Hyderabad, India

January 20, 2008

Whew. Catching my thoughts—and my breath—in the sweltering airport departure lounge after six frenzied days in this Southern India city … a week of brilliantly colored saris and filthy rags, fragrant cooking aromas and foul open sewers, Rolls-Royces and three wheelers, quiet meditation and continuous cacophony: Hyderabad assaults the senses. It’s wonderful!

My purpose here, as elsewhere on this trip, was to cultivate prospects for Pitt to strengthen its research and training relationships with academic health institutions. Larry Feick, Director of the University Center for International Studies (UCIS), accompanied me here in his role to build international relationships across the lower campus. Given Larry’s pre-UCIS background in the School of Business, we also paid special attention to Hyderabad academic business and management programs as well as health programs.

I came to Hyderabad to learn more about the small empire of health institutions built from scratch by Professor Pessara Sudekhar Reddy, better known simply as “P.S.” He was born in a district about 150 km north of here and completed his medical degree at the Gandhi Medical College in Hyderabad before coming to the United States where has been a successful Pitt School of Medicine academic cardiologist for more than 30 years. In the mid 1980s, P.S. and a nucleus of Indian-American physicians and friends launched project SHARE, a non-profit organization dedicated to improving medical training and care in the Hyderabad region. SHARE went on to successfully spawn a medical school, a nursing school, a tertiary city hospital, a large community hospital, a state-wide AIDS control program, and a district-wide maternal and child health program. P.S. led the creation of all these programs as he continuously shuttled back and forth between Pittsburgh and Hyderabad. Now trim and patrician as he approaches 70, P.S. speaks softly, never fretting or ruffling. He effortlessly and radiantly glides through Hyderabad’s chaos. Larry and I lodged together with P.S. at the SHARE apartment guest house for the week. P.S. accompanied us on all our meetings, and we ate every meal with him! Although gracious throughout, I’ll bet he was relieved to see us go.

Dr. P.S. Reddy, MediCity founder, looking out at the hospital from the balcony of the medical school.

Medical history hobbyist that I am, I recalled that it was in Secunderabad (the smaller half of the Hyderabad-Secunderabad twin cities) that Major Ronald Ross in 1897 discovered the role of mosquitoes in the transmission of malaria. So on the Sunday I arrived we promptly visited the site, a dilapidated but partially restored, musty, single-storied British military hospital, not much more than a shack. I lit metaphorical incense at this latter-day shrine to Ross’s Nobel Prize-winning work. Later, on Tuesday—an Indian festival holiday—I was given a tour of the India Institute of the History of Medicine. Their prize holdings are dozens of extraordinarily well preserved bound palm leaf Aruveydic texts, some four to five hundred years old. They are now digitizing many of their holdings for online display. In the helter-skelter of daily Hyderabad life, it can be easy to overlook the rich history here.

Overall, I found the potential for medical research and training collaborations here to be terrific. The MediCiti hospital in Medchal district is a 500-bed facility situated on a rock-strewn, 600-acre rural campus (Medchal is the name of the district; the “Med” in Medchal has local language roots, and nothing to do with medicine). The hospital consists of six spartan but clean and adequately equipped four-story buildings. Sixty physicians covering all the major specialties treat inpatients, see about 500 outpatients daily, and teach at the medical college better known as the MediCiti Institute of Medical Sciences (MIMS). Although there is a hospital laboratory, most patients are diagnosed and managed on clinical grounds. The MIMS medical and nursing colleges are also “no-frills.” Each medical school class has about 100 students who are awarded an MBBS and each nursing school class has 60 students who take a three year course leading to a diploma.

Now that the schools are established, P.S. is trying to create an academic culture at MIMS. He has a marketer’s knack for acronyms; the major research projects are named REACH (Rural Effective Affordable Comprehensive Healthcare) and CATCH (Community Access to Cervical Health).

The goal of the REACH project is to provide universal quality health care in Medchal, which has a population of about 48,000. The centerpiece is a program to measure and reduce infant and maternal mortality rates. This is carried out by a cadre of 45 semi-educated women who serve as community health volunteers (CHVs), one per village. The women, who know their village neighbors well, record all pregnancies, births, and deaths. They monitor the health and vaccination status of every infant. All these data, along with GIS mapping of households, kinships, and socio-economic data are regularly reported to the REACH data system. When a vaccination is missed, the local community health volunteer arranges for an on-site immunization. The percent of children who are completely immunized rose in Medchal from the national rural average of less than 50 percent to its current level of more than 90 percent.

Community Health Volunteers assembled to meet with me (they really are much warmer and friendlier than comes through in this photo).

Vaccination in an infant's bum

Moms and their small children awaiting vaccination

The women also conduct a program to provide half-day preschool activities, and a nutritious lunch, for all 2-to-6-year-olds. The children sat on the floor, answering their teacher in unison, then clapping and singing tunes together. Outside, an elderly grandma prepared upma, a bland but nutritious semolinia gruel that the kids seemed to relish. It was orderly, efficient, and loving. I was moved.

