India Alliance Fellow Spotlight: Yogeshwar Kalkonde, SEARCH Gadchiroli
05 Aug 2019
The district of Gadchiroli in Maharashtra—a hinterland of India—may be considered backward owing the large percentage of its population living below the poverty line. However, a group of physician-scientists working here at SEARCH (Society for Education, Action and Research in Community Health) and their success stories in community health care systems have put Gadchiroli on the world map. In this interview, we meet Dr Yogeshwar Kalkonde, India Alliance Intermediate Fellow, who speaks about his journey from Houston to Gadchiroli to join the team at SEARCH and work for the people.
You trained in clinical neurology in Houston and now you are trying to reduce the burden of stroke in rural Gadchiroli. Can you tell us about your journey from Houston to Gadchiroli?
It was one of the most interesting and meaningful journeys of my life. This journey of about 14000 kilometres from one of the largest medical centres in the world to one of the most under developed districts of India was personally a journey from ‘what I like’ to ‘where I am needed’.
I trained in neuro-immunology and clinical neurology in the US and loved what I was doing. However, a trip to rural Gadchiroli made me realize the pressing needs for public health research and action for people at the bottom of the pyramid. In 2011, I gave up my position in the Department of Neurology at the Baylor College of Medicine and moved to work with SEARCH in Gadchiroli.
What made the transition possible and sustainable was unwavering support of my wife and family and adoption of following: being solution-centric and not problem-centric; keeping frustrations at bay; thinking creatively to arrive at a solution rather than blaming others during tough times; and trying to be the change that I want to see in the world.
(I have shared the journey and my learnings in a talk series—OYE TALKS—available here.)
What motivated you to become a public health researcher?
I was primarily motivated by the healthcare needs of rural and tribal people and the realization of the ability of public health approaches to produce lasting impacts on society.
What are you currently working on?
I am currently working with my team to reduce stroke deaths in rural Gadchiroli. We found that stroke was a leading cause of death in this region and accounted for 14% of all deaths. This was quite surprising, as one would not expect stroke to be a major health problem in a rural, underdeveloped region like Gadchiroli. What was more concerning was that organised stroke care was not available in this district, and we were confronted with a real-life question—how do we reduce stroke deaths in rural Gadchiroli?
Although stroke is a devastating disease, it is also preventable. We had set the goal to prevent strokes in Gadchiroli; the challenge at hand was to figure out a way to do it. Data from developed countries showed us that controlling high blood pressure and diabetes and providing treatment to prevent stroke recurrence prevents strokes. The next challenge was—who will deliver such care in rural, under-resourced setting? To address this problem, we designed a community-based intervention where we trained village women as community-health workers (CHWs) to screen for high blood pressure, diabetes, and stroke using simple tools. The intervention has a mobile medical unit that visits intervention villages once every 3 months, and a physician provides treatment for high blood pressure, diabetes, and stroke prevention. The CHWs then follow up with patients to make sure they are taking their medicines as instructed. We are testing whether this intervention would reduce stroke deaths in a cluster randomised controlled trial.
The trial has started in 2016 will continue until December 2019. Screening of individuals who are 50 years or older in the 32 intervention villages has led to the identification of more than 2800 patients either having hypertension, diabetes or stroke. The results so far have suggested that such a community-based intervention is feasible and acceptable in rural Gadchiroli. By next year, we will know whether this intervention will reduce stroke deaths and this possibility excites us.
A community health worker examining the blood pressure of a patient at her home
What is the impact of your work?
The trial attempts to address a crucial question in global public health research: Can stroke be prevented in rural, under-resourced communities? Stroke is now the third leading cause of death globally and close to 70% of stroke deaths occur in low- and middle-income countries (LMICs). Therefore, reducing stroke deaths in LMICs is important to improve global health. However, no one knows how to do this effectively in rural areas of LMICs.To our knowledge ours is the first trial in a rural area of an LMIC, which tests effect of a community-based intervention to reduce stroke deaths.
The other important thing about this trial is that it is testing a method to control high blood pressure in a rural, under-resourced area. High blood pressure is a leading risk factor for death globally,and it kills close to 9 million people every year. So essentially, we are trying to address one of the leading global risk factors for death in a challenging healthcare delivery setting—Gadchiroli.
