As he approached his 40^th birthday, his career chart had already taken a steep vertical path upwards, and there were strong rumours in his company that he would be the next CEO. Then all of a sudden, one day, he died of a massive heart attack.

The tragedy reverberated at several levels. For his devastated wife and two small children, Sharma’s death was a severe emotional loss. It also meant a drastic alteration of financial circumstances. His company, on the other hand, lost a promising resource that it had invested a great deal in over the years.

Sharma’s could be the typical case study. Hasn’t everybody heard at least one such numbing story? The tragedy in India is that, in recent years, cases like Sharma’s have become the norm rather than the exception.

Strikes early

In 1999, The World Health Organisation (WHO) reported that one out of every three deaths in India is due to heart disease. It was once considered a disease of the old. But several studies in the past decade have established that Indians are increasingly becoming susceptible to cardiovascular diseases (CVD) at a younger age, and are more likely to die of it. In effect, it is killing part of a society’s workforce at the prime of its working life.

The highest growth in heart disease is among young executives because of their high-profile lifestyle. There has been a two-fold rise in cardiac problems in the Indian corporate workers over the past 15 years. The pressure to perform and an abnormal lifestyle have increased the prevalence of heart disease among corporate executives from 15 per cent to 30-40 per cent in the last 10 years, according to Dr Salyest Bose of Apollo Hospital, Kolkata.

The theory that the health of the population and health interventions are intrinsically linked to a country’s development has been well established. It was documented most recently in the 2002 report of WHO’s commission on macroeconomics and health in the study Macroeconomics and health: Investing the health for economic development.

As developing countries like India undergo a health transition, they are in the unenviable position for bearing the burden of both communicable and non-communicable diseases. On the one hand, disease like tuberculosis, malaria and HIV/AIDS continue to ravage communities. On the other, diabetes, cardiovascular diseases and cancer are also on the rise, and are hitting Indians hard, particularly the young.

There are many reasons for this. The first is genetics. Some doctors believe that Indians suffer from the Metabolic X syndrome, which makes them genetically susceptible to a verity of problems, leading to CVD. The second reason is demography. As more people survive to grow older, the number of patients suffering from CVD also increases. Lifestyle is another important cause for the rise in CVD. As the middle class grows and prospers, dietary habits change: more fried and processed foods and fewer green vegetables. This is compounded by a sedentary way of life, a more white-collared, desk-bound existence.

This lifestyle, admittedly introduced at the upper echelons, has now percolated to the rest of Indian society. "It’s always the rich who begin a trend, which then permeates to all sections of society," says Dr K. Srinath Reddy, Professor of Cardiology, AIIMS. He points to 19^th century Britain, when smoking was fashionable in exclusive clubs of London. It subsequently became a mass habit. Similarly, fat-rich, processed foods were once considered a luxury in America till they became mass produced and easily available in neighbourhood supermarkets. "By that time", Dr Reddy says, "the rich had got the message. In the US, it is now the rich and educated who eat salads and smoke less".

According to an Earth Institute report of 2004, low and middle-income countries account for 80 per cent of the CVD deaths and 87 per cent of the CVD-related disabilities. Indians are further hurt, being susceptible to the disease at an earlier age: 88 Indian men of working age (35-64) out of a sample population of 100,000 will die of CVD, compared to 55 in the US, 51 in Portugal and only 37 in China. By 2020, causes of CVD are expected to increase in India by 120 per cent in women, and 137 per cent in men. And it is going to be a killer. In the period of 2000-2030, more than a third of all CVD deaths in India will occur to working people.

As in other parts of the world, in India too a more stressful working life adds to the risk. In 2003, a study by researchers at University College London, monitoring more than 10,000 civil servants, showed a definite link between job strain, job demands, decision latitude and the risk of cardiovascular diseases.

Early data about the health of the Indian workforce is alarming. Almost a third of all men and a fourth of all women have hypertension. Diabetes occurs in a tenth of this population. Taking recently-defined obesity standards for Indians, a whopping 50 per cent are considered overweight, and around 30 per cent suffer abdominal obesity (what is often referred to as a beer belly). Forty per cent of the men have high levels of ‘bad’ cholesterol and 20 per cent smoke regularly.

Although the prevalence of all risk factors increases with age, even in the 20-29 years age group, 12 per cent of the Indians suffer from hypertension and 30 per cent are overweight. As they reach their 30s, almost a fifth of them are hypertensive and half of them are overweight.

The economic cost of heart disease can be measured at several levels. The loss of productivity for a company or business unit deprived of an experienced hand is the most obvious. Next comes the salary loss for a dependant family that has to make consumption compromises. Then, there is the cost of treatment. After a heart attack or stroke, if a person becomes disabled, there is the cost of supporting him or her for life. Not just the patients, often the entire family spirals into crisis or even poverty, as the breadwinner is affected.

CVD deaths in the 35-64 years age group have been estimated to affect as many as 5 million members of Indian households. A study supported by the National Commission for Women found that in West Bengal, when there is an adult death in a household, a child of less than two years had a 12-fold higher probability of death.

Health economists use the awkward abbreviation of PPYLL (potentially productive years of life loss) to measure the actual cost of a disease. This is the number of working years a country is deprived of when a citizen dies before the age of retirement.

In 2000, India’s collective disease was 9.2 million years, in comparison to 6.6 million years in China and 1.0 million years in the US. In 2030, in India’s PPYLL will be 17.9 million years, compared to 10.4 million for China and 1.9 million years for the US.

In short, while the American heart will remain about as healthy, Chinese and Indian tickers will decline. Yet, even when seen against China, a developing country with a large population, India will lose 70 per cent more by way of PPYLL in 2030. Columbia University researchers estimate that payroll loss duty to cardiovascular disease-related deaths occurring between 35 and 64 years in the Indian workforce is $ 198 million (figures for 2000).

This figure excludes healthcare cost. It was arrived at after assuming that two-third of the CVD deaths are in urban areas, and factoring in labour force participation rates by age and gender, urban and rural residence.

Many Indians survive a heart attack or a stroke, but the disease leaves them paralysed or disabled in some way. Assuming that disability precedes 5 per cent of the cardiovascular disease deaths and that the duration of the disability averages three years, the three-years’ wages loss due to CVD-related disability is estimated to be $30 million.

Then there are the immediate costs. Nobody knows how much the direct cost of treatment for cardiovascular disease is in India, but with Rs 2 lakh for a heart surgery, on an average, it cannot be cheap. Then there are the social costs, which do not lend themselves easily to balance sheets. When a parent is ailing in a poor household, a child may have to give up school to stay at home, and look after the family, say sociologists. Often this burden falls on the girl child, with consequences that extend beyond the economic.

Yet, insists Dr Reddy, it is not totally a doomsday scenario. With proper public health interventions, India still has a large window of opportunity to bring the disease under control. It could be as simple as being careful about one’s diet. "In Poland and the Czech Republic, for example, dietary changes in the population, with the availability of more vegetables and fruit, and less of animal fat, resulted in lower rates of cardiovascular diseases and related mortality," he points out. There are similar reports from England.

In the US, a 1996 study published in the Journal of American Diet Association concluded that even a 1-3 per cent reduction in dietary saturated fats (the type you eat in butter, for example ) would result in 30,000-90,000 people per year being saved from heart disease. This would save $4.1 billion in medical, and $12.7 billion in productivity costs, the study stated.