Disability is neither purely medical nor purely social. Rather, it is an outcome of their interplay.

By Veena S. Kulkarni, Vani S. Kulkarni and Raghav Gaiha
NEW DELHI, Jul 31 2017 (IPS)

The Rights of Persons with Disabilities Act 2016 (or RPD Act) is laudable in its intent and procedural detail, but mostly silent on disabilities among the elderly. Indeed, for this reason alone, it is arguable that its overarching goal—“The appropriate Government shall ensure that the persons with disabilities enjoy the right to equality, life with dignity and respect for his or her integrity equally with others” —is mere rhetoric, if not a pipe dream.

Disability is part of human condition. Almost everyone will be temporarily or permanently impaired at some point in life, and those who survive to old age will experience increasing difficulties in functioning. Disability is neither purely medical nor purely social. Rather, it is an outcome of their interplay. Chronic diseases (e.g. diabetes, cardiovascular disease and cancer) are associated with impairments that get aggravated by stigma, discrimination in access to educational and medical services, and job market. Higher disability rates among older people reflect an accumulation of health risks across a lifespan of disease, injury, and chronic illness (WHO and World Bank, 2011). The co-occurrence of NCDs and disabilities among them poses considerably higher risk of mortality, relative to those not suffering from either or one.

Raghav Gaiha

There is a bidirectional link between disability and poverty: disability may increase the risk of poverty, and poverty may increase the risk of disability. Households with a disabled member are more likely to experience material hardship.

Detailed evidence on disabilities and their correlates is particularly relevant as India’s elderly population (60 years or more) is growing three times faster than the population as a whole. Three demographic processes are at work: declining fertility rates, increasing longevity and large cohorts advancing to old age (Bloom et al. 2014). As both non-communicable diseases (NCDs) and disabilities tend to rise with age, often in tandem, the inadequacies of the present health systems, community networks and family support may magnify to render these support systems largely ineffective. If the costs in terms of productivity losses are added, the total cost burden of looking after the disabled elderly may be enormously higher in the near future.

Disability is usually measured by a set of items on self-reported limitations with severity of disability ranked by the number of positively answered items. Disabilities in activities of daily living (ADL) show dependence of an individual on others, with need for assistance in daily life. The activities of feeding, dressing, bathing or showering, walking 1 km, hearing, transferring from bed and chair, normal vision, and continence are central to self-care and are called basic ADLs.

A review of the evidence from the India Human Development Survey 2015 (IHDS) that tracks the same sample of individuals over the period 2005-2012, yields useful insights from a policy perspective. IHDS covers seven disabilities already defined.

At an all-India level, there was a very rapid rise in the prevalence of all disabilities among the elderly during 2005-2012, from 8.4% to over 36%.

The prevalence was much higher among the older elderly (i.e. >70 years) than among 60-70 years old. Besides, it shot up to over 50% among the former in 2012 as compared with 33% among the latter. So the more rapid the ageing of India’s population, the higher will be the prevalence of disabilities.

The disability prevalence was slightly higher among elderly females, but became considerably higher in 2012. From about 9.4% in 2005, it rose to nearly 40% in 2012. Thus lower survival prospects for elderly women are likely to reflect greater disability.

There was a reversal in the rural-urban disabilities, with a slightly larger prevalence in urban areas, but both rose substantially with a larger prevalence in rural areas (about 37% as compared with 35%). If we use caste as a predictor of socio-economic deprivation, we find that disabilities rose much faster among the SCs than in the General category, with the prevalence among the former rising from 6.9% to about 37%. Besides, each category (including OBCs, and STs) witnessed a sharp rise in disabilities.

There are two ways of examining the link between poverty and disabilities: one is to assess whether the prevalence of disability is higher among the poor, using the official poverty line, and another is to rely on a ranking based on assets. We prefer the latter, since income fluctuates more than assets. Distinguishing between the least wealthy (or the first wealth quartile) and the most wealthy (the fourth quartile), we find that while the prevalence of disabilities was about the same in both (about 9.7%), it rose at a much faster rate among the least wealthy, resulting in the highest prevalence (39.5%) in 2012. As there is a strong association between NCDs and disabilities (e.g. between diabetes and restricted mobility and vision impairment, heart disease and limited mobility, stroke and speech and mobility impairment), some of the risk factors associated with the former are also linked to the latter. These include smoking, alcohol consumption, dietary transition to consumption of energy-dense foods—high in salts, fats and sugars—and sedentary lifestyles. As the population ages, and the burden of NCDs rises, disabilities are likely to be far more pervasive. Compounded by lack of access to disability-related services (e.g. assistive devices such as wheelchair, hearing aid, specialised medical services, rehabilitation), and persistence of negative imagery and language, stereotypes, and stigma—with deep historic roots-leading to discrimination in education and employment—the temptation to offer simplistic but largely medical solutions must be resisted. In brief, a multidimensional strategy is needed that includes prevention of disabling barriers as well as prevention and treatment of underlying health conditions.

This story was originally published by The Sunday Guardian.

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By Veena S. Kulkarni, Vani S. Kulkarni and Raghav Gaiha
NEW DELHI, Jun 23 2017 (IPS)

Evidence shows that health systems must be recast to accommodate the needs of chronic disease prevention.

