The Kerala government has identified a cluster of diseases, including cardiovascular disease, type 2 diabetes, cancer, and chronic respiratory disease, as lifestyle diseases (ജീവിതശൈലി രോഗങ്ങൾ) (GOK 2019). It has initiated a statewide programme to combat these health challenges. Regrettably, the prevalence of these so-called lifestyle diseases is increasing with severe social and economic consequences. Chronic diseases such as hypertension and diabetes account for approximately 68% of all chronic diseases in India. Notably, Kerala has the highest prevalence of chronic diseases in the country, standing at 54% (Jana, Chattopadhyay 2022) (Muraleedharan, and Omprakash Chandak 2022).
The absence of a public health perspective in Kerala’s health policies is a primary reason for the failure to achieve desired outcomes from interventions. The dominance of the medical community in health discourse has led to the narrow classification of noncommunicable chronic diseases as lifestyle diseases, exemplifying medical control over health discussions.
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Kerala model: Missing public perspective
A public health perspective focuses on the well-being of the entire population, emphasising the prevention of illnesses and injuries by promoting healthy social conditions, conducting disease and injury prevention research, detecting, and responding to infectious diseases, and advocating structural reforms to integrate environmental factors for better health outcomes.
According to a report, ‘India: Health of the Nation’s States’ by the Indian Council of Medical Research (ICMR) (2017), the proportion of deaths due to noncommunicable diseases (NCDs) in India has risen from 37.9% in 1990 to 61.8% in 2016. The four major NCDs — cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes — share common behavioural risk factors, including unhealthy diets, lack of physical activity, and tobacco and alcohol use. However, this study fails to address the structural and social determinants of NCDs.
Global evidence suggests that the prevalence of diabetes is on the rise due to various factors. Therefore, understanding disparities in risk factor profiles and the burden of diabetes across different populations is crucial for effective prevention and control (Ong et al., 2023).
The latest data and evidence emphasise the need for a comprehensive public health approach that integrates structural and social determinants in addressing NCDs (Yang et al., 2018). Nevertheless, current efforts to prevent and control chronic diseases primarily focus on individual behaviour and lifestyle factors, which stem from policymakers’ inadequate understanding of the structural and social determinants of these diseases (Yang, Mamudu, & John, 2018). Social determinants have increasingly been recognised as fundamental influences on health, rather than distant or secondary factors (Cockerham et al., 2017).
Describing a complex set of diseases solely from a narrow biomedical perspective by labelling them as lifestyle diseases further exacerbates the issue. Such categorisation stigmatises and blames individuals with chronic diseases. The use of the term lifestyle diseases by the Kerala government in its policy documents leads to unintended negative consequences. Therefore, it is essential for the Kerala government to cease using the term lifestyle diseases and rectify any references to it in policy and programme documents. Some experts recommend adopting the conventional term chronic diseases (Ackland et al., 2003).
In the Indian system, health falls under the purview of the state government. The federal government’s Department of Health & Family Welfare provides technical and financial support to the states and Union territories.
Chronic diseases or lifestyle diseases
The Union government implements the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) (2010) based on proposals received from the states/UTs. This programme focuses on strengthening infrastructure, developing human resources, promoting health awareness, early diagnosis, management, and referral for the treatment of NCDs. However, the NPCDCS does not consider the structural and social determinants of NCD/CD, although it refrains from labelling chronic diseases as lifestyle diseases. In contrast, the Union government’s National Health Policy (2017) uses noncommunicable diseases and chronic diseases interchangeably.
The naming of diseases plays a crucial role in public health and communication. The World Health Organisation (WHO) has issued best practices for naming human diseases to minimise negative impacts on trade, travel, tourism, and cultural sensitivities.
According to the WHO, disease names should comprise generic descriptive terms based on symptoms and, when possible, more specific descriptors related to the disease’s manifestations, affected populations, severity, or seasonality. Eponyms (names based on individuals), geographic locations, animals, food, or cultural references should be avoided to prevent stigmatisation and other negative consequences.
The International Classification of Diseases (ICD) system assigns standard names for diseases worldwide, taking into consideration scientific, communication, and policy considerations. Notably, no disease is classified as a lifestyle disease in the ICD.
Despite its commendable health indicators, Kerala’s health policy requires a well-defined public health perspective and system. A public health system encompasses various governmental, private, and public sector entities that collectively support public health’s mission and core functions. It encompasses resources, infrastructure, and policies that influence community health (Jarvis et al., 2020).
Addressing the entrenchment of commercial interests that endanger public health due to NCDs necessitates a re-evaluation of the preferred governance model. The assumption that governmental engagement and co-regulation with the private sector are the best approaches to manage NCDs requires reconsideration (Buse et al., 2017).
