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“The obesity problem is a more complicated one than tobacco”

Chronic disease has emerged as a serious public health problem in the developing world. It might seem counter-intuitive as infections rage and under-nutrition continues to extract a terrible price. However, as World Health Organization’s research shows, 80% of chronic disease deaths occur in low and middle income countries.

Kenneth E. Thorpe a health economist at Emory University in US has studied this problem extensively and is a member of the Partnership to Fight Chronic Disease, an organization of patients and health policy experts, among others, which works on raising awareness of the problem.

On a recent visit to India, Thorpe spoke about the issue. Edited excerpts.

WHO has identified chronic disease as a growing problem in low income countries such as India. Doesn’t it seem counter-intuitive as infections have been seen as the problem?

If you look at India and China- these are two good examples- as their economies have grown what you have seen is movement of people from rural areas to urban areas. What has happened in the transition is you have a change in diet, exercise, eating patterns, nutrition patterns. You have seen obesity rates in both countries go up. They are the two leading diabetes countries in the world. But a lot of this is related to changes in lifestyle. The good news is that we can potentially prevent most of these.

Twenty years ago did research anticipate that low income countries would have huge Non Communicable Disease (NCD) problem?

No. Even in the United States, this issue did not take off till about the late 1980s. In US between the mid-1960s and 1980s the obesity rates were constant. Between 1980s and today, it (obesity rates) has doubled. It is kind of similar to other countries as well.

Low and middle income countries face two simultaneous challenges. They face a challenge from infectious disease and also lifestyle disease. How did US and Western Europe deal with challenges?

We are still in the middle of the transition. Until the Affordable Care Act was passed in 2010, our system was largely reactive. We had a health insurance system that was really good for paying for things once you were sick. It was terrible for paying for things that prevented you from getting sick in the first place. But the Affordable Care Act is moving us in that direction. We have to set up clinical preventive services that are free. We have ongoing discussions about how to build delivery system models that really work the patients at home. Most of the care needed to manage these conditions is outside the hospital. How do we (build) a model like that? It doesn’t necessarily need to be physicians. It could be nurses.

In the United States, $3 trillion is spent; 86% of it is linked to chronically ill patients. We probably spend less than 3% of the healthcare dollar on prevention. The best part of the health reform that is ongoing is to have the 3% be bigger and have the whole pie get smaller. When you integrate health services with social services, the combination of these two do a better job of keeping populations healthy.

In India, you had worked out some numbers on enhancing the level of healthcare spending. Take us through that.

In India, we think it needs to go up to 6 to 7% (of GDP from current level of around 4%). So, it is a combination of ramping up the public side and private side.

How do we get more public investment? What are the options?  People are throwing out on the table things like more of a dedication of the tobacco tax to go directly in healthcare. Or, using all these sin taxes collectively. Or income related surcharge to help fund it.

On private side, (have) broader insurance. Better insurance for not just inpatient care but primary care and outpatient care.

How has India’s approach been in relation to other emerging markets when it comes to tackling non communicable disease?

NCD is a challenge because if you think of the sense of urgency we have with HIV or once the link came up between tobacco and cancer,  that is immediate. There was a sense of urgency to do something on that. NCDs are a little bit different because it is not a mortality issue, it is a morbidity issue. Part of our challenge to get movement here is to get a sense of urgency. The economic impact is enormous. So we presented data from different studies today (in a meeting with government officials) that looked out over the next 20 years and showed the lost GDP growth, lost productivity and higher healthcare spending to be about $2.5 trillion between now and 2030. This is not just confined to the health sectors, it has big implications for the growth of the Indian economy.

Kerala has just started off on a fat tax. What has been the experience of similar taxes elsewhere?

I think the obesity problem is a more complicated one than tobacco because we know the link between tobacco and cancer. So, if you don’t want to smoke or chew tobacco, you tax the heck out of it.

On the food side it is more complicated because the root of it is changing people’s behavior. You are not get sustained results unless you change people’s behavior. You can temporarily change where they get their calories from, but if you are not going to change their eating behavior and exercise behaviors, I don’t know if at the end of the day how much effect it will have.

The good news about it is it can be used as a source of funding for expanding the coverage on public sector side. The heart of this is really changing people’s behavior.

Is sugar being treated as tobacco was 20 years ago?

What is even worse is salt. Just because what we are learning about the underlying biology of these chronic conditions is it is fundamentally linked to inflammation. And salt is major source of inflammation. Salt is a big target in the United States. And sugar.

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Dr. Kenneth E. Thorpe

Dr. Kenneth E. Thorpe

Chairman, Partnership to Fight Chronic Disease

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