Interview

‘Our doctors need to be taught the skill of listening’

Chandrakant S Pandav has made the linking of science, statesmanship and society his very own life mission. It is the fuel that has helped the good doctor devote long years of exemplary service to a noble and critical cause: the elimination of iodine deficiency disorders in India and South Asia.

Dr Pandav did his medical studies at the All India Institute of Medical Sciences (AIIMS), New Delhi, and McMaster University, Canada, before embarking on what has been a distinguished career in community medicine. During this time, he served as head of the Centre for Community Medicine at AIIMS, New Delhi, and in a variety of responsibilities with national and global organisations.

A prolific writer, a cinephile and closely involved currently with India’s ambitious National Nutrition Mission, Dr Pandav speaks here to Christabelle Noronha. Excerpts from the interview:

You have been involved in India’s fight against iodine deficiency for several years. How has the country fared in this fight and what have those at the frontlines learned from it?

India was one of the first countries in the world to start a public health programme based on salt iodisation to address iodine deficiency disorders. The ‘iodine deficiency disorders [IDDs] control programme’ in India is a public health success story. According to the ‘national iodine and salt intake survey’ of 2014-15, 78% of households in India consume salt that is adequately iodised and 14% consume some amount of iodine (the balance 8% do not have access). However, those of us at the frontlines have learned that our success in eliminating the most common and visible manifestation of iodine deficiency — goitre and cretinism — has proved to be our bane.

I would strongly suggest that our medical students spend at least three months in India’s villages in what we call the village immersion course.”

Endemic goitre and endemic cretinism are only the tip of the iceberg. We need to focus on the invisible manifestations of IDDs. What is not painful and not seen is not considered a priority. The real challenge now is to address issues related to brain development.

Why has public healthcare in India been such a disaster? What are the biggest challenges here and how can they be overcome?

We in this country have had the practice, historically, of following the Indian system of medicine, which is about the preservation of health. Today it is all about curative care. We are losing our age-old heritage and our cultural and social way of life. In the context, the decision by the Union Ministry of Health and Family Welfare to convert sub-centres into health and wellness centres is a new beginning. But if you look at the budget distribution, only 9-10% of the total health budget is spent on public health.

Your involvement with the nutrition push that’s gathering force in India has been considerable. What’s the thinking on nutrition at the policy level and what are the obstacles that have to be dealt with on the ground?

Being a member of the National Nutritional Council, I was involved with the National Nutrition Mission (NNM), launched by the honourable Prime Minister [Narendra Modi] in March 2018. At the policy level the Mission is a visionary initiative to address the nutritional challenges India faces. It seeks to bring about a convergence among various ministries to work in a coordinated manner so that malnutrition can be quickly and progressively reduced.

The key features of this programme are the mobilisation and participation of communities across the country in addressing various aspects of the nutrition challenge. NNM’s goals are to improve the nutritional status of children from 0-6 years, adolescent girls, pregnant women and lactating mothers in a time-bound manner for the next three years. All ministries need to unite under NNM to achieve these goals.

To quote [the late jurist and economist] Nani Palkhivala, “We Indians are excellent solo players but we make a very poor orchestra.” The prime minister’s commitment has been able to work as an invisible hand in conducting this orchestra and, today, 13 ministries have come together on a common platform to address the malnutrition issue.

Achieving the Mission’s goals in such a short time frame is difficult. Most issues related to poor nutrition are intergenerational. Apart from that, social determinants such as water, sanitation, immunisation and, most importantly, behavioural change take time to address.

Nutrition would certainly benefit from the kind of backing that the Swachh Bharat Mission has garnered. Do you see that happening anytime soon?

Like the Swachh Bharat Mission, NNM is also expected to result in significant social, economic and health benefits. The Swachh Bharat Mission was backed by strong political will and inspiring leadership, with the prime minister championing the cause nationally and internationally. Both the missions have found constant reference in his addresses and public speeches, which encourage the masses to be a part of this jan andolan [people’s revolution]. It is critical to maintain progress to achieve goals.

Collaborations between governments and civil society organisations, including philanthropies and nonprofits, have been known to produce some good results in healthcare. Where and how do such collaborations work best, and what do you have to watch out for?

I always advocate the importance of partnerships between government agencies and civil society, international and bilateral agencies, NGOs, academics and universities, and the private sector. I call it the ‘panchsheel of partnership’. This is the principle on which the National Coalition for Sustained and Optimal Iodine Intake works. The Coalition has been instrumental in ensuring greater coordination and synergy among different stakeholders. Its most significant contribution has been to act as a high-level advocacy channel and to provide a platform for regular dialogue.

An anaemia prevention campaign in Uttar Pradesh; India needs to choose health preservation over the curing of diseases

As a former professor of community medicine, what do you make of the current state of medical education in India? What’s the panacea you would recommend to heal what seems to be a broken-down system?

The Medical Council of India has gone through several avatars of transformation. When I entered medical school, the first thing I encountered was a dead body; you could say I started my career of saving lives with a dead body. I think there has to be a dramatic shift in terms of this particular orientation, and it is vital in the early phase of medical education.

I would strongly suggest that our medical students spend at least three months in India’s villages in what we call the village immersion course. They should interact with people on the ground to understand the dimensions of the healthcare challenge this country faces. A second point is about ethics, which has been a challenge for the medical profession in today’s environment. Finally, there’s communication. Effective communication skills have to be taught to physicians. We seem to excel in the practice of all medical disciplines, be it allopathy, naturopathy or homeopathy, but our physicians conspicuously lack sympathy and empathy — and that is a critical necessity.

There’s another issue. The first interaction between patient and physician typically sees the doctor talking for 80% of the time. We need to have physicians listening to what a patient has to say. Our doctors need to be taught the skill of listening.

The major challenges that research and development faces are the failure to invest money, poor governance and poor implementation.”

The perennial problem remains of research and development resources being scarce for conditions that plague poor countries. What, in your opinion, is the way out?

The major challenges that research and development faces are the failure to invest money, poor governance and poor implementation. To address the issue of the developing world’s lack of progress in research and development, it is necessary to train a new generation of policy and programme managers, people from diverse backgrounds. Multidisciplinary work needs to be supported and encouraged at universities and other academic institutions.

It appears that you are busier in your retirement years than when you were earlier. What is it that most interests you, as a professional and a technocrat and at a personal level?

I would like to quote Swami Vivekanada: “Take up one idea. Make that one idea your life — think of it, dream of it, live on that idea. Let the brain, muscles, nerves, every part of your body be full of that idea, and just leave every other idea alone. This is the way to success.” For me that one idea and interest is achieving the sustainable elimination of IDDs and ensuring that every mother and child receives optimal nutrition.

My passion has always been to serve for the greater good of humanity. Maybe that’s why, as a young medical graduate at AIIMS in New Delhi, I left neurosurgery and joined community medicine. I have been blessed with amazing mentors such as Professor Vulimiri Ramalingaswami and Dr Basil Hetzel in my journey and they have moulded me into the person I am. There’s support, of course, from family and colleagues who drive me to achieve even more.

In the field of nutrition, as in politics, the task is to do what is possible without forgetting to do what is necessary. For control of micronutrient deficiency, it is necessary to focus our attention on public health measures, dietary diversification, supplementation and fortification. Believing is seeing. Only when we truly believe that it is possible to do something that we begin to look for ways to do it. Food fortification is possible. As the maxim has it: “If not now, when? If not here, where? If not we, who?”