After 50 years of vital engagement, Harvard Chan is scaling
up its work in India with a new center in Mumbai
The new Harvard T.H. Chan School of Public Health India Research Center, which opened in Mumbai earlier this year, firmly places the School in the midst of the world’s fastest-growing economy—and what will soon be the world’s most populous nation.
The India center is the latest installment of decades of vital engagement with India. Since at least the 1950s, faculty and students have been working in India alongside local experts in medical, government, nongovernmental, and public health settings. The School’s new anchor provides an opportunity to expand those efforts—from reducing tobacco-related diseases and preventing neonatal deaths to cutting pollution-related ailments and addressing the challenges of an aging population—through a combination of research, training, and collaboration on public policy and practice innovations.
A NATION OF CONTRASTS
With more than 1.3 billion people, India’s sheer size and vast contrasts make it a compelling place to carry out public health interventions and research.
While such key health indicators as life expectancy have improved, India is also home to one-third of the world’s poorest people—those living below the international poverty line of $1.25 per day. Chronic problems such as undernutrition and health care disparities are now joined by the challenges of an expanding economy, such as diabetes and cancer.
“India has a unique opportunity to improve the health of all its citizens, as well as to improve global health,” says Kasisomayajula “Vish” Viswanath, Lee Kum Kee Professor of Health Communication, who was born in the southeastern state of Andhra Pradesh and directs the School’s new research center in Mumbai. “By devising scalable interventions that improve the health of both the poor and emerg- ing middle class, we can show that solutions to public health problems in India can potentially be used in middle-income countries around the world.”
“India faces a dual burden of fighting old and new infectious diseases while urgently needing to prevent and address emerging epidemics of chronic disease and injuries,” adds Peter Berman, professor of the practice of global health systems and economics, and co-coordinator with Viswanath of Harvard Chan’s India Health Partnership. “But it also has the opportunity to create new health system models that can assure sufficient quality and be affordable as the country grows.”
Here are some of the areas in which the Harvard Chan School’s India collaborations are helping improve the public’s health:
REDUCING TOBACCO-RELATED DISEASE
Nearly one-third of India’s population uses tobacco in one of its many smokable or chew- able forms, and every day more than 5,500 children under the age of 15 try tobacco for the first time. Glorian Sorensen, professor of social and behavioral sciences, has been working for more than a decade with the Healis Sekhsaria Institute of Public Health in Mumbai on interventions to stop tobacco use among teachers in the state of Bihar and among manufacturing workers in Mumbai. Viswanath has been working with the Salaam Bombay Foundation to promote tobacco cessation by training treatment specialists who can help poor people quit tobacco use.
Both Sorensen and Viswanath, working with Salaam Bombay Foundation’s tobacco intervention—which cultivates life skills and confidence in low-income youth in Mumbai and neighboring areas in the state of Maharashtra—have shown that students enrolled in a school-based program were half as likely as other children to start using tobacco.
India is the second-largest producer of rice in the world, and has the second-largest number of people with diabetes, after China. Donna Spiegelman, professor of epidemiologic methods, and Frank Hu, professor of nutrition and epidemiology, are studying whether substituting whole-grain brown rice for polished white rice could stave off type 2 diabetes and other metabolic complications of a diet high in refined carbohydrates. Working in Chennai, they are evaluating whether consumers are willing to switch and are measuring the effects of brown rice on metabolic biomarkers of diabetes risk. If the intervention succeeds, replacing white rice with brown rice could substantially diminish the burden of diabetes in Asia and elsewhere.
Nearly 40 percent of the world’s stunted children—those whose heights are far below the median for their age—live in India, and approximately half of Indian children are stunted in their growth. S.V. Subramanian, professor of population health and geography, has found that the most important factors for child stunting are mother’s stature, father’s stature, mother’s education, dietary diversity, and father’s body mass index. In separate studies, Subramanian has shown that mothers and children who suffer domestic violence are more likely to be anemic and underweight. These findings underscore the intergenerational cycle of deprivation that leads to children’s growth failure in India and the importance of improving not only nutritional but also social conditions.
A BANGALORE-BOSTON COLLABORATION
India needs nutrition researchers, but few options exist in the country for graduate-level training. Since 2009, researchers at Harvard Chan and Tufts University have been bridging that gap with colleagues at St. John’s Research Institute, in Bangalore, through the Bangalore Boston Nutrition Collaborative. Led by Christopher Duggan, MPH ’94, professor in the Department of Nutrition, the Collaborative offers educational exchanges, distance learning, and an annual short course in international nutrition research methods.
IMPROVING HEALTH SYSTEMS
Out-of-pocket spending on health care is one of the leading causes of destitution in India, with outpatient care more impoverishing than inpatient care in urban and rural areas alike. Moreover, government health services generally provide low-quality treatment, even as they paradoxically waste scarce health care resources. India Health Partnership co-coordinator Peter Berman is analyzing India’s national- and state-level capacities to effectively use public budgets, proposing ideas to get “more health for the money,” working to expand innovative approaches to engage India’s private primary care providers in improving public health, and training leaders in health system policy and management.
