Myth busting

Chronic disease is not inevitable or natural, even with age

To stem the rising tide of chronic disease, we must alter the elements of our environment.

In the 1830s, British settlers in New Zealand imported European rabbits for food and sport. With no native predators, the rabbits soon took over. Accounts from the period describe thousands of hectares run through with burrows, and huge tracts of arable land destroyed by overgrazing.

In a desperate bid to stem the scourge, the New Zealanders brought in a natural predator of the rabbit – ferrets. Without native predators to pick them off, the new imports did well. But they also played a prominent role in the decline of several endangered bird species, including the kiwi, the weka, and the kakapo. It’s a familiar parable (Mark Twain even riffed on it) about unintended consequences, and the danger of applying reductionist logic to a world that is characterised by extraordinary interdependence and complexity.

As a physician, I can’t help but be reminded of ferrets in New Zealand as I write prescriptions for the drugs we use to manage chronic disease. Hydrochlorothiazide for high blood pressure. Sulfonylureas, a class of medication used to treat Type 2 diabetes. Statins for heart disease.

Don’t get me wrong, these drugs work. They absolutely save lives. But the human body is a precisely interdependent system, and these drugs are like sledgehammers. The ferrets did kill rabbits, but they were such an indelicate intervention that they wrought their own special havoc on the native ecosystem. The kakapo might never again be seen on the New Zealand mainland. How much collateral damage are we inflicting on the human ecosystem with our powerful medicines?

Perhaps more than we think. Hydrochlorothiazide, a widespread treatment for high blood pressure, increases haemoglobin A1C and impairs glucose tolerance. These are indices of insulin resistance, which is associated with diabetes, obesity, cardiovascular disease and dementia. Hydrochlorothiazide raises LDL cholesterol and triglycerides, and lowers HDL cholesterol – a pattern known to confer increased risk of cardiovascular disease.

Sulfonylureas have been shown to increase the risk of cardiovascular disease as well.

And statins, some of the most widely prescribed drugs in the United States, have been found to impair glucose tolerance and increase the risk of diabetes.

While there is no doubt that the collective benefit of these medications currently outweighs their adverse effects, it’s remarkable that many of the drugs we give to treat chronic disease can actually increase the risk of those selfsame diseases. It speaks to the intricacy of human biology, and to the crudity of even our most advanced pharmaceuticals. Twain would have loved the irony.

External forces of chronic disease

The hope of academic medicine is that research ­– especially in molecular biology and pharmaceuticals – will save us. As we zero in on the elusive, primordial mechanisms of disease, we can design ever more precise pharmaceuticals, or even cures.

But rather than producing any outright cures for chronic disease, decades of basic science research seem to have yielded a different kind of truth – that the human body is an incredibly, devilishly complex system. The deeper we dig, the more convoluted becomes the pathophysiology of chronic disease. What has become clear is that these chronic diseases – high blood pressure, diabetes, cardiovascular disease – are manifestations of aberrant metabolisms, rather than a lone faulty switch buried somewhere within our cells.

There seem to be no silver bullets. Causation at the molecular level, deep inside the body, appears to be beyond our current reach. But what about pushing against the ultimate cause – not within us, but in the outside world? Are we fated to follow the New Zealanders’ folly, causing damage with every effort to treat? Or, can we learn what external forces have made us so chronically ill, and push back there?

Perhaps we can. It turns out that traditional cultures across the globe, from hunter-gatherers to pastoralists to horticulturists, have shown little evidence of chronic disease. It’s not because they don’t live long enough – recent analysis has found a common lifespan of up to 78 years among hunter-gatherers, once the bottlenecks of high mortality in infancy and young adulthood are bypassed. We can’t blame genes, since many of these groups appear to be more genetically susceptible to chronic disease than those of European descent.

Evidence suggests it is how they live. Though traditional cultures span an immensely diverse gamut of lifestyles, they share a common denominator defined by the absence of modern banes: absence of processed foodstuffs, absence of sedentary lifestyle, and likely absence of chronic stressors.

The lifestyle factor

Indeed, evidence suggests that lack of chronic disease in these groups flows from how they live, how they move, how they eat. Diet looks to be an especially powerful driver – adoption of a Western diet, rich in processed foods, has mirrored the development of chronic disease worldwide, and prospective studies with healthy and diabetic subjects have documented the powerful influence of food on health. Physical exercise, long touted as merely a means to calorie disposal, turns out to have complex endocrine and metabolic effects on insulin signalling, stress response, sleep, mental health, and even neuronal function in the brain. What the science seems to say is that an ancestral way of life aligns the machinery of our metabolisms toward good health.

Thus it appears that our bodies aren’t, after all, destined for chronic disease as they age – rather, it is the environment we’ve put them in that should bear the blame.

But isn’t this obvious? Yes, physicians and public health researchers have long acknowledged the influence of environmental elements on health, but we remain beholden to a paradigm that places first priority on mastery of molecular mechanisms. The sophistication of our sciences is a triumph, and technological progress must no doubt continue. But we know enough about the environmental determinants of health to act, even if we don’t fully understand the mechanisms.

Our ship is sinking, and the current approach is akin to bailing with a thimble. If we are to stem the rising tide of chronic disease, we must alter the elements of our environment that promote chronic disease. With the global price tag of chronic disease projected to rise to $30 trillion by 2030, we simply can’t afford not to.

The writer is a medical resident at the Massachusetts General Hospital in Boston.

This article was first published on Aeon.

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Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.