K. Srinath Reddy
In the case of the hypothetical Mr. X, a clinician may diagnose acute myocardial infarction. A nosologist may classify the death as coronary heart disease for the public record. An epidemiologist's evidence may point to tobacco consumption, while a social scientist may attribute the cause to inequities in education, income, opportunities, and social networking. An economist may blame income disparities between or within countries.
"A public health professional will say 'all of the above,' and they all need to be attended to," said Reddy, president of the Public Health Foundation of India and professor of cardiology at the All India Institute of Medical Sciences.
Reddy has received India's Presidential Medal, known as Padma Bhushan, and top awards from the World Health Organization for global leadership in tobacco control and health promotion. He is now heading an initiative that involves HSPH to build a public health education, research, and policy infrastructure in India, including nearly one dozen new schools of public health. (See below).
Much attention focuses on identifying individuals at high risk of disease in developing countries and modifying their behaviors through education, said Reddy. If all of humanity is the bell-shaped curve of risk distribution, then the greatest impact for preventing disease will come from concentrating on the bulk of people in the main body. This group is often constituted by low-income countries and may benefit from modest changes in multiple risk factors, he said.
For example, of the 14 million deaths worldwide from cardiovascular disease, nine million now occur in developing countries. By the year 2020, Reddy said, overall cardiovascular mortality is projected to kill 24 million, 19 million of whom will be in developing countries.
"Postcolonial catch-up growth provides a shaky stepladder of health transition," he said. "The globalization tailwind has propelled societies into the vortex of the cardiovascular disease epidemic."
Accumulated knowledge points to a maze of causalities and suggests the necessity of a broad array of public health interventions, including national policies covering community empowerment, food and agricultural policy, pricing mechanisms, the food industry, and food labeling to counter unhealthy effects of international trade and global warming.
"Trade is competing for the minds and monies of people across the world and providing death and disabilities," Reddy said. "Tobacco and unhealthy food products compete with microbes to cross boundaries in search of vulnerable victims."
Public health provides a "grand commons" to gather partners and coordinate effective programs and policies to protect health within the larger political and social context, he said. Health professionals make their best contributions with a focused effort, such as tobacco control, said Reddy, a leader of the WHO Framework Convention on Tobacco Control. The framework has been signed by 140 countries, including the United States, which has not ratified the global health treaty.
To further its cause, public health needs to explain itself better to the public, said Reddy. Clinical medicine is familiar to people as the discipline that provides care to people who need it, but public health determines and tries to prevent what caused the problem in the first place. Public health also needs to distinguish itself better as a "conscience keeper" and agenda setter, he said.
Ultimately, the strength and power of public health rest in the field's ability to gather scientific evidence in an impeccable manner, influence appropriate policy, develop effective programs, and deliver improved health, Reddy said.
—CCM
Public Health in India: Reddy Gives Insight into Second Most Populous Country
In July, the Public Health Foundation of India opened its office in New Delhi. In two years, the Foundation aims to establish two new world-class Indian Institutes of Public Health. The original plans for at least five institutes have doubled. Future faculty are already in training at a dozen U.S. public health schools, including HSPH. The public-private partnership was launched this spring and involves the Indian government, HSPH, the Bill & Melinda Gates Foundation, and others. Foundation President K. Srinath Reddy sat down with Harvard Public Health NOW to give an update.
HPH NOW: WHERE IS THE FOUNDATION IN ITS DEVELOPMENT?
REDDY: In India, health is primarily a state subject. When we went to the states in India, we found an unexpectedly enthusiastic response. Twelve states [out of 32 states and union territories] wanted to partner with us by giving us land and building institutes, expressing not only readiness but eagerness. We are looking at establishing institutes in seven regions over six years. We are also looking at working with public health education departments at schools in other states to strengthen capacity and faculty where we can.
The great emphasis is on a two-year general master's program as the flagship. Initially, it will focus on people employed in the health system. As opportunities grow, we expect fresh graduates from undergraduate, professional, or other master's programs. We expect to wrap up curriculum development by March and to welcome the first entrants to the master's program by July 2008. The location of the first two schools, of the seven proposed, will be announced in mid-January 2007. One of the important priorities is establishing centers of excellence at the institutes-nutrition, health communication, health information technology, and chronic disease prevention and control.
We will offer an innovative, three-year bachelor's degree in public health. In addition to the traditional physics, chemistry, math, and biology, our B.Sc. will cover orientation to public health principles, training in disease and risk factor surveillance, health information technology, basic lab methods, behavior-change communication, and disaster management.
The states are hungry for short- and medium-term training of current employees. We will engage with all states in short-term training. After discussion with the states, the Public Health Foundation of India came up with a program to train 600 to 800 people per year, in two- to six-week programs at each institute. The programs will be customized for different groups. That will start in April 2007. We will also offer a diploma in public health, without the field practicum, for people in policy.
HPH NOW: ARE YOU LOOKING FOR FACULTY COLLABORATORS?
REDDY: We have three strategies for faculty development. We gave a commitment to the government and people that we will not poach existing academic institutions. We will be drawing upon existing senior-level faculty who have recently retired but remain intellectually vibrant. Retirement age, in India, is 60.
We will also draw on visiting faculty in the first three to four years. Some will have formal training in public health and teaching in reputable institutions. Others may not be in academic institutions but have a lot of experience in the field, maybe doing research or working in civil society. We will engage a large number of people from abroad. We have 130 CVs of people abroad who would like to serve on our faculty. The Indian diaspora sees this as a good way of coming back to the home country in a supportive academic environment where they can be productive and continue to collaborate with some of the best institutions in world. Some non-Indians, too, have applied.
We are also looking for younger people with strong academic credentials and attributes to grow into future faculty. This fall, we placed four people in the United Kingdom and 12 people in U.S. schools. In three years, we will have 100 people training abroad. The Association of Schools of Public Health in America waives the tuition fee. We pay for travel and local support, one visit back home, and the current salary to family and dependents so that they are not deprived. When the students finish their master's, we hope they register for the Ph.D. program that will be supervised [by the U.S. and U.K. schools], and come back and join us as research fellows and tutors in programs of relevance to India. We hope that they will be inducted eventually into faculty.
HPH NOW: HOW HAVE YOU BEEN ABLE TO ACCOMPLISH SO MUCH SO FAST? WHAT ARE THE FACTORS IN THESE EARLY SUCCESSES?
REDDY: The political leadership has recognized that health is a key ingredient of further development and cannot be seen as a passive consequence. Also critical has been the increasing level of funding provided for health programs, because of severe capacity gaps [such as the national rural health mission to improve health care delivery in underserved areas].
A second factor of our success lay in our finding some champions, not only for advocating the cause of public health in academic environments, but champions in the political and financial world who believe that health is an important investment for development. They have raised the political and financial capital required to make others believe that it will happen. The Indian government has contributed $15 million. Another $15 million was provided by the Gates Foundation, and $25 million by philanthropists in India. We're now in the process of raising more money. With the free land and money states have offered for construction, the money [budgeted] for two schools can now be spread to [build] four. Since we plan for seven to 10 schools, we will raise the additional resources for them. Our priority now, though, is to ensure that our first two schools are running by mid-2008.
—CCM
Copyright, 2007, President and Fellows of Harvard College
