Exclusive Interview with Professor Jacob John
Section A. On Health in India
Q1.According to you, what should be the top three health priorities in India?
According to me there are two: First, disease priorities such as tuberculosis, metabolic diseases (diabetes and hypertension), and malignancies (cancers/leukaemias).
Second, health management priorities: absence of formal public health, lack of clarity of accountability for disease control between centre and state and lack of entitlement of human right for healthcare.
Q2.What make you proud about health in India?
There has been progress in polio eradication which has been globally acclaimed. There has been success of HIV control India-designed programme. We now have availability of highly skilled surgeons and this is attracting medical tourism and earning much goodwill.
Q3.Where is India falling behind the world?
India is known as the TB and diabetes capital of the world; under-5 and maternal mortalities are high; nutritional status of under-5s very low; immunization coverage is very uneven and not equitable across states and across urban/rural and across educated/illiterate segments of population. Where India is really falling behind is in the lack of political ideology that stipulates “health of the people is state’s responsibility” – which is the guiding principle in nearly all capitalistic and all socialistic economic/political systems. No political party has adopted this ideology in India. Europe adopted this in 1800s.
Q4.Are there examples where other fast-growing economies are handling health problems better than India?
Yes, there are countries such as Sri Lanka, Thailand, Brazil which offer good examples. Cuba is also model.
Q5.If you think about India in 20 years time, what will the citizens of 2033 wish that we had done in 2013? Why?
They would wish that we had organised a health management system in which prevention of diseases – both communicable and non-communicable – were given due importance and was efficient; that every citizen who falls ill would have known where exactly she/he would be entitled to receive quality medical care; that we had reversed the trend of “commercialising” medical education so that doctors are not pressured to earn huge amounts to pay off investment in medical education; and we had reversed the trend of “commercialising” medical care and that makes undue profit in providing a basic human right called medical care – achieving all these by state system supervision of quality and costs – as in countries with formal functional public health. They would not forgive us for creating extensively drug resistant TB and multidrug resistant TB that are simply too difficult or too expensive to treat and are virtually uncontrollable. They would wish we had controlled diseases that many countries had controlled in the early 20th century and we did not leave it for them to grapple with – typhoid, cholera, dysentery, malaria, hepatitis A etc. They would any way be burdened with non-communicable diseases that are difficult and expensive to treat.
Q6.Which big societal trends do you think will have the most impact on health in India? (e.g. might be growing wealth disparities or environmental degradation)
Cultures evolved slowly and with statesmen/philosopher leaders. We are transitioning from our ancient culture to a new one, largely in imitation of the western culture, but without guidance by societal leaders or basic infrastructure to explore and monitor trends and consequences. This transition is palpable in urban rich and not in rural poor. Western culture has human equality as a basic tenet but we have entrenched inequality illustrated by divisions by caste, exploitation of the weak/vulnerable without societal checks and balances. This trend also results in uncaring degradation of environment. In most western countries water is a state resource to be shared equitably. But not in India where everyone is on one’s own. Water wash and water borne diseases and vector borne diseases will flourish.
Food habits without state regulations (like unhealthy foods and drinks available to children even in school premises) promote high body mass index. Modern societies have many advantages but also many pitfalls – how much chemicals in marketed foods? How sterile are canned foods on shelves of supermarkets? If someone got food-related toxic disease, will our system detect it and mitigate?
In short, nothing wrong in transforming cultural behaviour provided we know every change as a cause and every cause has an effect. We are not good at monitoring cause by effect, and effect by cause, as we do not systematically look for the potential effects. Science is the product of the European enlightenment of the recent centuries; we were enlightened when they were barbarians – but our enlightenment did not promote objectivity and instrumentation for the sake of science. The misalignment of the two cultures must be perceived and adjustments made to prevent all sorts of consequences, including in human health.
Q7. Which new technology do you think will make a difference to health outcomes in India over the next 20 years?
First, information technology and second biotechnology. Scientific approach to health economics will also make a difference.
Q8.What do you enjoy most about working in the health services field? What do you like the least about working in this field?
Every time I solve a problem, either for individuals in need of care, which must be preceded by correct diagnosis – or in the community facing an outbreak or a broken health management system, there is job satisfaction which is in the emotional domain, and also in the cognitive domain. The call that “what is done unto the least among you, you do it for Me” (“Me” being God) gives a sense of fulfillment. People who love to interact with other humans will appreciate working in health – just like those who love to interact with children appreciate teaching. Those who love nature may like conservation; those who like mechanical items like appropriate professions in material management.
What is least liked is the fact that the state, the custodian of resources and the manager with accountability for human health, leaves too much for individual health professionals.
Q9.If you could send a message about health, what would it be?
