India’s population is rapidly ageing – doctors aren’t prepared at all

Celine Anthony, a frail but charismatic woman, adjusts the blue patterned sari so the doctor can take her blood pressure.

Moments later, she’s given the all clear. With a toothy grin, she collects the Metformin tablets she needs for her Type 2 diabetes and Diclofenac, an anti-inflammatory, to reduce the symptoms of her arthritis, before heading home.

“I’m happy coming to the mobile clinic because I can speak more openly here than at the hospital; the doctors have more time to talk to me,” she says.

Ms Anthony, 88, is one of the benefactors of India’s first mobile health clinics for the elderly, a remarkable reality given that the country overtook China at the end of April to become the world’s most populous.

More than anything, it is indicative of the remarkable public health progress that India has made. Life expectancy in the country has increased from 59 in 1990 to 70 in 2022.

Until recently, geriatric care didn’t exist in India because it didn’t need to – yet that means the country is now grossly underprepared for the predicted 41 percent increase in the number of its elderly citizens over the next decade.

“Geriatric care, whether as a specialized discipline or a crucial component of primary health care, is not widely available and has largely been overlooked in India,” explains Dr Giridhar Babu, from the Public Health Foundation of India, based in Bengaluru.

“The Governments have predominantly concentrated their efforts on reproductive and child health so far, with an added emphasis on Covid-19 in recent years. Non-communicative diseases (NCDs) and geriatric care haven’t had a similar focus.” 

Given India’s ageing population, says Dr Babu, the prevalence of non-communicable diseases is expected to “significantly” rise. But without sufficient geriatric care, he adds, these illnesses will also drive a rise in premature deaths.

Kerala leading the way on health

Thankfully, Kerala, a southern state and long-term outlier in India, is laying an effective blueprint.

Decades of rule by leftist governments mean that available resources have been more focused on healthcare and education, while the state also has India’s largest expatriate workforce.

Famously, Kerala’s former Minister of Health, KK Shailaja, a 66-year-old retired physics teacher, featured on the front cover of Vogue India after her handling of the Covid-19 pandemic garnered global plaudits.

The average life expectancy in Kerala is 75 – compared to a national average of 69, according to World Bank data from 2019. This is the highest of any Indian state and, as a result, Kerala also has the largest percentage of elderly citizens.

In 2004, Dr S Irudaya Rajan, the Chair of the International Institute for Migration and Development in India, had already noticed an unusual trend in Kerala.

“My grandmother was one of nine, my mother was one of four but I was only one of two and that was very common across Kerala. The population demographics were already mirroring those in the West,” he recalls.

“But, we had a problem. People here were living longer but they weren’t in a healthy condition –  they had multiple morbidity issues and poor social engagement.”

Dr Rajan raised the alarm and the authorities listened; that year they conducted a large-scale survey across Kerala’s elderly population.

Its findings showed that despite the state’s relatively advanced healthcare system, its elderly residents were unable to travel long distances to hospitals for specific geriatric care while the minimum Indian monthly pension of Rs3,000 (£29) meant many poor Keralites could not afford medicines.

The state began an overhaul to bring geriatric care to those who need it the most. In 2011, Kerala launched the “Vayomithram” scheme, India’s first state-wide primary healthcare clinics for the elderly.

Now, there are over 2,000 of the clinics across Kerala. On a rotational basis, doctors hold clinics in the same neighbourhoods – in temples, churches, mosques or community centres – every two weeks.

Anyone over the age of 65 is able to visit and have their vitals checked, including blood pressure or blood glucose levels, as well as having a chat with a doctor about any other symptoms they might be experiencing.

“In the last ten years, we’ve seen a remarkable improvement in the care of the elderly in Kerala; people are definitely living longer. And, that is in no small part down to these clinics,” says Dr Nesni Nazar, 34, as she takes Ms Anthony’s blood pressure.

When the Telegraph visited the clinic in Chirakal, around 70 elderly men and women were waiting to speak with Dr Nazar. Any prescribed medicine will have been provided free of charge.

While the clinic's purpose is to screen and monitor long-term issues they can also act as a casualty, too.

Last month, an elderly lady presented at the same Chirakal clinic with dizziness and nausea. On noting her low blood pressure and chest pains, Dr Nazar arranged an auto rickshaw for the woman and sent her to a nearby hospital for an electrocardiogram scan.

