Disease, like death, is a great leveller, but the infection or disorder that gets you varies with where and how you live. Countrywide, infections are the undisputed dukes of hazard in the diseases reckoning, with the anti-infective medicines market valued at Rs 10,394 crore, which is almost one-fifth of the country's total top 15-selling drugs market of Rs 58,824 crore.
Medicines to treat heart disease are a low second, pegged at Rs 6,601 crore, followed by gastrointestinal problems worth Rs 6,203, shows data from Secondary Stockist Audit 2011.
The pecking order, however, changes depending on whether you live in a metro or a small city or village. Heart-related medicines top the prescription charts for Delhi, Mumbai, Chennai and Kolkata, along with the more affluent states of Gujarat, Kerala, and Tamil Nadu, replacing the more pedestrian infections that are the number-one afflicter of people countrywide. In rural areas, cardiac problems are pegged at number five.
"It's to do with lifestyle, with people living in cities gaining weight rapidly because of inactivity and unhealthy diets. More than one study show that the longer you live in the city, the higher are your chances of having heart problems and diabetes as compared to those who remained in rural areas," says Dr R.R. Kasliwal, chairman, division of clinical and preventive cardiology, Medanta.
Booming towns, shrinking villages
Body fat, blood pressure and fasting insulin levels - a measure of your diabetes risk - of people in India shoot up within a decade of moving to a city, reported the American Journal of Epidemiology last year. The study compared the health of rural Indians to their siblings who moved to one of four cities in India - Lucknow, Nagpur, Hyderabad and Bangalore.
Both blood pressure and insulin kept rising steadily over time among urban residents, found the study. Siblings who lived in a city the longest had the highest average blood pressures. For instance, men who lived in a city for more than 30 years had an average systolic blood pressure of 128, compared to the rural average of 123. The change in body fat was most evident in the first 10 years after moving to a city, but then it levelled off.
India's urban population is growing by 1.1% each year, while the proportion of people in rural areas is shrinking by 0.37 %, shows UN data. But India's population is still predominantly rural - currently, 30% of Indians live in urban areas, compared to 82% of people in the US - which explains why the anti-infective medicine sales countrywide far surpass those for heart disease and diabetes.
Split wide open
The big unifier in disease patterns is that apart from diabetes replacing respiratory infections in metros, the top 10 diseases remained the same countrywide across the urban-rural divide. Anti-diabetes drugs were a low number 7 and 8 among the drugs sold countrywide and in rural areas respectively, which surprised given that India is the diabetes Capital of the world with 50.8 million people living with diabetes.
"There are several reasons for this. Under-diagnosis, where people are not getting diagnosed because diabetes creeps up silently, with symptoms showing up years after - if at all - a person develops the disorder. Also, diabetes is often sub-optimally treated, where people try changes in diet, alternative therapies or stop treatment mid-way hoping for a permanent cure, even when international guidelines clearly state people should start medication immediately after diagnosis as the beta-cell function goes down precipitously if left untreated," says Dr Anoop Misra, chairman, Fortis C-DOC centre for Diabetes. Pancreatic beta cells secrete insulin in response to a rising blood glucose levels. Diabetes is caused by the inability of beta cells to produce adequate insulin. The more laidback lifestyles of people living in Class 1-6 towns ensures their disease patterns closely track people living in rural areas than the highly-stressed metropolitan residents.
"Ironically, while modern medicines and better infrastructure - clean drinking water, better sanitation etc - have kept infections in check, poor lifestyles have increased lifestyle diseases in large cities. There's just no getting away from eating healthy, controlling weight and getting more active," says Dr Misra.