India Alliance Fellow Spotlight: Dr Prashanth Nuggehalli Srinivas
11 Dec 2019
The quest for a society where people could realise healthy lives irrespective of their social-geographical-economic identities—this is what motivates our Fellow in Spotlight for this month. In this interview, we meet Dr Prashanth Nuggehalli Srinivas, India Alliance Intermediate Fellow, who speaks about his work, as a public health researcher, on addressing health inequalities.
You trained as a physician and now you are a public health researcher working to address health inequalities in tribal populations. What motivated you to become a public health researcher?
My love for work in public health can be best described as a happy accident with two punctuations: my initiation into community health at Biligirirangana (BR) Hills as a doctor and my return to BR Hills as a public health researcher. Nearly a decade ago, I remember reflecting back on what took me (then) from a medical college to a tiger reserve.
Since my days at school, I have had a fascination for the natural world of insects, birds, and animals. When I was at medical college, I met a birdwatcher who introduced me to the wonderful world of birds, and I spent many holidays (and class-days too!) at a nearby forest, BR Hills. Upon completing medicine, the only way I could continue to spend time in a forest was to work at the Vivekananda Girijana Kalyana Kendra (VGKK), an NGO founded by Dr. Sudarshan working with the Soliga people of BR Hills. Therefore, my initial draw was not so much the grand idea of health for all, but a personal quest for birds and wildlife.
However, in the work of Dr. Sudarshan and among various wonderful doctors and health workers that I met at VGKK, I found joy and fulfilment in working within community health settings. I suddenly realised the limitations of clinical medicine in improving population health. Dr. Sudarshan’s work had already demonstrated that medical services alone, while vital and important, made relatively limited contributions to overall improvements in health and well-being. Wider social inequalities are rooted in histories, policies, and in societal norms, and these can only be addressed through social movements and collective action. Indeed, the quest for a comprehensive primary health care approach was rooted in such an understanding of social inequalities. At the heart of various community health movements in the 1980s has been the powerful idea of how social action has to emerge within individuals and collectives, especially those at the margins of our mainstream. And, working with the Soliga people in BR Hills I witnessed and learned how health itself and various resources those contribute to better health need long-term, respectful, and empowering engagement within and among communities
Subsequently, I joined the Institute of Public Health (IPH), Bangalore where I trained formally as a researcher and obtained my PhD in public health. After my PhD, when I began to move into a research track, the quest for health equity emerged as both a personal quest and a research goal.
Tell us more about your work.
My work currently focuses on setting up a cluster/team that will do long-term work on improving health equity in India, called the Health Equity Cluster, at IPH Bangalore. Although setting up of the cluster pre-dates the India Alliance Fellowship, it is really the Fellowship that has given life to and allowed me to begin several important research tracks on furthering health equity.
The primary project under my Fellowship is the “Towards Health Equity and Transformative Action on Tribal Health (THETA)” project. Under the THETA project, we aim to first describe inequality patterns at a fine-scale in three forested regions of India, and then develop a clearer understanding of the possible multiple drivers of such inequities, which could vary from one site to another. We hope to develop a conceptual framework that brings in the rich literature that exists on Adivasi issues outside of mainstream public health literature and integrate them into a theoretical understanding of why there is consistently worse-off health and healthcare in Adivasi areas.
Finally, the THETA project aims to work closely with local NGOs and the Soliga people’s community-based organisation to implement one/few health equity enhancing interventions in the next two years.
In addition, collaborations have been set up with nearby medical colleges and with other public health institutions to try and work along multiple drivers of health inequities. The health equity cluster at IPH co-hosts the secretariat for the Health Equity Network India, a network that seeks to move towards a body of knowledge and action on various health inequities in India. The secretariat supports a bimonthly webinar series called Equilogues that invites speakers from across various institutes in the country to present research on addressing health inequities.
Other work of the cluster includes work on mental health in primary health care, strengthening health systems for action on zoonoses using integrated/One Health approaches, and collaborative work to strengthen primary health care in tribal areas.
A survey site of the THETA project in South India
How do you envision the impact of your work?
Under the THETA project, we have an aspiration of setting up a long-term participatory and embedded research centre that could be shaped and led by the Soliga people; this centre can be facilitated by other local actors including VGKK and government health and social welfare departments. We hope that THETA project will result in the setting up of such a centre that, while being embedded and located within community settings will be linked up with medical colleges and Universities. We envision this centre to galvanise engagement of scientists and academia towards improvement of the health of Adivasi communities in Mysore and Chamarajangar districts of Karnataka. Over time, I am hoping that the body of work in the form of publications as well as policy and public engagement will have a positive impact on Adivasi health.
What is your favourite part of working in the field of public health research? What is it that keeps you going every day?
The quest for a society where people could realise healthy lives irrespective of their social-geographical-economic identities—this is my primary motivation to work and persevere in the field of public health. A hope that science and its various applications can help us in this societal journey acts as the addendum.
I recently got an opportunity to give a TEDx talk at a school, as part of a public engagement activity I undertook during my Fellowship. In the talk, I begin with the question on whether health is a matter of chance or a matter of choice. Titled “Giving health a fair chance” the talk delves further into the important challenge of addressing social determinants of health. However, I am immediately aware that science itself is only as effective as the scientist is and hence I hope we in the scientific community can improve our own consciousness about the social determinants of health and marshal the decades and centuries of cognitive and intellectual progress of science towards the task of moving towards a fairer society. To be a part of this wider movement—to be socially responsible and accountable in science—is a source of strength and hope for me. While science is exciting, at the same time, it has a huge societal imperative that requires coalition-building and working across disciplines, sectors, languages and geographies. I am happy that my Fellowship gives me the opportunity to take up this journey.
