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Chronic diseases now a leading causes of death in rural India - mortality data from the Andhra Pradesh Rural Health Initiative
Rohina Joshi1, Magnolia Cardona1, Srinivas lyengar2,
A Sukumar2, C Ravi Raju2, K Rama Raju2,
Krishnam Raju3, K Srinath Reddy4, Alan Lopez5,
Bruce Neal1
1The George Institute for International Health, PO Box M201,
Missenden Road, Sydney NSW 2050, Australia; 2Byrraju
Foundation, Satyam Enclave, 2-74 Jeedimetla Village, NH-7, Hyderabad,
Andhra Pradesh 500855, India; 3CARE Foundation, Banjara
Hills, Hyderabad, Andhra Pradesh, India; 4Centre for Chronic
Disease Control, V15 Green Park Extension, New Delhi 110016, India,
5School of Population Health, University of Queensland,
Queensland, Australia
ABSTRACT
Introduction
India is undergoing rapid epidemiological transition as a consequence of
economic and social change. The pattern of mortality is a key indicator
of the consequent health effects but up-to-date, precise and reliable
statistics are few, particularly in rural areas.
Methods
Deaths occurring in 45 villages (population 180,162) were documented
during a 12 month period in 2003-4 by multipurpose primary healthcare
workers trained in the use of a proven verbal autopsy tool. Algorithms
were used to define causes of death according to a limited list derived
from the international classification of disease version 10. Causes were
assigned by two independent physicians with disagreements resolved by a
third.
Results
1354 deaths were recorded with verbal autopsies completed for 98%. A
specific underlying cause of death was assigned for 82% of all verbal
autopsies done. The crude death rate was 7.5/1000. Diseases of the
circulatory system were the leading causes of mortality (32%), with
similar proportions of deaths attributable to ischaemic heart disease
and stroke. Second was injury and external causes of mortality (13%)
with one third of these deaths attributable to deliberate self harm.
Third were infectious and parasitic diseases (12%). Tuberculosis and
intestinal conditions each caused one third of deaths within this
category, HIV was assigned as the cause for 2% of all deaths.
The fourth and fifth leading causes of death were neoplasms (7%) and
diseases of the respiratory system (5%).
Conclusion
Non communicable and chronic diseases are the leading causes of death in
this part of rural India. The observed pattern of death is unlikely to
be unique to these villages and these findings have significant
implications for the rural health system.
INTRODUCTION
Many urban and rural areas of India are undergoing rapid epidemiological
transition as a consequence of economic and social changes.1,2
As these changes occur ongoing modification of the health system is
required to ensure that the services provided address the main diseases
suffered by the population. The Hyderabad-based Byrraju Satyanarayana
Raju Foundation3 sponsors a rural development initiative in
Andhra Pradesh which includes a significant health care component. The
Foundation is keen to ensure that the scarce resources available for
health care are used to maximum effect and mortality data were
identified as essential to the decision making process. Since precise,
reliable and up-to-date statistics about causes of death were not
available for these villages or a close by area we established a cause
of death surveillance system using the well-established verbal autopsy
method.4 We report here the results from the first
twelve months.
METHODS
This work has been conducted as collaboration (the Andhra Pradesh Rural
Health Initiative) between five Indian and Australian institutions
(listed in Acknowledgements). The data reported here were collected
between 1st October 2003 and 30th September 2004.
Approval for the project was received from the Ethics Committees of the
CARE Hospital, Hyderabad, India and the University of Sydney, Australia.
Written informed consent was obtained from each respondent prior to the
collection of any data and we sought to design and conduct the project
in line with the Declaration of Helsinki and its subsequent amendments.
Population studied
This project was conducted in 45 villages in East and West Godavari in
Andhra Pradesh, India. The population (n=180,162) age and sex structure
was defined by a population census conducted by the Foundation in 2002-3
and is shown alongside earlier state-wide estimates for rural Andhra
Pradesh5 (Figure 1). From a concurrent survey done in the
Foundation villages it is known that about 54% of the population are
literate, that the average monthly household income is about US$50
dollars and that the majority of the population are agricultural and
aquaculture labourers.
Identification of deaths
The Foundation Multipurpose Primary Healthcare Worker (MPHW) resident in
each village was the primary mechanism for identifying deaths.
