Here is our fourth interview with Anant Shah, who is a Program Officer on the Vaccine Delivery team of the Bill & Melinda Gates Foundation’s Global Development Program, currently based in New Delhi, India. His role is focused on contributing to child health and reductions in the burden of vaccine preventable diseases through efforts to bolster India’s immunisation system and help enable the inclusion of new childhood vaccines in India’s public health immunisation program.
Prior to joining the foundation, Anant Shah was at the US Centers for Disease Control and Prevention in Atlanta, GA. Over the course of six years at CDC, his roles spanned serving as consultant; Special Assistant to the Director of CDC’s Office of Terrorism, Preparedness, and Emergency Response; Special Assistant to the Chief of Staff; public health analyst with the International Emerging Infections Program in Kenya; and lead for a cross-agency workgroup developing a new strategy for public health through healthcare quality and patient safety. He received his Bachelor of Science in Public Health, Health Policy and Administration, from the University of North Carolina at Chapel Hill, and his Master of Public Health in Epidemiology from Yale.
Here is a taste of some his thought-provoking responses to our questions:
- I always say that the moment India wills-and-chooses to do something; it can do anything. The sky is the limit. That’s the power of India. Smallpox, polio, HIV, information-technology, the highway and railway systems, and increasingly education, are all great examples.
- It is hard to imagine that we sit in what was once was a roaring economy with ‘Brand India’ gracing the covers of magazine after magazine. The more I learn and travel across India, the less I am convinced that India is necessarily “emerging” with the exception of a concentrated few. Think about this: there are >300 million people living on less than a mere $1.25/day – not to mention the millions more living on only $2, $3, or $5 per day – while India’s richest 100 individuals’ net worth is nearly $270 billion, or a about one-eighth of India’s $2 trillion economy.
- In terms of criminalising homosexuality, India is on the list of countries like Iraq and Somalia. Even in terms of the set of childhood vaccines included within the national public health immunization program, India is behind countries near and far alike: Pakistan, Rwanda, Brazil, Mexico, Bangladesh, South Africa are all using more vaccines to protect kids against more diseases ..
- I really hope we look back and see that leaders used the economic growth that India experienced to invest in the high-return areas of health and development. To build modern communities with infrastructure based on smart urban-planning; prioritise public health and prevention so even the poorest of the poor have the chance to survive and become productive citizens…
A. The following questions are related views on the status of health in India.
1. According to you, what should be the top three health priorities in India?
Urgency, urgency, urgency. Take child survival. More than 1.5 million kids under-five die every year, not to mention the millions more that get sick, are hospitalised, or god forbid, permanently disabled from diseases. Yet, despite all of its amazing talent, I don’t feel India loses enough sleep over that fact. No one seems outraged or truly compelled to act. I always say that the moment India wills-and-chooses to do something; it can do anything. The sky is the limit. That’s the power of India. Smallpox, polio, HIV, information-technology, the highway and railway systems, and increasingly education, are all great examples. Similarly, I would love to see urgency and creativity put behind child health and prevention. Vaccines are a great example where more urgent action would reap tremendous benefits in terms of lives saved, lives enriched, and costs averted to families, government and society at-large.
Take diarrhoea and pneumonia. More than 400,000 kids every year don’t celebrate their fifth birthday because of these two diseases alone. That’s more than HIV and malaria combined in terms of annual deaths. There is a public health emergency happening right under our nose, an epidemic that warrants an emergency response.
The moment India wills-and-chooses to act urgently for child health, India will be poised to realise its full potential as a great nation and fulfill its promise as the largest democracy on the planet.
2. What makes you proud about health in India?
The potential that it has for for radical innovation that can change the lives of millions, including the poorest and most disenfranchised. From eradicating human disease and offering cutting-edge, cheap surgical procedures for cataract disease – like at Aravind Eye Care – to using the simple mobile phone to improve health and financial services, and manufacturing lower-priced, high-quality drugs and vaccines, India is an epicenter for innovation in health. Innovation surrounds us. It just needs to be harnessed by leadership more effectively in ways that can achieve positive health impact at-scale. India’s so-called ‘innovation quotient’ excites me and makes me proud.
3. Where is India falling behind the world?
I have been discussing this question with family and friends a lot these past weeks. With the one-year anniversary of the tragic and infamous gang-rape and ongoing violence and disrespect toward women, the recent re-criminalisation of homosexuality, stark disparity between the haves-and-have-nots – I think India is falling very, very far behind the rest of the world. I hate to say it; but it is hard to imagine that we sit in what was once was a roaring economy with ‘Brand India’ gracing the covers of magazine after magazine. The more I learn and travel across India, the less I am convinced that India is necessarily “emerging” with the exception of a concentrated few. Think about this: there are >300 million people living on less than a mere $1.25/day – not to mention the millions more living on only $2, $3, or $5 per day – while India’s richest 100 individuals’ net worth is nearly $270 billion, or a whole one-eighth of India’s economy. Talk about concentrated. In terms of criminalising homosexuality, India is on the list of countries like Iraq and Somalia. Even in terms of the set of childhood vaccines included within the national public health immunization program, India is behind countries near and far alike: Pakistan, Rwanda, Brazil, Mexico, Bangladesh, South Africa are all using more vaccines to protect kids against more diseases – including diarrhoea and pneumonia – than India. The culture of inequality, inequity and a deep-rooted tolerance for the status quo must be broken in order for India to catch-up and be the global super power it can surely be.