Healthy kids in project REACH day care, awaiting lunch

The CATCH program, carried out in collaboration with my old colleague Dr. Patty Gravitt at Johns Hopkins, is a program on HPV and cervical cancer in Medchal women older than 25. More than 2,000 study participants have been screened for human papillomavirus, had a pelvic exam, and a biopsy and treatment whenever necessary. The genius of the CATCH program is that builds directly off the extraordinary REACH data system. The difficulties are those expected in any population, including gaining participation and informed consent, and compliance. The CATCH project has clearly demonstrated that sophisticated and detailed studies can be done in this rural population. This message was clear to me.

Back at the hospital, P.S. and the MediCiti group gave me the honor of cutting the ribbon at the opening ceremony for a modern 6,000-square-foot Research Center that should provide a valuable core facility for MIMS investigators and their foreign collaborators. Ever the promoter, P.S. had an office in his new center ready for me, complete with a “University of Pittsburgh” sign on the door. After the ceremony the entire hospital staff celebrated with a luncheon of kabobs and curries.

Another major SHARE program in Hyderabad is the Andhra Pradesh AIDS Consortium Project (APAIDSCON), a state-wide HIV/AIDS education, prevention, and treatment program at 15 medical colleges. The program is well funded by the US PEPFAR (President’s Emergency Program for AIDS Relief) and has emerged as one of the largest providers of AIDS services, public or private, in the state. SHARE has just constructed a new building that will house APAIDSCON together with an AIDS outpatient treatment ward and a full-service diagnostic laboratory. The doctors I met were young, bright, and enthusiastic.

It so happens that several of India’s largest new biotech companies are in Hyderabad, so I took the opportunity to visit two, Shanta Biotech and Bharat Biotech. Both are modern WHO-approved, state-of-the-art manufacturing plants that market vaccines worldwide, mostly through UNICEF to developing countries. We were taken on a full tour of Shanta Biotech’s diphtheria vaccine manufacturing building, which I found to be scrupulously clean, well run, and compliant with the highest standards.

Shanta Biotech Vaccine manufacturing facility in Hyderabad.

Several other academic institutions in Hyderabad that could be valuable partners:
The University of Hyderabad already provides a home to the Pitt in India program, so we called upon them. The University is led by Chancellor Seyed Hasnain, a brilliant and dynamic microbiologist with a special interest in tuberculosis. He revealed his plans to launch a new Center for Medical Sciences with a focus on human diseases including tuberculosis. Here too there were obvious opportunities for collaboration. However, when I suggested to Professor Hasnain that he should visit Pittsburgh, he candidly proclaimed that he had stopped travelling to the United States for several years now because the hassles of obtaining visas and clearances were simply too great. Instead he travels to Europe for scientific meetings.

Another important new institution for Pitt’s plans in India is the Public Health Foundation of India. The Foundation, headed by Professor Srinath Reddy (not a direct relative of P.S.’s) aims to build, equip, staff, and support 11 new schools of public health all across India. The furthest along is the school in Hyderabad. Land has been acquired, plans approved, and construction is to begin next month. GSPH is already training one Indian physician who is in the MPH program in preparation for his taking up a position as one of the first faculty members at the school of public health in Hyderabad.

At the site of the future Hyderabad School of Public Health (with the project director and the site manager).

Along with Larry Feick, we called upon Pitt Business School Professor Kuldeep Shastri who was in Hyderabad to teach at the private Indian School of Business. The ISB facilities are gorgeous. Kuldeep will teach his course on risk management for just six weeks then return to Pitt. He, like many Indian-American expats who return to India to teach at ISB, uses his time in India to visit with family, in his case his elderly mother.

I am very enthusiastic about the potential for Hyderabad and especially the SHARE as an excellent partner for Pitt global health activities. A whole host of projects could be done on childhood nutrition, tuberculosis, or vaccine-preventable diseases. When I asked the Community Health Volunteers to suggest a top priority, they almost unanimously wanted an effort on motor vehicle accidents. Hair-raising incident after hair-raising incident on the Hyderabad roads left me unsurprised that they answered that way. However, the most productive new studies would be those built upon the currently existing and highly successful REACH maternal-infant cohort. P.S. and I decided to move ahead full speed with a pilot project aimed at creating in Hyderabad a project parallel to the National Children’s Study; Roberta Ness and Clare Bunker have already begun drawing up plans for it.

Now I’m off for Wuhan, China.

Hyderabad Rocks

An odd feature of the terrain around Hyderabad is its rocks. The city and countryside are strewn with boulders and mounds. All are rounded or ovoid, ranging in size from hundreds of meters across to single stones of a few tons and on down. It is commonplace to find a 10-ton boulder perched precariously atop another boulder of only slightly larger size, defying logic – and gravity. Here and there you can spot a formation with yet a third boulder atop. Although I’m sure there’s a rational geological explanation, my own theory is that that such quirky formations must have been placed by an ancient race of giants. No other explanation seemed adequate. The photo above is not mine, but is from a New York Times article that you can read here.