Identification of deaths by the MPHW was facilitated by her daily
contact with the villagers and a network of key informants including the
village headman, the 'Panchayat' (village governing body responsible for
registration of deaths), priests and cremation staff, other community
leaders and the government MPHW. The completeness of the identification
process was checked between 25th April 2005 and 30th
May 2005 by the field supervisor or MPHWs visiting every house in every
village and checking that all deaths in the period 1st October 2003 to
30th September 2004 had been recorded.
Data collection
For each death recorded, the Foundation MPHW sought to visit the
deceased's household within four weeks of the date of death. The family
member or other carer best able to report on the events antecedent to
the death was identified and a systematic inquiry into the events
leading up to the death was made using a semi structured verbal autopsy
tool according to an established technique. The verbal autopsy process
used in this project was based closely on the method developed for the
Registrar General of India's Sample Registration System6 with
only minor modifications made to suit local terminology. Separate
questionnaires were used for deaths in each of three age groups (0-28
days, 29 days to 15 years and 15 years onwards) and all included a
series of structured questions and an open narrative section. The open
narrative section was completed with the aid of systematic prompting by
the MPHW using a defined symptom list with specific inquiry about
prescribed treatments, medical procedures and associated documentation.
The MPHWs were trained in data collection prior to commencement of the
study with refresher training after 6 months.
Cause of death assignment
Cause of death assignment was also done using materials and processes
developed for the Registrar General of India's Sample Registration
System.6 In brief, each verbal autopsy was assessed
independently by two trained physicians who each assigned an underlying
cause of death for all cases with immediate and contributory causes also
assigned wherever possible. Causes of death were selected from a
restricted fist derived from the 10th version of the international
classification of disease (ICD-10). The causes selected for inclusion in
the list comprise the main causes of death which it is considered that
trained physician reviewers can reasonably assign on the basis of the
information typically provided in a verbal autopsy. Assignment of the
causes of death by the physicians was facilitated by a series of
algorithms developed for the Sample Registration System.7 In
the event of disagreement between the underlying causes of death
assigned by the two physicians, a third physician reviewed the evidence
and decided upon the underlying cause.
Outcomes
The main outcomes for this study were rates of death by age and sex and
the proportion of deaths in men and women attributable to main
underlying causes defined by the chapter headings in the International
Classification of Diseases version 10. Where more than 50 deaths fell
within one grouping a further breakdown of the main components has been
provided.
Analysis
The rates of death, overall and for each age and sex group, were
calculated by dividing the relevant number of deaths by the number of
individuals defined by the 2002-3 population census done by the
Foundation. These results are expressed as rates per 1000 for the 12
months between 1st October 2003 and 30th September
2004. Proportions of deaths were calculated by dividing the number of
deaths attributed to a specific cause by the total number of deaths for
which a verbal autopsy was done and these results are expressed as
percent. Analyses were done using SPSS version12.
RESULTS
Identification of deaths and cause
of death assignment
Between 1st October 2003 and 30th September 2004
there were 1354 deaths identified. Verbal autopsies were completed for
1329 (98%) deaths and a specific underlying cause of death was assigned
for 1084 (82% of all verbal autopsies done). For 18% a symptom code was
assigned because a definite cause of death could not be arrived at. The
majority (73%) of those for whom no specific underlying cause of death
could be assigned on the basis of the verbal autopsy were over 60 years
of age. A third physician was required to resolve a discrepancy between
the underlying causes of death assigned by the two independent physician
reviewers in 173 (13%) cases.
Death rates and proportions
attributable to main causes
The population crude death rate was 7.5/1000 (Table 1)
with an approximately log-linear increase in death rates with age for
men and women from 5 years of age upwards (Figure 2). Rates of death for
males exceeded those of females for all age groups except for deaths at
4 years of age or under.
The first leading cause of death in the villages was diseases of the
circulatory system (32%) with comparable proportions of ischemic heart
disease (14%) and cerebrovascular disease (13%) comprising the majority
of deaths in this category. The second most common cause of death was
injury and other external causes of mortality (13%). One third of all
deaths attributable to injury were due to self inflicted injuries, and
one fifth were due to falls. Infectious diseases (12%) were the third
leading cause of death with tuberculosis and intestinal infections each
accounting for one third of deaths in this category. HIV was assigned as
the cause in 2% of all deaths. The other main causes were neoplasms (7%)
and diseases of the respiratory system (5%). These five leading causes
of death accounted for two thirds of all deaths.
