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K. Srinath Reddy

Year: February 18th, 2005
Location: Orlando, Florida
Interviewed by: Labarthe, Darwin

Abstract

Dr. Reddy is a pioneer in CVD epidemiology and prevention practice and research in India, and credits his family for preparing his attitudes, his predecessors, like S. Padmavati for the vision, and the International 10-day Seminar for the inspiration and opportunities to engage in important studies and reports. He emphasizes the various stages of the Epidemiologic Transition (he calls the Health Transition) that coexist in the length and breadth of India and the difficulties in mobilizing professional, public and legislative support for preventive strategies in a country with great diversity and wide poverty and social concerns. He suggests that the epidemic of metabolic syndrome, and the demonstrated susceptibility to its components in Indians gives promise of improving the picture. (Henry Blackburn)

Quotes

Health Priorities

… Rheumatic heart disease at that time was the most challenging issue in terms of cardiovascular disease in our country, because coronary heart disease, hypertension, and stroke, while they were recognized as important problems, still in the hospital setting even in the early 70s were dwarfed by the huge proportion of rheumatic heart disease patients getting admitted. And rheumatic heart disease classically represented a disease of poverty, a disease of overcrowding, a disease of people who for a variety of reasons, maybe under-nutrition because of poor social and hygienic conditions were exposed to a huge load of streptococcal infection and had autoimmune disease develop as a result, severely crippling their valves and leading to early disability and death. And very few solutions were offered for rheumatic heart disease other than expensive surgery at that point in time. In terms of prevention, secondary prevention through penicillin was possible, but even that was not always useful in warding off the effects of already damaged valves. So when we looked at primary prevention we really found nothing other than looking at social solutions like bringing about better housing and better hygienic conditions and better nutritional status. So again, clearly there we understood the limitations of what we had to offer as cardiologists. (3)

The 10-day Seminar in CVD Epidemiology

I had no particular orientation to epidemiology at that time, but philosophically I believed in prevention as a very important component of health care and in order to get a better orientation I decided to go to the seminar and fortunately I was selected. The seminar was, I think, a very, very important turning point in my life in terms of influencing my perspectives… It was certainly a life-changing experience. Geoffrey Rose was not there at the seminar, but Jerry Stamler was there and the power of his personality, the passion with which he argued the case and at the same time the scientific rigor with which he wanted evidence to be examined, I think all of these things profoundly impressed me. It also became very clear by the time I went through the 10 days that you could appraise evidence in a much more methodical fashion than we were accustomed to. I mean we were always accustomed to looking at abstracts of journals and then reading through the important messages, but we never really looked at them from the methodological rigor point of view and critical appraisal. So all these were eye-openers for me and they opened up a fairly exciting world. (4)

Delhi: World Congress of Cardiology 1966

I was told there were two very important episodes or events that occurred during that Congress. One was the birth of the 10-day Seminar and the actual coming to life of the [International] Council on Epidemiology and Prevention. The Seminar idea was probably crystallized there. The second event I was told was that in one of the elevators of the Asahi Hotel where the conference was held Bernard Lown ran into Eugenie Chasov from Russia and then while traveling in the lift Bernard Lown sort of, I wouldn’t say collared, but engaged Chasov and said, “It’s a shame that both our countries are producing these nuclear weapons and are bringing the world into such great danger. We should do something about it.” And that is how through their conversation and subsequent partnership the International Physicians for the Prevention of Nuclear War (IPPW) was born, which went on to win the Nobel Peace Prize in 1985. So the Delhi Congress was auspicious for several things. (8)

WHO CVD Unit

…it was probably 1956 that the Executive Board of the World Health Organization and later the Assembly the Health Minister at that time introduced a resolution asking for creation of a separate program for cardiovascular diseases in WHO emphasizing the growing problem in the developing countries and asking for WHO’s attention for prevention and management of these problems. And it is in response to this resolution in India that I understand the CVD Unit was created for the first time in WHO. And its going to be 50 years in 2006.

I’m surprised that it was an Indian Health Minister who was prescient enough to do that at that point in time and must have felt passionately about something and that could have been rheumatic heart disease or that could have been an appreciation of the fact that hypertension also was becoming a problem. I do not know what exactly compelled that particular move. But despite India having been the prime mover of that at the policy level at least until the 1990s there was really no move made for an organized governmental effort to tackle cardiovascular disease or even to look at the development of a program.

