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Elections 2008-09: Tobacco or Health – Lets decide!
An appeal to Indian Political Parties and elected public representatives
"There are lessons to be learned from the developed world which faced a similar crisis in the 1970s and has been successful in handling it through effective public health measures. All is not lost if we act now and in cohesion. Government alone cannot solve our problems and we need active civil society participation in this fight."
Sidhant Jena : August 27, 2008
India's economic growth brought about by rapid industrialization and urbanization has led to significant lifestyle changes causing an alarming increase in the prevalence and incidence of chronic diseases such as Heart Disease, Cancer and Diabetes. These diseases are predominantly caused by lifestyle habits such as physical inactivity, tobacco use, and unhealthy diet that elevate risk factors such as high blood pressure, cholesterol, and obesity.
While communicable diseases such as HIV/AIDS, Malaria and TB are gradually being brought under control, the threat from chronic diseases is projected to increase and by 2020 these diseases will account for close to 60% of India's total disease burden, up from 30% in 1990.
This "Disease Transition", typical of any industrializing society is exemplified by the fact that while heart disease accounted for 24% of all deaths in 1990, in 2020 it is projected to cause 42% of all deaths in India, 35% of which will occur in the 35-64 year age-group1. As our population becomes younger, the productivity losses due to these premature deaths in addition to the exorbitant costs of treatment pose a serious economic and social challenge to our nation's progress (Figure 2). We stand to lose $237 billion dollars between 2005 and 2015 due to absenteeism and premature deaths from chronic diseases. By 2015, our annual losses would dwarf those of China and Russia put together, given our younger demographic.
As a country that is trying to pull itself out of poverty, we can ill-afford these losses. There are lessons to be learned from the developed world which faced a similar crisis in the 1970s and has been successful in handling it through effective public health measures. All is not lost if we act now and in cohesion. Government alone cannot solve our problems and we need active civil society participation in this fight. This paper addresses how political parties and public representatives can proactively contribute towards combating this crisis.
What's broken with the current healthcare system?
Our population can be split into three groups: healthy, at risk, and diseased. Given the fact that we are a young nation with an average age of 25 years, most of our population should fall under the healthy category. However, the sweeping lifestyle changes occurring today are causing an increasingly larger pie of our healthy population to develop risk factors and ultimately get diseased leading to severe economic and social consequences.
This burgeoning problem is compounded by our current healthcare system which doesn't focus enough on prevention, and as a result we have people needing expensive procedures such as heart surgeries, pacemakers, insulin pumps, chemotherapy, and prescription drugs in their middle ages to cure these illnesses. We cannot solve the chronic disease problem by increasing the number of super-specialty hospitals for cardiovascular surgery or cancer treatment, as the cost of these procedures can bankrupt millions of our hardworking middle class and push them below the poverty line.
It is therefore imperative for us to profess the importance of prevention by promoting healthy habits and introducing and implementing effective legislation. At least 80% of premature heart disease, diabetes, and 40% of cancer could be prevented through healthy diet, regular physical activity and avoidance of tobacco products.
Lessons from the developed world
In the early 1970s the developed world woke up to the burden chronic diseases. Starting with a small program in Finland (which had the highest mortality rates due to heart disease at the time), these countries initiated countrywide public health measures with a heavy emphasis on public awareness and advocacy. They complemented this by passing appropriate legislation such as cigarette taxes, ban on trans-fat foods, ban on direct and surrogate advertising of tobacco, ban on smoking in public places, food labeling regulations etc. As a result, chronic disease rates started declining from their peak in the early 1970s. This effort freed up billions of dollars which could then be pooled into medical research and to develop healthcare infrastructure. Finland, which pioneered this effort managed to reduce its mortality rate due to heart disease by 70% between 1972 and 1997, saving itself 17.5 billion dollars4.
A realistic scenario
The World Health Organization estimates that a 2% annual reduction in chronic disease death rates in India would result in an economic gain of 15 billion dollars. This is a very realistic scenario if we act in cohesion as a society. At a time when we are debating how to secure our energy and food supplies, we also need to pledge to secure the health of our future generations. It will require not just government action but active civil society participation.
The need to pick our battles: Tobacco
Tobacco is the only legally available consumer product which kills people when it is used entirely as intended. Its use is a risk factor for six of the eight leading causes of death in the world, known to cause chronic diseases such as Cancer, TB, Lung Disease and at least one-third of all heart disease. By 2015, it is projected to kill 50% more people than HIV/AIDS, and to be responsible for 10% of all deaths globally, with 80% of these deaths occurring in the developing world. India which accounts for nearly 12% of the world's cigarette consumption is going to the bear the brunt of these losses5.
The tobacco epidemic has spread not through a virus or bacteria, but through the business strategy of its industry. It wouldn't exist but for the billions of dollars pumped in by the tobacco industry on marketing and promotion of their brand. Moreover, many of these marketing and lobbying tactics (such as surrogate advertising – use of the same name brand for a different product, eg. Wills) which have been outlawed in the developed world are now being used to boost sales and use in the developing world.