Disability is the umbrella term for impairments, activity limitations and participation restrictions. (Representational image) | Photo Credit: Getty Images

The National Health Policy (NHP), 2017, is long on banalities and short on specifics. In a somewhat glaring omission, little has been said about the rapid rise in the share of the old — i.e. 60 years or more — and associated morbidities, especially sharply rising non-communicable diseases (NCDs) and disabilities. In the context of declining family support and severely limited old-age income security, catastrophic consequences for destitutes afflicted with these conditions can’t be ruled out. Besides, continuing neglect and failure to anticipate these demographic and epidemiological shifts — from infectious diseases to NCDs — may result in enormously costlier policy challenges. An estimate provided for the 2014 World Economic Forum suggests that NCDs may cost as much as $4.3 trillion in productivity losses and health-care expenditure between 2012 and 2030, twice India’s annual GDP.

Detailed projections of the old in India by the United Nations Population Division (UN 2011) show that India’s population, ages 60 and older, will climb from 8% in 2010 to 19% in 2050. By mid-century, their number is expected to be 323 million.

Population dynamics and a rapidly changing age structure reflect the combined impact of increasing life expectancy and declining fertility. Life expectancy at birth in India climbed from 37 years in 1950 to 65 years in 2011, stemming from declines in infant mortality and survival at older ages due to public health improvements. The key question is whether longer lives have translated into healthier lives. Our evidence raises serious doubts.

Vani S. Kulkarni

Evidence from IHDS survey
Our analysis, based on the India Human Development Survey (IHDS) 2015, the only nation-wide panel survey covering the period 2005-2012, throws new light on these issues. A major advantage of the panel survey is that the same individuals are tracked over a period of seven years.

The prevalence of high blood pressure among the old almost doubled over the period 2005-12; that of heart disease rose 1.7 times; the prevalence of cancer rose 1.2 times; that of diabetes more than doubled, as also that of asthma; other NCDs rose more rapidly (i.e. by two and a half times).

A related question is whether multi-morbidity (i.e. co-occurrence of two or more NCDs) also rose over this period. Often multi-morbidities occur non-randomly or systematically. The prevalence of high blood pressure and heart disease rose more than twice while that of high blood pressure and diabetes nearly doubled.

Veena S. Kulkarni

Wealth quartiles were constructed to examine whether prevalence of NCDs varied across them and over time. Often it is asserted that the burden of NCDs is increasingly borne by less affluent sections. of the population. In other words, wealth and health deprivations have a larger overlap because of more sedentary life-styles, dietary shifts towards more fatty and processed foods, rising obesity, high rates of smoking and alcohol consumption, rural-urban migration and changing age structure. The burden of NCDs shifted from the most affluent to the least affluent over this period. In both the first (least wealthy) and fourth (wealthiest) quartiles, the prevalence rose sharply in most cases but in all the rises were faster among the least wealthy. The ratio of high blood pressure in the first quartile relative to the fourth rose from 0.36 in 2005 to 0.40 in 2012; that of heart disease rose from 0.31 to 0.38; that of diabetes from 0.23 to 0.34; and that of blood pressure and heart disease rose from 0.11 to 0.58. As NCDs are associated with a large majority of deaths among the old — about 93% of the total deaths among 70 years or more in 2013 — they are now more vulnerable to mortality risk. In fact, the least wealthy have become more susceptible to this risk.

By age 60, the major burdens of disability and death arise from age-related losses in hearing, seeing or moving, and NCDs (WHO, 2015). Thus co-occurrence of disability and NCDs poses a higher risk of mortality.

Raghav Gaiha

Assessing disability
Disability is the umbrella term for impairments, activity limitations and participation restrictions. An assessment of functioning in activities of daily living (ADLs) is one method widely used to assess disability in older persons. Disability is usually measured by a set of items on self-reported limitations with severity of disability ranked by the number of positively answered items. Disabilities in ADL show dependence of an individual on others, with need for assistance in daily life. The activities of feeding, dressing, bathing or showering, walking 1 km, hearing, transferring from bed and chair, normal vision, and continence are central to self-care and are called basic ADLs. The IHDS provides data on seven disabilities defined in this manner.

In select disabilities, there is a sharp rise with age and over time. Difficulty in walking was 1.7 times greater in the age group 70-plus years relative to 60-69 years in 2012. Over the period 2005-2012, overall prevalence rose 6.1 times. Difficulty in using toilet facilities was 2.3 times higher among the older group (70-plus years). Overall prevalence was five times higher in 2012. Difficulty in dressing was about 2.5 times higher in the older group. Overall prevalence jumped about five times between 2005-12. Hearing difficulty was just under twice as high among the older group in 2012, while the overall prevalence rose 4.7 times over this period.

To assess severity of disabilities, these are classified into counts of 1-4 and greater than 4. The proportion of old women was larger than that of males in both groups and years. At the aggregate level too, disabilities grew in both groups, especially in the group greater than 4. Thus both prevalence and severity of disabilities rose during 2005-2012.

As observed earlier, it is the co-occurrence of NCDs and disabilities that is more likely to be fatal. We find that in most cases there was an increase. Heart disease and disabilities (1-4) rose 1.3 times. Blood pressure and disabilities in this range rose 1.2 times, as also diabetes and disabilities. Blood pressure and heart disease and disabilities increased 1.4 times.

In brief, that the curse of old age has become worse is undeniable. Along with expansion of old age pension and health insurance, and public spending on programmes targeted to the health care of the old, careful attention must be given to reorient health systems to accommodate the needs of chronic disease prevention and control by enhancing the skills of health-care providers and equipping health-care facilities to provide services related to health promotion, risk detection, and risk reduction.

This story was originally published by The Hindu.

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