Can India lead the way in managing cardiovascular disease?
There are more than 55 million people in India with cardiovascular disease. As India considers a national Essential Diagnostics List, University of Michigan researchers Lee Schroeder and Ahmad Abdul-Aziz take a deep dive on how this list might provide much-needed help for tackling the burden of cardiovascular diseases in India.
What is the Essential Diagnostics List and how does it relate to the World Health Organization's List of Essential Medicines?
Schroeder: The WHO first established the Essential Medicines List in 1977. This was because the best medicines were not available and patients would find ineffective or dangerous alternatives in pharmacies.
The EML is considered one of the great achievements of the WHO and while access to medicines is far from perfect, it has aligned the major stakeholders in the delivery of medicines. This happens because countries establish their own national-level EMLs and this list then guides procurement. Over 130 countries now have national-level EMLs, including India.
Currently, the state of diagnostics in many low- and middle-income countries is very much like the state of medicine many decades ago. It is largely unregulated, of low quality and often not available. This leaves physicians to diagnose syndromically, ie., based on symptoms and signs alone.
The WHO established the first Essential Diagnostics List in 2018 in the hopes of aligning stakeholders to improve the state of diagnostics.
No country has officially adopted a national-level EDL yet, but India is likely to be the first. They are leading the way, having published a draft version as well as a substantive report on their process so that other countries can learn from them.
How might a National Essential Diagnostics List help in India?
Schroeder: A country-level Essential Diagnostics List could help in a variety of ways, especially in a country like India.
There are many forces that are playing a role in focusing attention on diagnostics: the call for universal health coverage in the United Nations Sustainable Development Goals, the rising threat of antimicrobial resistance and surveillance for epidemic outbreaks. A strong diagnostics system is essential to address each of these global health priorities.
A strong diagnostics system also requires several moving parts to work together: quality of laboratories, training of human resources, specimen transport systems for referral between levels in the health care system, service of instruments and supply chains.
It can also help with affordability, as it guides industry to manufacturer-appropriate and affordable diagnostics, perhaps in-country.
Without prioritizing the development of diagnostics systems, they will never be improved. That is the first step to spark an interest by government ministries to focus on improving their diagnostics systems. We believe an NEDL can be that spark.
Cardiovascular disease has become the leading cause of death in India, can you comment on the changing burdens of disease?
Abdul-Aziz: For many years, cardiovascular diseases were viewed as afflictions of the wealthy. As a result, the amount of attention paid to cardiovascular diseases in low- and middle-income countries has been suboptimal. However, cardiovascular diseases are currently the leading cause of death worldwide, outpacing noncommunicable conditions such as cancer and communicable diseases such as HIV/AIDS, tuberculosis and malaria.
This transition has been very apparent in India. In 2016, approximately 55 million people were affected by the disease. One in four deaths in India are due to cardiovascular diseases, with ischemic heart disease and stroke responsible for 80 percent of this burden.
This epidemiologic transition is largely due to an increase in risk factors like diabetes, hypertension and hyperlipidemia. Like medicines, diagnostic tests are crucial to improving health care delivery. Having an NEDL can help in the diagnosis and management of cardiovascular diseases.