Here is our third Exclusive Interview with Dr. Vikram Jaggi, who is the Medical Director of the Asthma, Chest & Allergy Centres in New Delhi.The Asthma, Chest & Allergy Centres are premier institutes dealing with diagnosis, treatment, research and spreading awareness on asthma and allergies. Dr. Vikram Jaggi is an alumnus and a double gold medalist from New Delhi’s Maulana Azad Medical College. He is passionate about spreading awareness about health topics in general and asthma in particular. He regularly contributes article to national dailies and health magazines and has written over 15 books/booklets on asthma and allergy. He has successfully run a website,www.acac.in, since 2007 which is a rich source of helpful information for patients and through which he sends out monthly newsletters to over 7000 subscribers.
Here is a taste of some his thought-provoking responses to our questions:
- In India, we truly have the best and the worst that the health care has to offer. New multi- specialty corporate hospitals are glitzy and shiny examples of the best doctors, facilities and technology- comparable to the best in the world. But, how many Indians can afford that?
- The under five-mortality rate is a cause of shame for us.
- Our westernised diet of fizzy drinks, fried food, ready to eat foods, colours and preservatives and a diet lacking in fruits, nuts and vegetables is also responsible for the increasing trends of allergy. Obesity is also linked to asthma.
- Having seen the medical establishment in many western countries, where healthcare is not only extremely expensive but also impossible to access quickly when there is an urgent need, I feel proud that doctors in India are immediately available, both physically and on the phone, to help out their patients. Though our healthcare system is fragmented and disorganised, it still works!
- India has 16% of the world population and 20% of the world morbidity and mortality. Yet, only 1-2% of the worlds spend on health is spent in India.
- Asthma and allergy have become so common nowadays that these medical terms have become household names!
Read the whole of Dr. Vikram Jaggi’s interview below.
Please tell us how you would answer our 20 questions — we want to run several interviews with readers too. Click here to be interviewed.
A. On the status of health in India
1. According to you, what should be the top three health priorities in India?
India is the quintessential paradox. We can proudly speak of “India Shining” but it only applies to the privileged few living in the metro cities. The real India is not shining. The same paradox applies to healthcare facilities in India.
Our healthcare priorities are many but the three most important, according to me, are:
- Unequal distribution of healthcare.
- Double whammy of burden of infectious diseases and the modern epidemic of non-communicable diseases
- Insufficiency of government provided health facilities.
In India, we truly have the best and the worst that the health care has to offer. New multi- specialty corporate hospitals are glitzy and shiny examples of the best doctors, facilities and technology- comparable to the best in the world. But, how many Indians can afford that?
Compare that to the pitiful situation in the government run hospital. Lack of doctors and staff, no medicines, non-working machinery and the huge number of patients that simply swamp the system- the list is endless. Faced with such insurmountable problems, well-meaning doctors are left helpless.
The other paradox is that India is reeling under the dual burden of infectious diseases like diarrhoea, tuberculosis, dengue and malaria, which we have not been able to eradicate. At the same time the modern India is plagued with the epidemic of stress related diseases like diabetes, heart diseases, cancers and allergy.
The government has not been able to do enough on this front. There is not even basic drinking water and sanitation in all parts of the country, what to say of healthcare. The government spends about 2% of its GDP on healthcare where most developed countries spend upwards of 7 %.
2. What makes you proud about health in India?
I wish there were more things in our health care that I could genuinely say that I am proud of. Yes, there are some. The first thing that comes to my mind is our successful Pulse Polio Programme. This is a great example of how concerted efforts by the government, media, celebrity endorsement and public participation could lead to a mass movement to achieve the desired aim.
The other achievements we could be proud of are the ASHA scheme where local ladies are selected from a village and trained to provide the very basic medical care in remote areas, where proper medical facilities are not present. Since it is not feasible to have fully qualified doctors in all villages, it is these kind of novel schemes tailored to the local needs, which are going to work.