4. Are there examples where other fast-growing economies are handling health problems better than India?
Yes. There are examples right here in India, at least in terms of health outcomes. Tamil Nadu and Kerala are famous examples where health systems are relatively strong with lessons that need to be tailored and shared more broadly across India. Outside India, you have Mexico, Brazil, and South Africa for instance. According to data I saw in a recent Bloomberg Businessweek piece, I believe Mexico spends about 6.5% of GDP on health and Brazil spends about 10% of GDP on health. In contrast, India spends only 1-1.5% of GDP on health. Health spend as a percentage of GDP is not the perfect indicator of health efficiency – the U.S. spends close to 20% of GDP on health with less return on health outcome than many other countries – but, it is a helpful proxy for where health stands a national priority. I think India should spend and do more. There are many lessons from India and around the world that should be drawn.
5. If you think about India in 20 years, what will the citizens of 2033 wish that we had done in 2013? (Why?)
Invest in its people through smart public policy. I really hope we will look back and say 2013/2014 was an inflection point for India. That leaders invested in the high-return areas of health and development. Build modern communities with infrastructure based on smart urban-planning; prioritise public health and prevention so even the poorest of the poor have the chance to survive and become productive citizens; invest in laws that mandate equality and enable everyone to live in safe communities, grow up educated, and participate in a free-economy. I do not mean infinite hand-outs. That’s not sustainable and is not what characterizes a healthy democracy. I would like to look back and say that yes, India pursued a technocratic approach to its biggest challenges, governed with integrity, and harnessed innovation – from India and around the world – in ways that empowered its people toward a 21st century India. And by the way, I hope we look back and say year 2014 was the year of rotavirus vaccine!
6.Which big societal trends do you think will have the most impact on health in India?
Growing up, my father – who emigrated from Gujarat in the early 1960s – used to say cynically that ‘India’s greatest problem is that just does not value life.’ Poverty, sickness, death surrounds you in such magnitude that it is the norm, and therefore tolerated. I do not believe this to be true literally. Deep down, I know Indians care and serious progress is being made year-by-year. But as a society – there is room for accelerating a trend, or a movement, for valuing life and human dignity. Such a trend would offer a breakthrough for health in India. In fact, it relates directly to the theme of necessary urgency we discussed earlier.
7. Which new technology do you think will make a difference to health outcomes in India over the next 20 years?
Vaccines. They are miraculous. They help prevent infection in the first place; they are exceptionally cost-effective; they can be delivered at-scale, across the rich and poor, urban and rural; and they protect even those that are not vaccinated. The latter – a phenomenon known as the indirect effect, or ‘herd immunity’ – fascinates me. When kids get vaccinated, they get sick a lot less often; and when they get sick a lot less often, so too do their parents, siblings, teachers, caretakers, and so on. Take rotavirus vaccines as an example. Countries including Brazil, El Salvador, and the United States have seen reductions in rotavirus hospitalizations among unvaccinated groups of 20%, 30%, 40%, 50%. It’s one of the many reasons I believe in the power of prevention through vaccination.
In the end, whether it’s Mother Nature’s technology of breast milk, simple technologies like soap or the condom, or more complicated technologies like vaccines – I believe firmly that safe, effective, affordable technologies have a huge role to play in health for the next twenty years and beyond. I hope India embraces them with urgency.
8.What do you enjoy most about working in the health services field? What do you like the least about working in this field?
I love politics, policy, people, and science. That’s what drew me to public health. And through public health, I love the possibility of having making a difference at-scale. One policy, one decision, one innovation can literally change lives. But it is gut-wrenching to witness the poor – I often recall visiting a Musahaar community in Bihar – who at no fault of their own, are vulnerable to diseases that rich people like you and I don’t think twice about. I hate it. At the same time, I am motivated to wake up and contribute in whatever small way I can.
B. These next few questions are on immunisation and prevention.
1.Many say that India will face a wave of non-communicable diseases. What can the country do to prevent this?
This is not an area I know well in the Indian landscape, other than they are serious and on the rise. The good news is that these diseases affect the rich too. So they get attention and resources. Sadly, the more than 1.5 million children dying of diseases like diarrhoea, pneumonia, newborn sepsis disproportionately affect the poor, and so that means less attention, less money. I hope life-threatening diseases like diarrhoea begin to get as much attention as diabetes, obesity, heart disease.