Diseases of the circulatory system were responsible for a greater
proportion of deaths in men although there was some variation in the
pattern for the major vascular causes. External causes of mortality were
also, overall, more frequent in males with greater numbers of deaths
from transport accidents, deliberate self harm and contact with venomous
animals and plants in men and only exposure to fire, smoke and flame and
accidental drowning more common in women. There were comparable
proportions of deaths from infectious and parasitic causes in each
gender group since greater numbers of deaths from tuberculosis and HIV
in men were balanced by greater numbers of deaths from intestinal
infectious diseases in women. Neoplasms, by contrast, were almost twice
as frequent in women as men. Greater proportions of neoplasms of the
lip, oral cavity and oropharynx in women and greater proportions of
neoplasms of the respiratory and thoracic organs in men were likely a
consequence of differential use of chewing tobacco and smoking
respectively. Higher proportions of deaths from chronic lower
respiratory disease in men are also likely a consequence of smoking
habits. There was no difference between sexes apparent for diseases of
the liver.
Overall, 60% of deaths occurred among individuals aged 60 years or over
with the majority of the other deaths being among younger adults. Only
6% of deaths occurred at ages of 14 or less and the majority of these
were among individuals aged less than 4 years. About one quarter of all
deaths attributed to diseases of the circulatory system, two fifths of
deaths from cancers, one half of deaths due to infectious diseases and
two thirds of all deaths due to external causes occurred at age 60 or
less.
DISCUSSION
This study shows that chronic diseases and injuries are now the leading
causes of death in East and West Godavari surpassing by a considerable
margin deaths attributable to communicable diseases and conditions of
pregnancy, the puerperium and childhood. While correspondingly current
information about the pattern of death in most other parts of rural
India is not available, the findings of this project are in line with
those observed in the earlier Andhra Pradesh Rural Cause of Death study
8,9 and estimates made for India as a whole by the Global
Burden of Disease Study.10 In both of those studies chronic
diseases were identified as leading causes of death with cardiovascular
conditions predominating and both injuries and cancer among the leading
few causes. A further recent study done in the neighbouring state of
Tamil Nadu also documented a large proportion of rural deaths from
chronic and non-communicable conditions although that study was not able
to provide comparative data across age groups since it included only
adult deaths.11,12 The data reported here also serve to
highlight the premature age at which deaths from non-communicable
disease occur in developing regions such as India with a quarter of all
deaths attributable to non communicable diseases and injuries occurring
at age 60 or less.13
Although the two districts of Andhra Pradesh included in this study are
some of the better developed in the State, agriculture remains the
primary employer and the districts are not dissimilar to many other
parts of the country. In conjunction with the work of others,8,10
our data suggest that chronic and non-communicable diseases may well now
be the main causes of death in much of rural India as well as in urban
areas.14 Probably only in the poorest areas of the country do
communicable conditions still predominate as the main causes of death.
The preponderance of chronic and non-communicable causes of death in the
study villages fits closely with the population age-structure which
shows recent lowering of fertility rates and a consequent increase in
mean age. This has likely been driven by rapid economic and societal
development along with the delivery of basic health services such as
vaccination programs and other maternal and child focussed health care.
Among the communicable causes of death that were still widespread in the
villages gastro-intestinal infections and tuberculosis were prominent
but so too was HIV/AIDS. HIV/AIDS was identified as the underlying cause
of death in 2.2% of cases but this is likely to be an underestimate of
the true proportion of deaths for which HIV/AIDS was a contributor. As
in other societies, there are significant cultural sensitivities with
regard to the reporting of HIV/AIDS and HIV/AIDS may well have been a
contributor to other of the deaths, in particular some of those
attributed to tuberculosis.15 It would seem that HIV/AIDS
could become a very serious problem in this area of India unless
effective disease control strategies are rapidly implemented.
The crude death rate observed in this project (7.5/1000) was lower than
the State average (8.1/1000)16 and could either represent a
real lower death rate in the study districts or a failure to detect all
deaths.17 Checking of antenatal records against live births,
comparison of study records against the civil death registration system
and a door-to-door survey that included every house in every village
should have ensured that most deaths that occurred during the 12 month
study period were recorded, although a small proportion will likely
still have been missed. The difference in crude death rates might also
be a consequence of a greater degree of development in the study
villages compared to rural Andhra Pradesh as a whole.18 This
may also mean that the patterns of death observed here are shifted
further toward chronic and non-communicable conditions than in other
parts of the State.
