Last year almost 71% of the 57 million deaths worldwide were due to Non-Communicable Diseases (NCDs), with the big four- cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes contributing approximately 60% of mortality. That is almost 38 million people in the last year alone. These deaths were in large part attributable to shared risk factors- tobacco usage, unhealthy diet, physical inactivity and the harmful use of alcohol that can be easily mitigated through preventive measures.

 

The Sustainable Development Goals (SDGs) articulate clearly laid out indicators and targets for a policy-driven intervention designed to target health concerns related to NCDs, deaths due to road accidents as well as deaths due to poor mental health. This triad of NCDs, mental health and substance abuse, and motor accident related deaths have defined targets enshrined in 3.4; 3.5; 3.6 and 3A of the global indicator framework, developed by the Interagency and Expert Group on SDG Indicators (IAEG-SDGs).

 

While the SDGs clearly recognize mortality from these causes, and have developed detailed frameworks to address these issues, the implementation of these frameworks, especially in resource poor, low- and mid-income countries is uneven at best. This is especially so because these NCDs and mental health form a silent epidemic, addressable by lifestyle changes, and sustained long term campaigns of education- something resource poor countries have not demonstrated much success in implementing.

 

The primary challenge with NCDs and Mental Health related mortality is that any attempt to reduce mortality, needs to address the underlying shared risk factors, and social determinants. Unlike communicable diseases, the underlying risk factors in these cases are best addressed by preventive medical interventions; and require, as the Global Action Plan for Prevention and Control of Non Communicable Diseases 2013-20 points out, ‘the creation of a health promoting framework.’

 

In the absence of a global willingness to dedicate adequate resources to create an affirmative and comprehensive ‘health-promoting framework,’ governments across the world have turned to regulatory policy to mitigate risk factors- particularly tobacco usage, and the harmful use of alcohol.

 

If we look at age-standardized prevalence of current tobacco usage amongst persons 15 years or older, a global picture of decline emerges, especially in low- and mid- income countries. The Global Adult Tobacco Survey (GATS -2) India factsheet shows a decline in current tobacco usage from 2010 to 2017 of almost 6% in India (from a prevalence of 34.6% to 28.6%). Bangladesh, a low income country has demonstrated a reduction in prevalence of 8% in a shorter reference period. Both countries have resorted to top-down interventions involving the regulation and sale of tobacco products, increasing taxation on tobacco, as well as banning various forms of advertisement and promotion.

 

From a policy point of view, increasing the opportunity cost of tobacco consumption in certain segments of the population seems to have driven down current tobacco usage prevalence, but in order to build on these gains a comprehensive ‘health promoting framework,’ which involves ‘evidence based mass-media campaigns,’ and smoking cessation support and education is required. India has recently started to introduce hard-hitting educational campaigns in the mass media, but offers almost no smoking cessation support frameworks. Interestingly, despite the lack of introduction of evidence based campaigns in Bangladesh, where tobacco restrictions are significantly lower, it has registered a sharper decline in current tobacco usage prevalence.

 

In case of France, where 1 million people have quit tobacco in just 1 year due the well coordinated anti-tobacco measures, clearly demonstrates the efficacy of an investment in a ‘health-promoting environment’ in reducing NCD mortality.

 

The SDGs discuss tobacco usage in all forms- smokeless as well as cigarettes, beedis etc, and while usage across all categories has decreased, the focus of intervention in countries like India and Bangladesh seem to be on cigarette usage only, with smokeless tobacco (a form used predominantly by women in these countries) receiving little or no attention. Clearly, a more holistic strategy that includes women tobacco consumers is an essential component of mitigating risk.

 

This gender based bias towards addressing NCDs and Mental Health issues manifests itself also in attempts to address the suicide mortality rate in a country like India. There is a clearly gender skew in suicide mortality rates in India, which is one of only 5 countries where the female suicide mortality rate is more than 13- as of 2016 it stood at 14.7, a marginal decline over the years. The overall suicide mortality rate for India is 16.3, a decline of 1.1 per 100,000 people since 2000, which is an insignificant gain. Russia, on the other hand has shown a dramatic decrease in suicide rates from 52 per 100,000 to 31 per 100,000 in the period from 2000-2016, as opposed to almost all other Former Soviet Union states suggesting once again that a sustained mental health intervention can reduce rates. In India’s case, unlike most low- mid- income countries the significant amount of suicides seem to come from younger women of reproductive age as traditional family and support structures unravel, particularly in South India while no concrete steps to address inadequate access to mental health support systems, and also entrenched cultural attitudes towards women seeking mental health support worsen the situation.

 

While India’s performance in reducing tobacco usage prevalence is moderately successful, reduction in harmful consumption of alcohol (SDG 3.5.2) seems to be a long way off, and is actually increasing significantly- from “2.4 litres of pure alcohol per 15+ aged person in a calendar year in 2005, to 4.3 litres in 2010, and 5.7 litres in 2016.” India is projected to increase its APC (alcohol per capita consumption) by another 2.2 litres by 2025, failing miserably in its attempts to reduce the harmful use of alcohol, and the South-East Asia Region (SEAR) is one of the few parts of the world where APC amongst women drinkers is expected to increase, albeit marginally.

 

There is a direct relationship between harmful consumption of alcohol, and road traffic accidents, and while India has taken significant steps to reduce road traffic accidents, without tackling underlying causes adequately, and incorporating female harmful consumption of alcohol in its mitigation strategy, India will not be able to achieve its SDG targets on substance abuse and alcohol consumption, and on reduction in NCDs and suicide mortality.

 

The case of India suggests that interventions in improving the landscape of NCDs and mental health are not on track to achieve their SDG targets primarily because their focus has been on regulation and taxation- choking off at source and increasing opportunity costs, without setting up any adequate infrastructure to manage cessation, de-addiction, and mental health support infrastructure. This situation has been especially exacerbated by ignoring interventions amongst an important group- woman, who will continue to share a disproportionate amount of the disease burden unless targeted interventions for them are put in place.

 

The need of the hour is for India to take giant leaps and not small steps more so because the success of Agenda 2030 globally will depend much on India’s progress on the SDGs.