Dr Nazar was later told that without her quick thinking, the woman would have suffered a cardiac arrest. “The elderly here in Kerala are extremely privileged to have such a program. We’re allowing them to chase their small dreams by keeping them healthy for as long as possible,” she adds.

Other successful programs implemented over the past decade in Kerala include the “Pakal Veedu” scheme, which has established day homes in every state district for lonely elderly residents to socialise with one another, and the “Mandahasam” scheme, which provides financial assistance for emergency dental care.

Hundreds of care homes have also been established over the last decade. In India, historically, multiple generations of the same family have lived under the same roof but that is changing as more young people move away from their homes for employment.

In a quaint yellow bungalow in Kochi’s Palluruthy neighbourhood, Sister Margaret, 52, leads 12 elderly women in their midday prayers. A quick show of hands reveals that most of the women staying in the care home have children working overseas.

Doctors across the state told the Telegraph that newly-qualified doctors and nurses were noticeably receiving more training in geriatric care while more funds were being allocated for early screening of non-communicable diseases. 

“Infections are very less, we are dealing with issues like diabetes, hypertension, strokes, chronic kidney disease and dementia, instead,” says Dr Arun Madhavan, a consultant from the city of Palakkad, noting the average age of his patients has increased from 60 to 80 over the last 25 years.

“Fortunately, in Kerala the care is now very good although we still need more hospital beds in government facilities and more trained staff to deal with the increase.”

A state public healthcare system overhaul is expensive, though, and there are many competing priorities in India.

India is home to the world’s fastest-growing major economy but must create approximately 90 million non-agricultural jobs over the next decade alone to match population growth.

In 2021, India saw the first ever unemployment riots in its history in Bihar and Uttar Pradesh, the country’s two poorest states, while the percentage of Indian women working fell to 25 percent in 2022.

This year’s £442 billion annual budget includes a 33 percent hike in spending on job creation and the Indian government estimates it will need to spend a further £128 billion on renewable energy sources each year for the next decade if it is to achieve its goal of net zero emissions by 2070.

Education will also require vast sums of investment. Two-thirds of Indian firms report a shortage of talented employees, with the IT and engineering sectors worst affected. Meanwhile, there are only approximately 1,000 universities in India despite the fact that one million Indians turn 18 every month.

Not enough hospital beds

Perhaps the greatest challenge will still come in healthcare, though. Since its independence, India has been one of the world’s lowest spenders on health, per capita, allocating just 2.1 percent of its GDP in 2023.

According to the last available government statistics, the country has a shortage of 600,000 doctors and two million nurses. Meanwhile, two-thirds of rural health care centres do not have a specialist doctor.

As was seen with devastating effect during the Covid-19 pandemic, the country simply doesn’t have enough hospitals, either, with one bed for every 2,239 people. The World Health Organisation recommends three beds for every 1,000 people.

The private sector is expected to pick up the slack but with 90 percent of Indians earning less than Rs25,000 (£243) a month, few can afford the care it offers.

Although Kerala is not India’s richest, the average per capita income is still four times that of Bihar and Uttar Pradesh, so it still has more resources than many other states.

But, for India’s leading public health experts, embracing geriatric care and the non-communicable and degenerative diseases that come with it is now unavoidable.

“We now need to build up an entire program for non-communicable disease as India becomes more advanced in its age profile,” argues Professor K Srinath Reddy, a member of Chatham House's Commission for Universal Health.

“I think our systems are only just waking up to it. We need better nationwide screening systems so that we can identify disease before complications develop by using telehealth services at a person’s home or as close to as possible.”

Back in Kerala, a new survey is about to get underway. This time, the state will carry out India’s first state-wide study into dementia prevalence. By 2036, it is estimated that there will be 17 million Indians living with dementia but presently, only ten percent of those with the condition get a timely diagnosis.

Just before the Telegraph leaves Kerala, we are invited to a dance class in Kochi’s Mekkara neighbourhood, designed to slow the symptoms of degenerative conditions.

There, a troop of elderly women, some who are in their 90s, complete a series of complex dance moves in the baking mid-summer heat.

“We were so lonely before our classes started,” says Rathna Sivaram, 95. “But, now, dancing helps us get together and to talk and share our problems, we can feel that our mental health is better already.”

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