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NEW DELHI : Stroke is the third leading cause of death in India, which has one-fifth of the world’s population. A recent global burden of diseases (GBD) study indicated a significant spurt in the number of strokes being witnessed in India. In an interview, Dr M.V. Padma Srivastava, head-department of neurology at All India Institute of Medical Sciences (AIIMS), New Delhi, spoke about the increase is stroke cases due to covid-19, the challenges of management of stroke patients in India, unawareness, lack of proper implementation of health policies, shortage of neurologists and the way forward. Edited excerpts from an interview:


What is the reason for increase in stroke cases in India? Has covid-19 also contributed to the numbers?

This increase in strokes can be attributed to many lifestyle factors such as stress, sedentary lifestyle, smoking, and high cholesterol. However, medically, there are two main causes of stroke, the first is a blocked artery, the second is a ruptured blood vessel. A blocked artery causes ischemic stroke, it is the most common form of stroke. It usually happens when fat gets deposited in a blood vessel. Haemorrhagic stroke happens when a blood vessel bursts, resulting in brain haemorrhage. There are various reasons, such as stress, uncontrolled BP, using blood thinners in excess, and deposition of protein on blood vessel walls, for the bursting of an artery. Recently, there have also been some studies that have observed a correlation between covid-19 patients and stroke, wherein patients affected by the virus have been shown to develop micro-thrombi, that is, small clots, making them more susceptible to strokes. Approximate age-adjusted prevalence of stroke in India is 84 to 262 per 100,000 in rural and 334 to 424 per 100,000 in urban areas, and the age-adjusted incidence of stroke is 135 to 152/100,000 person years.


Why does stroke management remain a challenge for India?

Diseases occurring in developing countries can largely be attributed to poverty, poor healthcare infrastructure, and limited access to care. However, many developing countries such as India have undergone economic and demographic growth in recent years, resulting in a transition from diseases caused by poverty towards chronic, non-communicable, lifestyle-related diseases. Despite this recent rapid economic growth, a large proportion of the Indian population lives in poverty. Although risk factors for stroke in urban Indian populations are similar to developed nations, it is likely that they may be quite different among those afflicted by poverty. Furthermore, treatment options for stroke are fewer in India. Well-organized stroke services and emergency transport services are lacking, many treatments are unaffordable, and socio-cultural factors may influence access to medical care for many stroke victims. Most stroke centres are currently in the private sector and establishing such centres in the public sector will require enormous capital investment. Given the limited resources available for hospital treatments, it would be logical to place a greater emphasis on effective population-wide interventions to control or reduce exposure to leading stroke risk factors. There also needs to be a concerted effort to ensure access to stroke care programmes that are tailored to suit Indian communities and are accessible to the large majority of the population, especially the economically challenged section.


What is the situation of government attention towards the treatment of strokes in India? What barriers do you see in successful implementation of policies?

Stroke is incorporated in the National Program for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke. The objectives of the programme include behavior changes for lifestyle modification, screening, and prevention of non-communicable diseases, capacity building, optimizing treatment at all levels of healthcare and surveillance systems for disease burden and monitoring. Stroke registry programme was started in 2012 to collect data about stroke patients, and, as of 2016, 62 institutions across India have registered with it. This venture was initiated by the Indian Council of Medical Research (ICMR) along with the National Centre for Disease Informatics and Research. An Indo-US collaborative stroke registry was started with 5 major teaching institutes from India and one major institute from the US to develop a registry with high-quality data. However, there are multiple barriers in the implementation of optimized care among patients with stroke at the level patient is–(late arrival or low awareness of stroke symptoms, denial of stroke, financial incapacity, socio-cultural practices or beliefs inhibiting access or seeking optimal stroke care). At the hospital or health system level it is personnel with expertise in managing stroke, management will and support, lack of adequate medical facilities or equipment, well-defined protocols and standard operating procedures as also policies, supporting policies, organizational context, or norms, which support the implementation of evidence-based care. Further at the stroke specialists and professionals’ levels it is—stroke teams, competence, skill, awareness, confidence, and experience in dealing with clinical situations, ability to take timely clinical decisions and confidence to do so, motivations, attitudes, and willingness to provide evidence-based stroke care. Also, there are barriers at the level of national health policies such as political viewpoint, allocation of resources, reimbursement of costs to different health care sectors, to support stroke patients’ access to optimal care and the regulatory frameworks or policies to support stroke care.


