadan R, Arunkumar G, Laserson KF, et al. (2018) Towards global health security: response to the May 2018 Nipah virus outbreak linked to Pteropus bats in Kerala, India. BMJ Glob Health. . 2018 Nov 9;3(6):e001086. doi: 10.1136/bmjgh-2018-001086. eCollection 2018
Tobollik, M., Razum, O., Wintermeyer, D., & Plass, D. (2015). Burden of Outdoor Air Pollution in Kerala, India—A First Health Risk Assessment at State Level. International journal of environmental research and public health, 12(9), 10602–10619.
Dr Joe Thomas is Professor of Public Health, Institute of Health and Management, Victoria, Australia. Opinions expressed in this article are personal.