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Remembering the external context when addressing non-compliance

As India has seen a growth of its middle class over the last two decades of globalization, there has been a rise in the prevalence of noncommunicable diseases like hypertension, type II diabetes and chronic kidney disease. Yesterday, we were introduced to the Tanker Foundation: a non-profit charitable trust based here in Chennai that was founded by Dr. Georgi Abraham with the aim of providing subsidized dialysis for the underprivileged with kidney disease.

Beyond providing dialysis to patients who would otherwise be impoverished by the cost, the Tanker Foundation has invested in outreach programs that focus on prevention of kidney disease and awareness of conditions that predispose to kidney problems. I was shocked to learn that nearly half of all patients with known CKD here in India present in stage V. To help answer the question of why that is, my mind referred back to Paul Farmer’s Lancet piece on healthcare delivery systems (you can find it here: In it he underlines the critical importance of identifying and addressing the external context. Neither patients nor healthcare systems operate in a vacuum. Rather, unique social and economic circumstances profoundly affect the health of individuals and the health of a care delivery system as a whole.

Medication non-compliance is a big issue here, and of course we see this at home as well. Some patients lack the funds or transport. They might also lack the education or health literacy to appreciate why certain medicines are vital to their health. Furthermore, patients with high blood pressure and poorly-controlled diabetes are often asymptomatic. But what gave me pause was some of the other explanations for non-adherence posed by our colleagues at Tanker Foundation. For example, how can we expect patients to be compliant when there are taboos against daily medication use? Or when rumor has it that CKD can be cured with a single dialysis session? How can we convince patients to take their lisinopril or metformin if it means missing a day’s earnings to line up for hours at a clinic to get a refill?

This is where the Tanker Foundation’s prevention and awareness program is hard-hitting. The program was born out of an appreciation for the intricacies of their patients’ unique circumstances, and this is how I know they will continue to be successful.


This entry was posted in BMC.
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