By 2020, tobacco alone will cause 13% of all deaths in India. Its use in India is in the form of cigarettes (20%), bidis (40%), hookah, paan masala, gutka and mishri (40%). Importantly, the social gradient of its use is characterized by higher consumption patterns among the poor (Figure 7) which makes for a significant socio-economic issue6.
When, for example, a 45-year-old man in Orissa who heads a low-income household dies of cancer from a 35-year bidi habit, the survival of his entire family is at stake. His lost economic capacity is magnified as his spouse, children and other dependants sink deeper into poverty and government or extended family members must take on their support. In India, nearly a quarter of all deaths among middle-aged men are caused by smoking. It's pretty clear that tobacco's net economic impact is to deepen poverty. The industry's business objective - to get more customers addicted - disproportionally hurts the poor. For the poor, money spent on tobacco means money not spent on basic necessities such as food, shelter, education and health care.
The big question now is what political parties and public representatives could do outside of passing anti-tobacco legislation.
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What can political parties or public representatives do?
While political parties and elected public representatives (Members of Parliament, Members of Legislative Assemblies, and local bodies), can influence public policy and pass legislation against tobacco usage in India, an important aspect that is often overlooked is their ability to communicate with the masses, market ideas and form public opinion. Whether it's the Congress party trying to stress on a progressive left of center ideology or the BJP trying to promote a conservative right wing free-market ideology, political parties in India have mastered the science of social marketing and remain an unexploited medium to educate our masses on the importance of healthy habits. Since evidence from developed countries points out that the chronic disease epidemic can be effectively countered through the promotion and advocacy of healthy habits, it is all the more necessary to use any available channels to reach out to the millions of our rural and urban poor that don't fall within traditional media markets. The Congress, the Left and the BJP can differ on national security, on the economy, on fiscal policy, or on the country's nuclear regime, but they can't disagree on the fact that tobacco threatens the economic and social stability of our country.
India will be holding elections in November in three large states (Rajasthan, Madhya Pradesh, and Delhi) and subsequently General Elections in 2009, which will result in tons of media coverage and thousands of public meetings across the country. Given the fact that public spending on tobacco control pales in comparison to the revenues generated by the tobacco industry (for every US $5000 collected in tobacco tax revenue, US $1 is spent on tobacco control in developing countries)5, we could piggyback the anti-tobacco message by using elections as a vehicle to advocate reasons to quit tobacco. The following suggestions are initiatives that political parties and elected public representatives could undertake in this regard
i. Pass bi-partisan resolutions in the Parliament and State Legislatures, asking elected members and party candidates to devote 3-5 minutes of each public speech during elections to advocate against the use of tobacco. This could be supported by a signature campaign amongst MPs, MLAs pledging to do so in their respective constituencies. Young MPs and MLAs and youth wings of political parties can play a significant role in this, given the fact that tobacco companies have long targeted youth as "replacement smokers" to take the place of those who quit or die. Additionally, this could have a multiplicative impact at the lower levels of our government and reach out to millions of voters that are endangered by tobacco.
ii. A multiparty declaration to use signage during elections with an anti-tobacco theme. Party symbols such as the Hand (INC), Lotus (BJP), Elephant (BSP), Sickle and Hammer (CPI-M) are things people identify with. They could be used to send an effective anti-tobacco message. The use of such innovative signage at party-offices or public meetings organized by political parties would cater to a very large population. One of the best examples of social marketing is the use of the charkha during our freedom movement to espouse the concept of "swadeshi". If competition from the cotton mills of Manchester led to the charkha becoming synonymous with our determination to be sovereign and self reliant, then the threat from tobacco companies that endangers the health of millions in our country should lead to an appropriate response from our political class.
iii. At a time, when the political class is constantly criticized to being partisan and selfish, these simple measures would not only fight the evils of disease but also improve its own image. The tobacco epidemic doesn't require a breakthrough cure or vaccination, but can be solved through a responsible political class that is willing to pass appropriate legislation and participate vigorously in advocating against this evil product. Let's resolve to make this election year a referendum on Tobacco OR Health!
1. National Commission on Macroeconomics and Health; Burden of Disease in India. Govt. of India; New Delhi; 2005.
2. World Health Organization: An estimation of the economic impact of chronic non communicable diseases in selected countries; 2008. http://www.who.int/chp/working_paper_growth%20model29may.pdf.
3. Report of the National Commission on Macroeconomics and Health; Govt. of India; New Delhi; 2005.
4. Disease Control Priorities Project: Disease Control Priorities in Developing Countries, second edition; 2006 http://www.dcp2.org/pubs/DCP.
5. World Health Organization: WHO Report on Global Disease Epidemic, The mPower package. 2008.
6. S V Subramanian, Shailen Nandy, Michelle Kelly, Dave Gordon and George: Patterns and distribution of tobacco consumption in India: cross sectional multisectional multilevel evidence from the 1998-9 national health survey. British Medical Journal;2004;328;801-806
(Author was a Volunteer to 14th World Conference on Tobacco OR Health, Mumbai, India)