Dr. Devi Shetty (one of India’s leading cardiac surgeons and founder of the Narayana Hrudyalaya Institute of Cardiac Sciences) has shown that well-meaning individual actions can have an impact at a wider range. Individuals have to take action. People like Dr. Devi Shetty have shown that leveraging the economies of scale can provide affordable healthcare to the masses at even Rs. 10 per month. Dr. Shetty is called the Henry Ford of Heart Surgery.
Having seen the medical establishment in many western countries, where healthcare is not only extremely expensive but also impossible to access quickly when there is an urgent need, I feel proud that doctors in India are immediately available, both physically and on the phone, to help out their patients. Though our healthcare system is fragmented and disorganised, it still works! Like the Indian jugaad or our Mumbai’s dabba system !!
3. Where is India falling behind the world?
Our health care parameters, whether it is infant mortality, maternal mortality, number of beds/doctor/nurses per population, health insurance coverage, vaccination rates or disease specific health care indicators are quite poor. They are, of course, nowhere near those of the developed countries, but are also lagging behind many similar developing countries. That is worrisome. India, as a country in general and the government in particular, is spending too little on healthcare. For instance, India has 16% of the world population and 20% of the world morbidity and mortality. Yet, only 1-2% of the worlds spend on health is spent in India.
4. Are there examples where other fast growing economies are handling health problems better than India?
That is a good question! Yes there are. Let us only talk about similar countries, which have started alongside us on healthcare situation, say, 50 years age and see how they have fared. And if they have fared better than us, to derive lessons. Brazil, Thailand and South Korea had started like India in 1960s. However, they made a long-term road map for health and with concerted efforts, they have been able to improve their health indicators far better than us.
What are the lessons for India? I think what we have to learn and do is:
- Transforming the healthcare system is a long-term journey and has to be championed and driven by political leadership over a sustained period. There are no easy ways or shortcuts.
- These facilities have to reach all.
- In countries like ours of low per capita income, out of pocket payment for health care is not sustainable. The government has to provide finances for health insurance.
- In the initial phases, the government has to play the role of a provider and creator of services and once these are in place, assume the role of the payer of these services.
- The government alone cannot do all this. A trusting public private partnership with fair regulatory checks is necessary to bring about this change.
The government has taken the correct first steps. The 12th Five Year Plan has laid a lot of importance to health care. The slogan of “Universal Healthcare” has been raised. A long term roadmap is being readied. I have met many dynamic and well-meaning bureaucrats in the healthcare sector. Many private healthcare enterprises are willing to chip in as part of their corporate social responsibility. All this has to be sewn together. The dots have to be joined. There is a lot of hard work to be done and done in a sustained manner.
5. Which big societal trend do you think will have the most impact on health in India?
People are now becoming more aware of their rights. Just as the right to information (RTI) has awakened in the general public a feeling that this is their birth right, similarly people are going to expect government to provide at least basic medical facilities to all. The government can no longer keep the populace happy and satisfied by the slogans of roti, kapda or makaan (food, clothes, house). Right to education and healthcare is soon going to become a normal expectation that the government has to fulfill. This will soon become an election issue. Then, the government will be spurred to act.
6. Which new technology do you think will make a difference to health outcomes in India over the next 20 years?
Many new technologies will influence healthcare at the micro level to help individual patients – better diagnostics, better and more targeted radiotherapy and robotic surgery. However, the one use of technology that will impact the masses in the next 20 years is going to be telemedicine.
India is one of the five lucky, or let us say technologically advanced, nations to have their own satellites. Secondly, more than 50 per cent of our population has their own mobile phones. These two facts are going to be the drivers of advances in telemedicine. Try to picturise the scene in the Hindi movie the “Three Idiots” where a successful delivery is conducted in a remote area by the doctor guiding the procedure through the internet. Medical consultations from a distance, second opinions from expert doctors through video conferencing, even robotic surgery performed by a doctor sitting in Delhi and surgery taking place in Dibrugarh are now a reality and this is no longer in the realms of fiction.