And this springs from several reasons. Partly because of the perception among policy makers that communicable diseases are the dominant health problem and especially a problem with the poor and the disadvantaged sections of the country and they are the ones that require the maximum attention and allocation of resources. Cardiovascular diseases were not considered to be that important in terms of disease burdens because there were really no accurate measures and also the popular perception that most cardiovascular disease, especially coronary heart diseases, etc. were problems of the urban elite who could afford to pay for their health care and therefore the government didn’t really need to do much about them. So that was the popular perception that existed until almost 10 or 15 years ago. (10)

The Indian Epidemiologic Transition

The first major survey of coronary heart disease in an Indian population in two different areas of northern and southern India both urban and rural comparisons was organized with the Indian Council of Medical Research… Preceding that there were a couple of studies in north India conducted by other investigators and all of this cumulatively added to knowledge that the prevalence of coronary heart disease was indeed quite substantial in terms of the prevalence figures that we were obtaining by the standard criteria of the modified Rose questionnaire and the ECG criteria, Minnesota Code.

But at the same time suddenly we started getting information from Indians being studied abroad in migrant settings, of disproportionately high mortality rates among Indian migrants studied in a variety of countries all over the world. Whichever the native population or other migrant population that was being held as the comparison group in comparison with that the Indian migrants, both men and women from 20 years and above seemed to have excess mortality and morbidity due to coronary heart disease and this whole area became a major area of investigational interest for the people abroad. And naturally people started asking what’s happening back home in India?

…And whatever data emerged suggested clearly that risk factor burdens were quite high in urban settings and prevalence of coronary heart disease was very high in urban settings. Then suddenly a spate of projects started getting commissioned and carried out by a variety of investigators looking at all of these, including diabetes. because there was a very active diabetes research community that suddenly emerged because of the huge burden of diabetes in India. India has the largest number of persons with diabetes in the world.

So I think the 90s really saw the accelerator being pushed on data gathering and I think by the late 90s it became abundantly clear to anybody who cared to listen that these were major, major problems and they were escalating. (13)

“India exists simultaneously in five centuries”

We believe that in terms of burdens of disease we have a very diverse picture across India in terms of regional variations and a lot of urban/rural differences. Therefore, we span almost the entire spectrum of health transition… Somebody said that India exists simultaneously in five centuries and I suppose that fits very well in terms of even our health transition profile that there are a number of areas… backward developmentally, failed, underdeveloped areas in northern India and eastern India where rheumatic heart disease is still a major problem. There are places in urban India where rheumatic heart disease is virtually faded out and certainly coronary heart disease and ischemic stroke that are the major problems. So we see the whole spectrum.

But in terms of coronary heart disease probably we have a distinctive disadvantage because we do seem to have, for whatever reasons, a greater propensity for developing diabetes and dyslipidemia because of the higher prevalence of abdominal adiposity, perhaps, because of very low levels of physical activity, especially in the urban areas and diminishing even in the rural areas. Whatever may be the reasons we seem to be having a greater proclivity for developing dyslipidemia and cardiovascular complications and metabolic complications of glucose intolerance and dyslipidemia combined.

So India, I think, represents not only the diversity of health transition, but also a very accelerated phase of developing coronary heart disease in particular because of the high frequency with which risk factors cluster in individuals. (14)

Public Inaction

I think our problem has been in not being able to provide the government with very clear, actionable points for cardiovascular disease prevention and control. Even the professionals have spoken in multiple voices: some people would emphasize creation of tertiary care facilities, some people would talk in terms of mass screening for hypertension, things like that. Unless we really come up with feasible, cost-effective, sustainable plans where we can have an impact both on the population distribution of risk factors as well as cost-effective detection and management strategies for high risk individuals and present them in a cogent manner to the government as something that the government can implement, even in a short time frame with some impact demonstrated, we’ll be losing the battle.

I think the critical challenge before developing country advocates of preventive cardiology is not to paint the program in the broadest brush strokes that they can see, but to give a very well etched-out roadmap to the governments and then build on it in a modular fashion. And I think we are now just beginning to get up to that challenge. (20)

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