Several tools have been developed to diagnose the social determinants of chronic diseases:
- Social Health Screening (SHS) aids clinicians in collecting data on social determinants of health (SDH) for use in clinical settings (Browne-Yung, Freeman, Battersby, McEvoy, Baum 2019).
- The social needs screening tool proposed by Wallace and colleagues (2020) integrates social needs screening into clinical care.
- The Tailored Implementation for Chronic Diseases (TICD) checklist serves as a comprehensive screening tool for determinants of practice, identifying areas requiring further investigation (Zipfel et al., 2021).
Kerala’s health policymakers should incorporate these assessment tools with necessary contextual modifications. A structural approach to NCDs focuses on the enduring social arrangements that dictate the distribution of NCDs and their risk factors in society. This approach requires the integration of social science and public health theories to address the chronic disease epidemic.
Naming diabetes as a lifestyle disease has complex and diverse consequences. It may wrongly imply that individual choices cause diabetes, leading to stigma, blame, and guilt among those with the condition. Additionally, it may overlook genetic, environmental, structural, and social factors contributing to diabetes. This misclassification could discourage individuals from seeking medical help, create a false sense of security among those without diabetes, and underestimate the seriousness of the condition.
Therefore, it is crucial to use accurate and respectful language when discussing diabetes, recognising its multifaceted nature, and providing support and empowerment to individuals with diabetes. Education and awareness are vital for prevention and early intervention.
The final naming of human diseases is the responsibility of the International Classification of Diseases (ICD), managed by the WHO. ICD standardises disease classification worldwide, facilitating communication among healthcare professionals, researchers, policymakers, and others.
While Kerala boasts impressive health indicators, there is a pressing need to adopt a comprehensive public health perspective and system. This entails recognising the broader social and structural determinants of chronic diseases, reframing governance models, and adhering to best practices in naming diseases to avoid stigmatisation and negative consequences.
References
Ackland M, Choi BCK, Puska P (2003). Rethinking the terms non communicable disease and chronic disease Journal of Epidemiology & Community Health 2003;57:838-839.
Browne-Yung K, Freeman T, Battersby M, McEvoy DR, Baum F. (2019). Developing a screening tool to recognise social determinants of health in Australian clinical settings. Public Health Res Pract. 2019;29(4):e28341813.
Buse K, Tanaka S, Hawkes S.(2017). Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of noncommunicable diseases and identifying options for reducing risk exposure. Glob Health. 2017;13(1):34.
Cockerham, W. C., Hamby, B. W., & Oates, G. R. (2017). The Social Determinants of Chronic Disease. American journal of preventive medicine, 52(1S1), S5–S12.
Jana A, Chattopadhyay A (2022). Prevalence and potential determinants of chronic disease among elderly in India: Rural-urban perspectives. PLoS ONE 17(3): e0264937.
Jarvis, T., Scott, F., El-Jardali, F. et al. (2020). Defining and classifying public health systems: a critical interpretive synthesis. Health Res Policy Sys 18, 68 (2020).
Manesh Muraleedharan, and Alaka Omprakash Chandak (2022). Emerging challenges in the health systems of Kerala, India: qualitative analysis of literature reviews. Journal of Health Research. Vol. 36 No. 2, 2022. pp. 242-254, Emerald Publishing Limited. e-ISSN: 2586-940X, p-ISSN: 0857-4421. DOI 10.1108/JHR-04-2020-0091
Ministry of Health and Family Welfare, government of India (2017) National Health Policy.
Ong, K. L., Stafford, L. K., McLaughlin, S. A., Boyko, E. J., Vollset, S. E., Smith, A. E., … Vos, T. (2023). Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. The Lancet.
Wallace AS, Luther B, Guo J, Wang C, Sisler S, Wong B. (2020). Implementing a Social Determinants Screening and Referral Infrastructure During Routine Emergency Department Visits, Utah, 2017–2018. Prev Chronic Dis 2020;17:190339. DOI:
WHO (2015) Best Practices for the Naming of New Human Infectious Diseases. May 2015
Yang, J.S., Mamudu, H.M. & John, R (2018). Incorporating a structural approach to reducing the burden of noncommunicable diseases. Global Health 14, 66 (2018).
Zipfel, N., Horreh, B., Hulshof, C.T.J. et al. (2021). Determinants for the implementation of person-cantered tools for workers with chronic health conditions: a mixed-method study using the Tailored Implementation for Chronic Diseases checklist. BMC Public Health 21, 1091 (2021).
കേരള ആരോഗ്യ നയം (2019) ആരോഗ്യ കുടുംബ ക്ഷേമ വകുപ്പ്, കേരള സർക്കാർ. 20/2019, 28/01/2019 (Malayalam)
Dr Joe Thomas is Global Public Health Chair at Sustainable Policy Solutions Foundation, a policy think tank based in New Delhi. He is also Professor of Public Health at Institute of Health and Management, Victoria, Australia. Opinions expressed in this article are personal.