Telemedicine can make healthcare better for the haves. However, the real beauty of telemedicine is that it can provide healthcare to the have-nots in inaccessible areas, which would otherwise be unthinkable and unimaginable to that population.
7. What do you enjoy most about working in health services field?
What I enjoy most is that I am doing meaningful work. Watching patients getting better due to your efforts and the human warmth that ensues from the patient and their family to the doctor is a feeling of pure joy which has to be experienced to be believed. Most doctors come into this profession to be able to help others and make a difference. Somewhere down the line, to make it big in their field and to be able to earn decent money, they forget the pure joy of doing good work for their patients. It is also my firm belief that if a doctor concentrates purely on doing good and honest work, fame and money automatically follows.
8. If you could send message about health, what would it be?
I would like to address this to the younger generation. By that I mean teenagers and young adults up to the age of 40 focused on pursuing their career. This generation is highly focused and driven. Nothing wrong with that. However, as a doctor I often see them doing so at the cost of taking care of their health. What they do, or do not do, about their health now may not become apparent immediately but will surely affect them in the coming decade. A proper diet of fruits and vegetables, avoiding junk food, finding time to do some regular exercise, avoiding smoking and excessive alcohol and getting some kind of periodic health check will go a long way in their remaining healthy.
B. On respiratory infections and Chronic Obstructive Pulmonary Disease (COPD)
1.Does indoor air pollution from cooking and heating with solid fuels pose a significant health risk? What are these risks?
Oh yes, it does! Not many people are aware that over 3 billion people, that is about half the world population, are exposed to smoke from biomass fuel. Compare that to about 1 billion people who smoke. Exposure to biomass smoke may be a bigger factor in causing COPD globally than cigarette smoke. Studies from our own country show that 25—45% of patients with COPD have never smoked. The burden of non-smoking COPD is therefore much higher than previously believed.
Naturally, the underdeveloped countries face this problem more. It is further compounded by the fact that such homes are small and very poorly ventilated. Women and children are exposed to this smoke. The effects on the lung health are well-known – frequent respiratory infections, chronic cough, pneumonias, aggravation of asthma and development of COPD.
2.According to data from WHO, India has an estimated 15-20 million asthmatics.
a.In your practice in the last 5 years, have you seen a rising incidence rate of asthma amongst patients?
b. If yes, what do you feel is the cause? What can be done to prevent this.
Asthma and allergy have become so common nowadays that these medical terms have become household names!
When, at a social gathering, I tell someone that I am an asthma & allergy specialist, the usual response is: “Doctor, why is asthma increasing so much? It must be the pollution.” This tells us two things. One, the increase is so clear and obvious that lay people have also observed it. Secondly, the popular perception is that it must be related to the increasing pollution. However, pollution is not the only or the main reason.
The epidemic rise in allergy is due to our immune system being misled or misdirected.
Over hygienic living, vaccinations, smaller families with fewer siblings and lesser infections coming home, early antibiotic use for every childhood infection have all resulted in the immune system of the younger generations not being called upon to work. Just as an idle mind is a devil’s workshop, an idle immune system is an allergy producer!
Much as we would like to blame pollution for the increasing incidence of asthma, it is not the real culprit. Pollution does not cause asthma. Yes, it does make existing asthma worse.
We give too much of the wrong kind of stimulation to our immune system. Our westernized diet of fizzy drinks, fried food, ready to eat foods, colours and preservatives and a diet lacking in fruits, nuts and vegetables is also responsible for the increasing trends of allergy. Obesity is also linked to asthma.
3.According to the IAP, India’s under-five death toll is higher than the number of deaths in Nigeria, Congo and Pakistan put together. 50% of world’s pneumonia deaths occur in India which means approximately 3.7 lakh children die of pneumonia annually in India.
a.Can you comment on this?
b. What are the three or four things that India could do to reduce this toll?
These figures are a cause of shame for us. Better education, more hygienic living conditions, primary health care facilities reaching remote areas, early diagnosis and prompt treatment will improve these figures. In addition, we have to be judicious in our use of antibiotics. Misuse of antibiotics is causing alarming rise in antibiotic resistance and many people are warning that we are reaching the “post antibiotic era” where even common infections will become untreatable because of antibiotic resistance. We alone are going to be held responsible for this.