SAFE AND EFFECTIVE HEALTH CARE
A key priority for improving population health is ensuring that the care people receive is safe, effective, and patient-centered. The Harvard Initiative on Global Health Quality is engaging with several of India’s top health institutions to measure and improve health care quality. The work focuses on defining what high-quality care is in India.
A key priority for improving population health is ensuring that the care people receive is safe, effective, and patient-centered. The Harvard Initiative on Global Health Quality is engaging with several of India’s top health institutions to measure and improve health care quality. The work focuses on defining what high-quality care is in Indian hospitals, designing indicators to track progress on performance, and outlining strategies to improve upon those indicators.
The School is currently working with public hospitals such as the Post Graduate Institute of Medical Education and Research in the city of Chandigarh and is expanding to other public and private institutions, in addition to neighboring countries, such as Nepal. The effort is led by Ashish Jha, MPH ’04, the K.T. Li Professor of International Health and director of the Harvard Global Health Institute.
SAVING BABIES AND MOTHERS
Although India has seen a consistent decline in infant mortality, a quarter of the world’s neonatal deaths and 15 percent of maternal deaths still occur in the country, and in 2015 India saw the highest number of stillbirths in the world. Atul Gawande, professor in the Department of Health Policy and Management, is the senior principal investigator on the BetterBirth Program, a partnership with the World Health Organization, India’s state and federal governments, and Population Services International to test the effectiveness of a checklist-based childbirth safety program with 140,000 mother-infant
pairs. Co-principal investigators include Katherine Semrau (Ariadne Labs and Harvard Medical School), Vishwajeet Kumar (Community Empowerment Lab, Lucknow), and Bhalachandra Kodkany (Jawaharlal Nehru Medical College, Belgaum).
In early 2017, the program will confirm whether it reached its goal to reduce deaths and improve the outcomes of mothers and infants in hospitals in Uttar Pradesh, one of India’s most disadvantaged states. A pilot study in the state of Karnataka showed that the program, which provides an implementation model for the WHO Safe Childbirth Checklist, markedly improved the use of essential childbirth practices, such as handwashing with soap, appropriate administration of oxytocin, and keeping mother and baby in skin-to-skin contact after birth to maintain the newborn’s temperature.
EASING OLD AGE
In addition to growing rapidly, India’s population is aging. In the coming decades, population aging will require new approaches to work, family life, and caregiving in India. The Longitudinal Aging Study in India (LASI) looks at family structure and social networks; health, health behaviors, and health care utilization; work and pension; housing and environment; and income, assets, debts, and consumption. The LASI team—led by David Bloom, Clarence James Gamble Professor of Economics and Demography, along with co-principal investigators P. Arokiasamy at the International Institute for Population Sciences, India, and Jinkook Lee at the University of Southern California—conducted a pilot study in 2010 across four Indian states: Karnataka, Kerala, Punjab, and Rajasthan.
The full-scale LASI survey will be launched in the fall of 2016 across all states and union territories. The sample of more than 60,000 individuals will be representative of people ages 45 and over and their spouses, irrespective of age. LASI will be the largest survey of its kind in India in terms of its sample size and the rich data that it collects on the various aspects of India’s aging population. Data from the first wave are expected to be publicly available before the end of 2017.
CLEANING UP THE ENVIRONMENT
In India, deadly fine particulate matter in the air has surpassed levels in China, and outdoor air pollution is believed to contribute to half a million premature deaths each year. Francesca Dominici, professor of biostatistics and senior associate dean for research, is leading a program that will involve faculty across the School to enhance research training and conduct studies needed to clarify the links between air pollution and cardio-metabolic risk factors and diseases in India. The goal is to collaborate with experts in urban and rural areas throughout India to generate the data needed to address the unique characteristics of India’s air pollution exposures, and to help local public health professionals conduct high- quality research that can be translated into policy.
India faces daunting gaps in its public health workforce. Harvard Chan is partnering with the Public Health Foundation of India (PHFI), the Indian Statistical Institute, and leading Indian medical universities to expand skills training, degree programs, and leadership development. Richard Cash, senior lecturer on global health, who was recently in residence at PHFI for more than five years as a visiting professor, teaches courses on ethical issues in global health research, infectious disease epidemiology, and noncommunicable diseases, and advises PHFI investigators on their research. This multipronged educational approach will be a model for programs in high-, middle-, and low- income countries around the world.
HARVARD T.H. CHAN SCHOOL OF PUBLIC HEALTH INDIA RESEARCH CENTER
In Fall 2015, the Harvard Chan School opened its new research center in Mumbai. For more information on the School’s projects in India and the goals of the center, visit https://www. hsph.harvard.edu/india-center.