Most importantly, this trial has health policy implications for India and other LMICs. The results of the trial can inform the chronic diseases programme of the Government of India. If the intervention successfully reduces blood pressure and stroke deaths, it can potentially be scaled up in other resource-poor settings of the world.
An outreach physician examining a patient in a village clinic
What is your favourite part of working in the field of public health research? What is it that keeps you going every day?
What fascinates me the most about public health research is its breadth! In public health, one has to work across disciplines—medicine, sociology, human behaviour, art, culture, politics, economics, mathematics, computing, management, and others. While working on our research project on stroke, I had to learn human behaviour to understand how people in rural India think, adult education methods to train community health workers, and programme management skills. I even tried my hand at writing scripts for educational movies. All this was real fun!
This continuous curve of learning in addition to the hardships faced by patients in rural and tribal areas keeps me going every day. I want to make a difference in whatever small way possible to improve their health.
A community health worker showing an informative video to a patient with high blood pressure as other family members curiously watch on
According to you, what are some of the key challenges in this field?
We lag in implementation of public health programmes and hence even the best thought out programmes fail to deliver. People who are poor often suffer the most, and this brings up the issue of equity in providing healthcare. Implementation research needs to be significantly strengthened so that fruits of discovery science reach people who need it the most.
Second, there is a need to generate public health and epidemiological data to systematically plan and target health care response in rural and tribal regions of India.
And to take care of the above challenges, we need well-trained public health professionals and scientists.
Has the Fellowship from India Alliance helped you?
Of course, in a big way! In 2013, studies conducted by us at SEARCH showed that stroke is the leading cause of death.When we were in the planning stage of designing an intervention to reduce stroke deaths, renowned psychiatrist Prof. Vikram Patel was visiting SEARCH and he suggested that I apply for the IAFellowship. I did and we got funded. So within two years of identifying stroke as community’s health priority we were already onto solving it. The fellowship funding came at a perfect time and is helping me address one of the burning problems in public health.
Do you have any advice for clinicians transitioning into public health research?
To improve health of people in a sustainable way, public health approach and research is a must in India. The field needs you!
It’s a fantastic and enormously gratifying field but needs patience. You will have to widen your perspective and learn how to diagnose and treat communities instead of individual patients.Developing simple and sustainable solutions is the real mantra! A simple salt solution, called ORS probably helped save more livesthan some of the complicated medical or surgical procedure.
You need to spend significant amount of your time with people to understand their needs and the context so that the solutions developed are people-centric.
What changes do you hope to see in the research ecosystem in India that will result in better support for clinical and public health researchers?
I have a long list of changes!
In India, policymakers, academic institutions, and clinicians should be sensitized to the pressing need and importance of public health and clinical research in India. I believe researchers should choose topics that are relevant to the existing needs of the population and this needs public health and clinical researchers to work closely with policymakers and implementers. Such association will also help policymakers and implementers see the value of public health and clinical research
Creation of career paths in public health and clinical research that clinicians find interesting and rewarding is also an envisioned change. Protected time could help clinical and public health researchers in a significant way. Lastly, research management support systems will be needed so that researchers can focus more on research and less on administrative matters.
What can we do to enhance public partnership in health research?
Here are a few things we can do to start with—
- Health research needs to be oriented towards solving community’s problems so that people will naturally feel an inclination to participate in research.
- Researchers should be sensitized to the importance of public partnership in health research and need to be trained in this task.
- Communication between public and researchers needs to be increased via public engagement sessions and India Alliance is already working on it.
- A majority of India’s population lives in rural areas and know very little about their health problems. The real challenge is to get rural people involved in health research. Culturally appropriate creative communication methods and tools need to be developed for people in rural areas to have such a dialogue.
- Health research funding bodies and journals are increasingly asking about public partnership in research, which I think is a good step.
Finally, if not a scientist, you would be a...
A botanist! I love trees!
Image Credits: Banner photograph by Umesh Jadhav and field photographs by Pranjal Koranne