C . On work and life
1. Could you tell us a bit about the work that you do? How did first get involved in the work that you are currently doing?
I now work almost exclusively on asthma and allergy.The interest awakened in my medical college days in 1985-90, when I was doing my residency in a large Government Hospital in Delhi. At that time the thinking was “Dama dam ke saath hi jaata hai” (asthma goes with the last breath) and asthmatics underwent untold misery and accepted their lot as if it was a curse of God.
I soon realised that despite the fact that effective and very cheap medicines were available in India, what was really keeping these patients away from proper treatment was their own non-acceptance of the diagnosis and the fears and misconceptions regarding the treatment in general and inhalers in particular.
Spending time educating them and guiding them to self manage their disease was the key to help them avail the benefits of treatment. Once I did that with some success, this became a passion for me. I now see my role more as a teacher than as only a doctor.
The next challenge was – how to reach out to more patients beyond the boundaries of the clinic. I tried to do that in many ways – by writing books and booklets in very simple language, creating videos, which carry the message effectively, by writing in newspapers, taking public lectures as well as lecture for doctors. Modern technology also helped. I now routinely take talks for general public/doctors via web cast to over 30 centres reaching an audience in thousands all at once. I started a website dedicated to patient education. This sends out educational newsletters to over 7000 subscribers. I also created a team of 10-15 patient educators whose sole job is to remove the doubts and myths of patients.
These efforts have reaped good results. Our centres in Delhi and Gurgaon are now considered premier centres in the country dealing with all aspects of asthma and allergy. I routinely see patients of asthma and allergy whose lives have been transformed by these simple measures.
2. What has surprised you most about working in this field?
When we are training to become doctors, there is a lot of stress laid on diagnosing difficult diseases and we are always in awe of our teachers who we consider diagnostically brilliant. They become our role models. Then we are also awed by innovative technology. However, when we start treating patients in the real world, we realise the truth in the aphorism that “common diseases occur commonly and rare diseases occur rarely”. Also, what is required of a doctor in treating common chronic diseases like diabetes, asthma or allergy are patience to listen to the patients, take out the time to teach them about the disease, good communication skills and an ability to partner a trusting relationship with them to eventually equip them to be able to treat their condition themselves. Just like the Chinese saying “You give a man a fish you feed him for a day. You teach him how to fish and you feed him for life.”
3. What do you think will change in this field over the next five years? What sort of trends do you see?
Asthma and allergy are fields, which move at a glacial pace. We are not expecting many new drugs to come out in the next 5 years. However, fortunately we already have quite effective drugs. What we need to do is to use them more effectively by training both the doctors and patients.
4. What is the best thing to happen since you started working in this field?
The best thing to happen is that now there is better acceptance of the label of ”asthma’ in patients and particularly in parents of asthmatic children. It is no longer as much of a stigma as it used to be earlier.
5. What might someone be surprised to know about you?
Since my childhood days, I have been interested in mechanical things and I would always open up my non-working toys, and sometimes even the working toys, to see how they worked. So it was not surprising that later in life, when I had spare money beyond my essential needs, I got interested in watches. Especially complicated and mechanical ones. I now have a passionate interest in watches and have an enviable collection. I can even open them up for minor repairs.
6. What do you do when you are not working?
Sports have been very dear to me since my school days. Lately I have started playing badminton. I play every day for at least an hour. I can quite easily beat players half my age! I only pray I do not get injured.
I also spend my free time listening to jazz or hindi semi classical music. Rest of my free time, I spend reading on varied subjects on my ipad. The Internet is great! It can take you in a second wherever your fancy wants you to go. I am also fond of traveling to new places. I have been lucky to have been able to see most of the world. I also love to spend time with my wife, who is also a doctor and my three kids. My older son has finished his under graduation in medicine and is now due to start post graduation. The other two kids, who are twins, are pursuing law and engineering.