Opinion Indians struggle with high blood pressure. And it’s not about lifestyle

A few days earlier, an analysis of data from the National Family Health Survey-5 (2019–2021) published in The Lancet Regional Health-Southeast Asia indicated that 18.3 per cent of the country’s population has hypertension (high blood pressure). The 2017-18 National NCD Monitoring Survey (NNMS) conducted by the Indian Council of Medical Research (ICMR) among the 18-69 years age group revealed a higher rate — 28.5 per cent. Given India’s large population size, these percentages translate to large numbers in terms of health service provisioning. Both surveys point to a common set of worrying findings: Low levels of awareness, treatment, and control of hypertension and a yawning gap between awareness and treatment.

The NMNS observed that 28 per cent of those with hypertension were aware of it and 52 per cent of those aware were actually being treated. Among those surveyed, 47.6 per cent reported having their blood pressure (BP) measured in their lifetime — women had a higher probability owing to ante-natal check ups. Those with higher levels of education and better-paying jobs had a higher probability of having their BP measured, and in turn, being diagnosed early. People living in south India had a nearly two-and-a-half times probability of having their BP measured — a likely marker of stronger health systems. Only 27.9 per cent of those detected with hypertension during the survey were aware of their disease status, 14.5 per cent were under treatment for hypertension and 12.6 per cent had their BP under control. Of those with hypertension, only 21 per cent accessed treatment from a public facility (there is no significant rural-urban difference on this count) and a very small proportion used AYUSH systems alone for the treatment.

The NFHS-5 analysis observed that among hypertensive individuals, 70.5 per cent were screened at least once (had their BP measured), 34.3 per cent had been diagnosed before the survey and were therefore aware of their hypertensive status, 13.7 per cent were receiving treatment with (prescribed anti-hypertensive medicines), and 7.8 per cent had their BP under control. Males, illiterates, poor, residents of rural areas, smokers/tobacco users and alcohol users were less likely to be in any of the treatment cascades.

To put these figures in context, India launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) in 2010. It was rolled out in 100 districts across 21 states during 2010-12 and has been under implementation in all states since March 2016. The programme is primarily limited to screening and treatment and is also part of the Comprehensive Primary Health Care (CPHC) package.

The 2018 Astana Declaration on Universal Healthcare and SDGs has reaffirmed commitment to the primary healthcare approach. It redefined the core functions of UHC as service provision, multisectoral action and empowerment of citizens. In the case of highly prevalent conditions like hypertension, governments must commit more resources to primary health care, implementing interventions to retain the rural health workforce, training frontline health workers to deliver core health interventions and engaging them in multi sectoral collaborations. This also involves increasing community engagement.

Contemporary clinical approaches to controlling CVD lean heavily on a risk factor approach. They focus on “lifestyle” risk factors such as dietary habits, physical inactivity, smoking, and adiposity. Such approaches concentrate on the identification, modification, and treatment of individual-level risk factors. The WHO’s Commission on Social Determinants of Health (CSDH) draws upon a rich repository of credible evidence to underscore that the so-called lifestyle risk factors are not really outcomes of choices, but compromises. The Commission, therefore, focuses on socioeconomic influences on CVD that operate across the lifespan of an individual — low birth weight, growth retardation, educational and environmental factors, job stresses in adult life and inadequate medical care, especially for the elderly. Epigenetic modifications may emerge due to a lifetime of disadvantage, structural inequalities and discrimination — these, in turn, have intergenerational influences.

The CSDH report sums up the situation: “Reducing health inequities is… an ethical imperative. Social injustice is killing people on a grand scale.”

The writer is professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi and Editor, Indian Journal of Public Health. Views expressed are personal