We have grown up believing health and disease are the results of internal imbalances – a tenet that was denied by modern medicine which taught that causes are extrinsic and amenable to state actions. While modern medicine has recently accepted that the non-communicable diseases are intrinsic and within our control to avoid or mitigate, most communicable diseases are extrinsic and need scientific interventions, which the state has to provide. Social or societal determinants of diseases cannot be neglected if we want to improve health.
Our body and mind are owned by each of us and to keep them healthy is our duty to ourselves, our families, and to our society and for those who believe in God, duty also to God. Those who knowingly neglect health are irresponsible to themselves and to all others mentioned above.
Section B. On Immunisation and Prevention
Q10.Many say that India will face a wave of non-communicable diseases. What can the country do to prevent this?
A country that has not gone through the “primary school” of preventing- easily prevented and single-agent caused infectious diseases will not be able to cope with the “high school” of preventing multi-factorial and not easily prevented non-communicable diseases. The wave has already started many years ago. We watch this as ‘paralysed witnesses’. The country must establish formal and functional public health, that system which will monitor risk factors of both communicable and non-communicable diseases. The division between the two is not watertight. Diabetes puts you at higher risk of TB; chikungunya causes higher death rates in those already having chronic diseases. Cancers of liver and uterine cervix are caused by virus infections. For the individual, infectious or non-infectious disease may have similar consequences – like financial burden, lack of access to care, lack of quality of care and lack of a caregiver to whom you can go as your right.
Q11.Will prevention be led by government, the voluntary sector or the private sector? What — positive or negative — do you think that each is likely to do?
Prevention has dimensions in all 3 segments. Prevention through public health actions is exclusively in the government domain (public health can be defined as what the government does – or should do, to prevent diseases and promote health – quite different from medical care that begins after you fall ill).
Private sector can work mostly in medical care – after people fall ill. For-profit medical care was unduly encouraged by governments hoping for the best. They have betrayed that trust. Not-for-profit medical care should have been chosen to partner with government, in a win-win partnership but government failed to grasp that opportunity, both in care and in education/training of care professionals.
There are a few elements of prevention that can be given by private sector and that includes screening for risk factors and early pathology as and when individuals seek care. Timely giving of immunisation is another. Check for blood pressure, glucose tolerance, breast screening, cervical screening are examples – but for the doctor, that takes time and effort and they are often perceived outside the “consultation”. The caregiver is not “in charge” of the individuals overall health, but only “in charge” of the immediate issue of an acute illness. Ideally, the caregiver must assume charge, but there is no such mandate or provision for that in our health management system.
If the state does not “spend” on disease care, it will not appreciate or measure the “saving” through prevention. Since 70-75% of spending is “out of pocket” the state seems to ignore disease prevention without understanding the relevant health economics. Diseases impoverish families. Poverty alleviation will not succeed without disease prevention.
Health insurance without ensuring quality is not the best solution. However, if managed well it can be a way of good public private partnership.
Q12. Many say that India is a paradox. It manufactures about 40 per cent of vaccines used in universal immunisation programmes across the world. However, a third of all unimmunised children are Indian. As a public health specialist, how do you see this contradiction?
The statement is fair. Our immunisation programme is felt by the system as a vaccine-delivery platform and they go through all the prescribed procedures and rituals. The vaccinators are not accountable for those who do not present themselves for vaccination sessions. They are in charge of vaccinating those who come. Then who is in charge of the unvaccinated? In rural areas now we have a vaccination facilitator, ASHA. What does it matter if a particular child was or was not vaccinated? Is ASHA’s incentive only that monetary reward she is entitled for? Unless the programme is transformed into a “disease control” modality, how should coverage matter?
If every case of diphtheria is investigated for immunisation status (and every other vaccine-targeted disease), then the segment of community that is under-vaccinated will immediately be picked up. Coverage is an inputs and process indicator, not the outcome indicator. For converting our immunisation programme to a disease control programme, we need Public Health.
Once we have many diseases under public health surveillance, the need for more vaccines against more diseases will stand out; that should be incentive to introduce more vaccines.
We should have two or three disciplines in our Department of Family Welfare that runs the immunisation programme. epidemiology in regular field application (and not merely in research and teaching); health economics to learn that vaccinations are not mere expenditure items but profitable investment; Ethics to show that the present state of affairs is unethical and the government is to be informed of the ethical imperatives of equity.
Q13.What is the biggest obstacle to universal immunisation? Is it finance, access, or lack of knowledge about the importance of immunisation?
India is rich enough; if cold drinks and ice cream, refrigerated milk and eggs can penetrate the communities, access is not the problem, except in very isolated communities. Once the community’s existence is “known” it is no longer inaccessible; we are in the 21st century. Ask any one and you will hear about the importance of immunization. Mothers want their children live and disease-free. Health workers, likewise. Vaccines are available and paid for by the government. Win-win-win! So why cannot we have at least 90% national average with at least 80% in every population unit? The biggest barrier, in my opinion is the absence of accountability. Is the government accountable? If so, the system will be adequately staffed and staff charged with accountability. The biggest barrier is the poorly designed system, (without accountability to prevent every case of diphtheria, whooping cough etc.) which should have been re-engineered and used as the platform for polio eradication. It should have been re-designed in the early 1990s, when India claimed to have achieved 80% coverage with age-appropriate vaccine doses. As it turned out, the vaccine delivery system was inadequate for polio eradication; hence a new vehicle, the National Polio Surveillance Project was created and given charge of polio eradication.
