Deepak GulatiDeepak Gulati, MD

I am writing this blog post on stroke care in India given my strong interest and a recent encounter with one of my family members requiring stroke care services in Chennai and New Delhi.

The stroke burden in India is enormous with more than 1.5 million stroke cases per year, much higher than Western industrialized countries. Stroke is the second most common cause of death in India. The most common cause of ischemic stroke in India is intracranial atherosclerosis as per some of the studies conducted in large academic centers from northern and southern India. There are reports of a high proportion of young stroke (first-ever stroke onset below 40 years of age), ranging between 15 and 30% of ischemic strokes.

Risk factors including hypertension, diabetes, smoking, and dyslipidemia are quite prevalent and inadequately controlled due to poor public awareness and inadequate infrastructure. The pattern of tobacco consumption is common among less educated persons and among families with lower socioeconomic conditions. One of the surveys showed that about one-fourth of urban and one-third of rural respondents had no knowledge of any warning symptom of stroke.

There are many reasons recognized for the high stroke burden. The use of thrombolytic therapy was started much later in India (approved by the FDA in 1996) at a very low rate due to some of the obvious reasons, including lack of awareness among the public and physicians. Its use has been consistently low with a lot of disparity between rural and urban populations. Due to poor recognition of stroke and a low perception of threat, there are significant delays in arrival to health care centers and, hence, initiation of treatment. There are other barriers in delay, including poor availability of transport in rural areas and busy traffic in urban areas. Another reason for the low thrombolysis rate is the cost of therapy. There is also a shortage of neurologists nationally, with 80% of India’s specialist doctors living in urban India. In regards to pre-hospital systems, there is limited data available and they are composed of mainly ambulances without trained personnel. In India, there are approximately 35 stroke centers, mostly situated in private sector hospitals.

The burden of stroke is increasing in India due to changing demographics and increased longevity while, at the same time, the burden of stroke has been decreased in developed nations due to better control of risk factors, creating awareness and symptoms of stroke at the community level, well-organized acute stroke care settings and rehabilitative centers.

There has been a recent increase in many projects in different parts of the country to improve stroke care, including development of the ‘spoke and hub model’ and use of smartphone apps as a means of transmitting brain imaging. The Government of India with private public partnership has established ambulance services in 29 States. The most popular model is the “dial 108” model. This ambulance service is provided free of charge by the government. There has also been work performed in the field of family-led rehabilitation for post-stroke care in India along with improvement in efforts for smoking cessation (anti-smoking laws and public education in theaters).

The Indo-US Collaborative Stroke Program (IUCSP) is one of the programs developed to prospectively collect Indian stroke patient data for comparative analysis and to train a core group of stroke researchers within a network of Indian stroke centers, to create a robust infrastructure that will enable future stroke clinical and research trials and collaborative clinical, genetic, and imaging studies.

Given the rising stroke burden, there appears to be an urgent need to develop stroke systems of care in India with the help of telestroke services throughout the country. One of the potential solutions could be the use of telestroke to provide improved access to patients mainly from rural areas in order to bridge a significant gap in stroke care. Telestroke has proven to be a powerful tool in advancing stroke care in many countries by increasing the number of patients getting thrombolysis and by properly triaging patients, which helps in reducing the socio-economic burden on the healthcare system. With the growing use of smartphones in India, efforts should be made to use this technology for stroke education, treatment, and rehabilitation.

Prevention of stroke is one of the best cost-effective strategies given the social and economic factors in India. Awareness drive should be stepped up in India. Efforts should be made for primary and secondary prevention, which appear to be very cost-effective tools in reducing the stroke burden.

Other potential areas for improving stroke care are by establishing stroke centers in referral hospitals at the district level with appropriate system of care. The integration and adequate utilization of different health programs should be emphasized with a common goal, for example, utilization of primary health care workers for stroke education in addition to providing antenatal care or common protocols/policies for stroke, trauma, and STEMI.

India was declared “polio-free” in 2014 after extensive efforts, which has now given rise to a belief that in spite of the large population, rural vs. urban disparity, and lack of an adequate healthcare infrastructure, it is possible to decrease morbidity and mortality of stroke and improve stroke care in India if efforts are made in the right direction. There is a need to build government partnerships with the private sector to develop stroke systems of care along with involvement of socio-religious leaders and celebrities to improve stroke education and awareness. There is also a need to create public ownership about improving brain health by controlling vascular risk factors by a sound, multipronged communication strategy.

One of the limitation factors in thrombolysis is the cost of medication and associated care. There should be efforts to make sure that the administration of thrombolysis is timely available and affordable irrespective of state, city, and the type of hospital either by providing subsidies or basic insurance.

The World Stroke Organization established the Global Stroke Guidelines and Quality Committee to facilitate stroke care especially in areas where healthcare resources are limited. There is a demand of time for India now to further improve stroke care by understanding and integrating the fact that India is a large producer of engineers in the world along with being a hub for generic pharmaceutic industries and a promoter of the “Made in India” approach.

Given the recent data from randomized controlled trials extending the window of mechanical thrombectomy, there is an additional need to gear up for the new challenge of providing interventional care to stroke patients in the country.