Verbal autopsy methods have been used extensively in previous studies
and remain a cornerstone of mortality surveillance systems in developing
countries.14,19 While the method was initially developed for
child20,21 and maternal deaths,22,23 extension of
the technique for use in deaths occurring across all age groups is now
well established.24-27 In this study careful training of the
MPHWs in data collection with close supervision by a dedicated field
coordinator and cause of death assignment done by experienced physician
coders trained in the use of standardised procedures should have ensured
consistency across the project. Nonetheless, it was not possible to
assign a specific cause for some 18% of deaths, a figure comparable to
that observed in previous studies.14,28 While it is difficult
to be sure how better knowledge of these deaths might have influenced
the findings it seems unlikely that it would substantively influence our
primary conclusions about the importance of chronic and non-communicable
conditions in these villages. For example, more than one quarter of the
unclassified deaths fell into the category 'sudden death' and would
likely have been due to cardiovascular causes29 and more than
three quarters of the unclassified deaths were in the elderly among whom
chronic and non-communicable conditions usually predominate. The pattern
of death across the sexes was also broadly consistent with that observed
for comparable projects for causes such as vascular disease, injuries,30,31,32,
HIV33 and cancer34 providing further reassurance
about the likely validity of the findings reported here.
The implications of these study results are substantial. Hundreds of
millions of individuals living in rural India are probably now at much
greater risk of death from chronic or non-communicable conditions than
from communicable diseases. While the primary healthcare system in India
appears to have been very effective in dealing with the problems of
infectious diseases and maternal and child health it is less well
equipped to deliver care and prevention for chronic diseases.35
An urgent reorientation of the health delivery system is required to
enable the implementation of evidence-based strategies that can address
this new challenge of non-communicable conditions.
ACKNOWLEDGEMENTS
The Andhra Pradesh Rural Health Initiative is a collaboration between
the Byrraju Satyanarayana Raju Foundation (Hyderabad, India), CARE
Hospital (Hyderabad, India), the Centre for Chronic Disease Control (New
Delhi, India), The George Institute for International Health (Sydney,
Australia) and the University of Queensland School of Population Health
(Brisbane, Australia). The authors wish to acknowledge: Ammaji P,
Ananthalakshmi A, Annamma M, Babu R, Baby K, Babyrani Y, Dhanalakshmi H,
Dhanalakshmi P, Durgadevi D, Durgadevi D, Durgadevi N, George CK,
Gholamrezaee L, Gowrisankaramma K, Heaven A, Hemakumari M, Hemalatha B,
Jyothi P, Kalpana G, Kamalakumari NA, Kanakadurga K, Kanakadurga Y,
Kanthamani K, Kumari B, Lakshmibai P, Lakshmidevi B.V.V.S, Leelavathi P,
Mangatayaru G, Manikyam B, Mary , ones G, Mirzaie M, Muralikrishnaveni
P, Nagalakshmi R, Nagamani G, Nagamani R, Nagasiromani K, Narasamma D,
Pettakanakamaha Lakshmi, Prameela K, Rajani P, Rajani P, Rajiniratnam N,
Rajyalakshmi P, Rani U, Ratnakumari AP, Santhakumari S, Sarojakumari S,
Sasikala G, Sathyavathi U, Satluri J, Shah M, Sitaratnam U, Snehi U,
Soni G, Sowbhayamma G, Sujatha N, Sujatha P, Sujatha T, Sunethe Kumari
K, Suneetha P, Suryakumari M, Suvarnaraju S, Swarna Latha V, Tadinara,
Tulasi P, Udayabharathi K, Usha Sundari G, Usharani P, Venkatalakshmi K,
Verma S, Vijaya D, Vijayakumari Ch,Vimaladevi D , and Yesudanam T and
all the interviewees who agreed to participate in the study.
Funding support for the India-based component of this project was
provided by the Byrraju Foundation. The George Institute's contribution
to this project was made possible by an award from the George
Foundation. Rohina Joshi is supported by the International Post-graduate
Research Scholarship and International Post-graduate Award from the
University of Sydney and Bruce Neal by a Fellowship from the National
Heart Foundation of Australia.
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FIGURE LEGENDS
Figure 1
Figure 1 Age and sex distribution of the population
The shaded bars indicate the age and sex distribution for rural Andhra
Pradesh based on the 1997-98 National Family Health Survey.5 The clear
outlined bars show the corresponding data of the study population for
the year 2002-'03.
Figure 2
Figure 2 Log plot of death rates by age for men and women
Table 1
Table 2
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