According to you, what are some of the key challenges in this field?
A major challenge for the kind of public health research we do under the THETA project is that the relative control on variables, which exists in a biomedical laboratory, is not possible herein. This imposes several challenges for which researchers are not typically trained for; my previous experience in community health work thankfully helps me navigate through these challenges.
Another key challenge in pursuing research embedded within community settings is the difficulty in setting up the required infrastructure and processes in limited resource settings. One needs to work closely with community representatives and people whose immediate needs are not research or even healthcare. Often research/researchers are not able to address many of the fundamental issues that are of primary concern in these settings. Therefore, the challenge of setting up a research agenda in a way that sets realistic expectations while incorporating respectful engagement and building relationships and platforms that allow dialogue with the people and community-based organisations is an important one.
Thanks to a collaboration that began during the Fellowship, our team got an opportunity to work with a visiting researcher to examine the nature of power-sharing and dialogue processes that we have established with the Soliga people. We are hoping to share some of the exciting results of this work soon; this will help improve our understanding of participatory research with Adivasi/indigenous communities.
Finally, there is also the challenge of responding to requests for technical inputs and support from the community and local health/government implementers on issues that may not be within the research project lifecycle. Indeed, these are as much challenges, as they are a cross-section of everyday life at district and community settings, where the silos and boundaries that laboratories and Universities offer do not exist!
Survey in progress at one of the houses of the survey site
Has the Fellowship from India Alliance helped you?
The India Alliance Fellowship has been crucial in accomplishing a dream of pursuing research while remaining embedded in community settings. I am unsure if there is currently any other grant opportunity in the country that allows the kind of opportunity that this fellowship offers: the mix of flexibility in funding accompanied with a focus on rigor and excellence in addition to the breadth of coverage across various scientific disciplines.
The fellowship has helped me set up a committed team of people pursuing research interests in health equity. The fellowship has allowed me to pursue the ambitious idea of setting up field sites in multiple remote locations across five states in India and in working with early career researchers at each of these sites.
Early on in the project, I decided to try to provide the kind of mentoring that I received at IPH during my early years as a researcher. I am happy to note that we found committed people wanting to start public health research careers. One among them is Julee Jerang who accomplished fieldwork in and around Pakke Tiger Reserve in Arunachal Pradesh; she hopes to begin a career as a public health researcher soon. A recent article written by Julee about an ASHA worker from Arunachal whom she met during her fieldwork was indeed inspiring—an ode to various health workers working “at the margins of India’s Health system”. Similarly, Yogish, another early career researcher joined THETA to lead the survey component and has over the last two years gained enormous experience in implementing surveys in remote areas.
The nature of collaborative work at IPH’s health equity cluster has broadened during the course my Fellowship; we have established collaborations with two medical colleges and with two national level public health research institutes.
Moreover, the work-outside-host-institute provision has allowed me to strengthen my research collaborations with the Institute of Tropical Medicine, Antwerp, which boasts of considerable experience in health policy and systems research methods.
The THETA project team with local health workers and ASHAs
What changes do you hope to see in the research ecosystem in India that will result in better support for researchers?
While India rightly aspires to reach higher goals of scientific excellence and is well resourced through a network of institutes doing high-quality research, we still lag behind in representing the wide cross-section of our society within our research eco-systems. I believe that the India Alliance has rightly begun to focus on the very important issue of #WomenInScience and has been pushing hard for changing the gender-biased institutional frameworks. Similarly, I believe we must push for a more inclusive research ecosystem in terms of not only inclusion by various axes such as gender, caste, socio-economic status and other vulnerabilities, but in terms of under-funded and under-represented disciplines such as the social sciences, implementation sciences and participatory/community-based research.
At the same time, we also need to aspire for many more in-country opportunities such as the India Alliance Fellowships within large state government universities. I hope that the India Alliance experience serves as a useful learning for setting up similar fellowship tracks in social sciences as well.
What can we do to enhance uptake of research through evidence-based policy?
There is a need for wider dialogue between policymakers and decision-makers, researchers and activists/civil society. Towards this end, IPH has been conducting a biennial conference, the National Conference on Bringing Evidence into Public Health Policy in partnership with state governments and with the National Health Systems Resource Centre, ICMR and other agencies. There is a need for many more such events and platforms that routinely bring together researchers and decision-makers. This will help bridge the divide that currently exists.
Furthermore, higher focus and embedded grants for policy and public engagement are important (such as the Wellcome Trust policy and public engagement grants) that allow researchers and research organisations to devote time and resources for this important activity.
That said, evidence-informed (rather than evidence-based) policy, for me, is a two-way process. While we researchers need to be more pro-active and work on our ability to translate research into products that are of practical use for decision-makers, decision-makers too need to create platforms and/or processes that formally allow evidence to contribute to the policy-making process. The initiative of the Department of Health Research to set up the Health Technology Assessment in India is a step in the latter direction, but the challenge is in achieving this at lower levels, for instance at state and even at district levels. The huge network of medical colleges and state universities offer an opportunity to set up platforms that allow better interactions between academia and decision-makers and perhaps setting up learning sites for such exchanges may help move towards evidence-informed policy.
Finally, if not a scientist, you would be a...