2. Many say that India is a paradox. It manufactures about 50% per cent of vaccines procured by UNICEF for developing country markets. However, about one-third of the world’s un-immunised children are Indian. Your thoughts?
It’s a tragic irony. India is commonly known as a land of contradictions, and you point out a great example. But their prowess in vaccine manufacturing is proof of what is possible in terms of health innovation in India, both for India and for the world. But much, much more needs to be done. There is no reason why India’s routine immunisation system should not be as state-of-the-art and world renowned as its thriving vaccine manufacturing industry. And there is also no reason India should avoid importing safe, cost-effective vaccines that domestic manufacturers have yet to produce.
It’s time for India to double-, triple-, quadruple-down on its efforts to protect kids and families from vaccine preventable diseases.
3.What is the biggest obstacle to universal immunisation? Is it finance, access, or lack of knowledge about the importance of immunisation?
We struggle with this question and continue to learn about a new challenge and new opportunity every day. The immunisation system is a large, complex value chain: from manufacturing and procurement all the way to a mother holding a baby under a tree to be vaccinated using a vial that needs to travels hundreds, if not thousands, of kilometers while being maintained at a specific temperature. It is remarkable.
In my opinion, there is no “single, biggest obstacle” per se. There is a wide range, each important and each interrelated. Whether it is information management and systems for accountability to the vaccine supply chain, the human workforce, and families believing in the value of vaccination enough to invest the time and energy to show up to an immunisation session feeling confident, safe, and proud for that matter.
We tend to dissent the challenges into supply- and demand-side issues. The good news: for the most part, India knows what to do. Thankfully, partners are collaborating to break down barriers to immunisation from multiple, different angles. Leveraging the impressive lessons from India’s polio program to bolster routine services is one example of that. There is no reason the next few years should not remembered as a renaissance for immunisation services in India.
4.Will prevention be led by the government or the private sector or both?
Both. Having the public and private sector partner more strategically and creatively will be a requirement for prevention and public health to succeed in India. Both are at-scale and both complement one another. Take vaccine preventable diseases. The private sector has the freedom and resources to constantly innovate – in manufacturing vaccines, in inventing diagnostics for infectious diseases, in managing an efficient supply chain practices, in seeing and treating patients, for example. The government has the authority and expertise to set child health policy, fund and implement a programs using an army of public, rural health workers, leverage its resources to achieve impact at-scale for communities far-and-wide.
The polio program and the recent progress toward the development of a new, locally invented rotavirus vaccine are two great instances where the power of public-private-partnerships is paying off.
C.We would like to know about your work:
1. 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?
It is serendipitous in many ways. I love science fiction and Michael Chrichton. One of my favorites is a bio-thriller called Andromeda Strain. It lured me into health and infectious diseases. Combine that with my love for public policy and some luck of being at the right place at the right time – here I am: from Arthur Andersen consulting to the CDC in Atlanta and Kenya to the Gates Foundation in Seattle and Delhi.
2. Why this organisation? What most excites you about this organisations’s role in improving health in India?
The Gates family’s vision to improve the human condition and make the world a better place is not a catch-phrase. No idea is too small or too large. It is an organisation that prioritizes optimism, innovation, team work, rigor and urgency; where we are held accountable for impact. Despite the everyday frustrations that come with any organisation, I am proud of the way we approach problems and humbled by the amazing people and partners from across the world with whom we interact. In terms of role, we are relatively young in India and have a lot to learn. Contrary to popular belief, our resources are relatively small compared to what governments and citizens spend, so at minimum, our role is to be a catalytic partner.
4.What’s the best thing to happen since you started working in this field?
The absolute ‘best thing’ has not happened yet. But so far, for me personally: more compassion. It’s easy to get caught up the numbers and conference room debates, forgetting about the family we are trying to serve from afar. Until my time with CDC and the Gates Foundation, I did not have any experience interacting directly with truly poor communities in developing countries. Thanks to working in Kenya and India, that changed. It shook me, and I more compassionate and humble because of it.
5. What might someone be surprised to know about you?
Given how much I talk, I doubt there is much people don’t know about me [laugh]. One might be surprised to know I love American civil rights history, love the power of oratory, and am infatuated with the US Constitution and Declaration of Independence. In fact, my biggest professional regret was not accompanying my MPH and a JD. I think public health is largely about social justice, and the law plays a big role.
6.What do you do when you aren’t working ?
I admit, I am a television-junkie. I also love photography, cooking, travel, and all-things sports.
**end of interview **
Disclaimer: The views reflected here are those of Anant Shah only, and they do not necessarily reflect the views of the Gates Foundation.