I believe the immunisation system is under-budgeted, under-staffed and under-valued by the very government which ought to accept accountability for universal immunisation. How did the polio programme reach over 99% of eligible children repeatedly? There was a mission to accomplish; and the target was clearly defined – not a single wild poliovirus and the project was accountable. What is the mission of the immunisation system? And what are the targets? Good management with all well known principles can transform the poorly performing system into one we all can be proud of, if only the government so desires.
Section C. About his work
Q14. Could you tell us a bit about the current work or research that you are doing? How did you first get involved in this field?
I have retired from academic work and wanted the freedom to do what I pleased – so I declined employment. My field of activities is concerned with disease prevention and immunisation is of special interest.
Way back in early 1960s, I was in charge of kwashiorkor (severe protein and calorie deficiencies leading to gross under-nutrition with high mortality) management in the Department of Child Health. Some 40% of them had been marginally nourished, and fell off the edge into kwashiorkor after they developed whooping cough or measles. These two are notorious for negative nitrogen balance. And both are vaccine-preventable. So I began teaching all about immunisations and missed no opportunity to ensure children get their due. In 1979 The Rotary International offered measles vaccine to Tamil Nadu and I was the only person around who had handled measles vaccine while in the USA for some 4 years (on study leave or sabbatical leave) – so I immediately became the person in charge and through Rotary in association with Tamil Nadu Ministry of Health, we vaccinated more than 4 million children. That experience was the basis on which the 7th Plan of the Planning Commission accepted my strong recommendation to include measles vaccine in our immunization programme.
In 1985 it was introduced in a phased manner, beginning with 80 districts till all districts were covered in 1990. Simultaneously India renamed the Expanded Programme on Immunisation (EPI) as the Universal Immunisation programme (UIP). There was stiff opposition from various quarters but it remains to the credit of Dr. HV Hande, the then Minister of Health in Tamil Nadu, and Shri Umashankar, then Union Government Health Secretary, who overruled all objections and put India on the right track. That success led on to the control of polio and the design of pulse immunisation. And I continue in the field by supporting immunisation, teaching vaccinology and doing research wherever possible. My research on Salk vaccine in the 1980s is very relevant today.
Q15. What has surprised you most about working in this field that you are currently working in? What do you find most challenging?
The greatest surprise, if I may call it surprise, was the gross mismatch between the need for a strong immunisation programme and the actual performance of the programme. I see no passion or professionalism in the leadership. I see no motivation at the top level to re-engineer the system. I see no guilt when children die in large numbers – of vaccine-preventable disease. I see no application of the basic management principle of systems approach in which the most sacrosanct element is the outcome and its measurement – but what I see is the focus only on inputs – namely coverage. The immunisation system is not integrated with primary medical care – as it was designed at a time when care was not accessible, not equitably distributed and not quality-assured. So the system was designed to be independent of the medical care avenue. Only recently has this been recognized and remedial actions taken. Ideally immunisation should be nested within public health, but India does not have a functional public health infrastructure.
Trying to convince in vain, that the system needs re-engineering, and not merely doing more of the same thing over and over again – and that India urgently needs public health infrastructure, has been frustrating. At least the leadership could analyse the success factors in Tamil Nadu, Goa and Kerala and the failure factors of other State – and that will give us a handle on the short term improvements while in the medium term we need system redesign and creation of public health.
Q16. What do you think will change about vaccine research in India over the next five years? What sorts of trends do you see?
I see a lot of development research on vaccines in India that is inspirational. You mentioned about the volume of quality vaccines made in India and supplied to the whole world; that came out of much development research. Meningococcal A conjugated vaccine was developed in India for the meningitis belt countries of Africa. India’s own Rotavirus vaccine is awaiting licensing processes after successful phase 3 evaluation. Oral cholera vaccine was field tested in India before it was declared effective and safe. I expect more such successes in the next five years. Unseen behind such successes is the capacity of our investigators to conduct rigorous vaccine trials. Several foreign collaborators have helped in all these success stories and we have earned the respect of all of them.
The change I would like to see is in innovations in vaccine development. There are signs of such innovations in industry and the Department of Biotechnology, but not so much in our Universities and in the Department of Health Research. Having innovative vaccines is not enough; we need to utilize them to the best advantage of our children. Our medical education does not promote research attitude or skills. The reasons and remedies require exploration.
— end of interview —