Do you think that the present treatment protocols and technologies are not helping the cause of containing the impact of incidence of strokes in Indians?

India has a hierarchical model of healthcare delivery with a three-tier system (primary, secondary, and tertiary). Primary health centres are managed mainly by physicians (with MBBS degree) and many such centres in rural areas do not have access to doctors. District hospitals form the second tier, and are better equipped with MD physicians and basic facilities. Medical colleges form the tertiary centres where most cases get referred to. Various strata of healthcare availability lead to heterogeneity in the care provided. Added to this complex system is the predominance of private healthcare providers who are providing treatment at costs prohibitive to the majority of Indian population. All these complexities that lead to inadequate infrastructure go against the conventional treatment protocol which requires the patient to be treated within 4.5 hours from the time of onset. However, in reality the data shows that an average time taken by the patient to reach the hospital in urban areas is 7.6 hours and in rural areas it is 34 hours. The delay in treatment increases the chances of permanent disability or even fatality for the patient. Advanced therapies such as mechanical thrombectomy can play a crucial role in such cases because this therapy is shown to be effective in some patients upto 24 hours post symptom onset. However, the adoption of these advancements would largely depend on government’s role to acknowledge these technologies to create programmes that extend support to make the therapy affordable and accessible for all.


What are the major hurdles that India faces in improving of acute stroke care across the country?

Quintessentially, the challenge is to make optimal stroke care accessible, affordable and acceptable to all Indians, irrespective of social, economic and geographic barriers. There is no universal insurance and coverage system in India and most of the patient pay from the pocket. Apart from this an effective stroke care program needs to include a national level stroke awareness program as well as well-equipped and swift ambulance services, swift access to radiology, trained paramedical and nursing personnel and rehabilitation facilities. Another challenges lack of neurologists, that is, 2,300 neurologists for 1.2 billion population. This skewed ratio means that stroke care will also have to be provided by physicians and other healthcare providers.


What changes in the healthcare system are needed to deal with the stroke cases?

Stroke awareness programmes at the national level should be planned by the government and Indian Stroke Association. Physicians and primary health centre doctors should be trained in stroke detection and management. While the primary health centres are pivotal for their proximity and acceptability to the interiors of Indian terrain, they can serve only the preventive and educational aspects of healthcare. In the stroke chain of survival, they can help in stroke recognition and referral, as well as in stroke prevention and rehabilitation. The district level hospitals in India are better equipped in terms of infrastructure and personnel and can serve as primary stroke centres. The medical colleges, institutes, and major public and private chain of hospitals are pillars of tertiary care and referral in all states which can be developed into comprehensive stroke centres. Incorporating the physicians in the national umbrella of the stroke programme will help tap their potential in the national fight-stroke programme and will be able to generate an adequate workforce. Because the physicians practise closer to the community, stroke care would reach closer to the general population. One of the major aspects in Indian healthcare delivery is the ratio of public and private sectors. Currently, nearly 70% of healthcare is managed by the private sector. Integrating the private health sector into the nationalized healthcare chain for holistically improving the access and affordability is a major challenge. One solution could be fostering the public-private partnerships in acceptable terms so as not to jeopardize the sustainability and growth of both sectors. Accessibility and affordability are major factors affecting a successful healthcare model, especially in a resource limited setting like India. The recent launch and enforcement of Modicare for all (Ayushman Bharat) has provided for identifying and ensuring at least 30% of the Indian population with lower socio=economic status to access and afford advanced healthcare.


What according to you is the road map ahead?

Timely access to a stroke-ready hospital is difficult, especially for those residing in remote areas and those areas with no dedicated and prompt public ambulance services to ferry patients. Increasing public awareness of stroke symptoms and therapeutic advances, political interventions for the availability of necessary treatment in public hospitals and reducing costs of treatments both at the industry and hospital level are desired steps to increase eligible patients receiving thrombolysis or timely supportive treatment. In-hospital delays should be minimized with highly organized workflows to achieve the desired/ideal door to needle times and door to groin puncture times. Effective strategies need to be instilled as a well-oiled machinery to reduce critical time delays. Some strategic interventions include education to the emergency staff, direct transfer to CT scan room from emergency and direct thrombolysis in the CT room, etc. which are eminently possible even in a primary stroke centre in India.

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