By Neena Bhandari

Growing up on the Christian Medical College campus in Ludhiana [Punjab], Rohina Joshi knew very little about professions other than medicine. She would see her dietician mother educate her staff about the ill-effects of tobacco and her dentist father promote oral health among school children. The amalgamation of all these influences motivated her to enrol in medicine.

In the very first year, she became aware of the power of prevention and realised that one can actually prevent people from falling sick. By her third year in medical college, she was certain that she wanted to do public health or community medicine. She did a Master of Public Health degree from the Sree Chitra Tirunal Institute for Medical Sciences and Technology in Thiruvananthapuram [Kerala].

“However, the 18-month post-graduation course felt incomplete. Post-graduation is a three-year degree and while I had learnt a bit of epidemiology, statistics and the rest, I felt the need to hone in on those skills and gain more practical experience”, says Associate Professor Joshi.

She began working with Prof K Srinath Reddy at the Centre for Chronic Disease Control in New Delhi, who introduced her to the George Institute’s founders. The Institute was starting a new project, the Andhra Pradesh Rural Health Initiative [APRHI], in India and she was encouraged to apply for a PhD at the University of Sydney. She was awarded the prestigious International Postgraduate Research Scholarship in 2003 and moved to Sydney and began working on the APRHI.

ANDHRA PRADESH RURAL HEALTH INITIATIVE PROJECT: In India, it’s not considered auspicious to talk about death, but as it so happened, the Institute’s first collaboration with the Byrraju Foundation was to set up a mortality surveillance. It was to collect data on death and its causes from 45 villages. Early in the project, she realised that there was very little information available about mortality or morbidity. So, they began training health workers to find out who is dying, and then used a tool called verbal autopsy to find out the cause of death.

“The one constant we found on every Village Panchayat blackboard was that child deaths were always zero. The family and primary healthcare personnel didn’t report child deaths for fear of being questioned on the cause of death. But once the health workers and the community began to understand the importance of true data, they became proactive”, says Associate Professor Joshi, who is currently working on a project to improve mortality data in 19 countries.

The study showed 30 percent people died due to cardiovascular diseases, and the second-leading cause of death was injuries followed by infections.

DOCTORS NEED TRAINING TO CERTIFY DEATHS: “The registration of death in India is around 65 to 70 percent, but noting the cause of death is still very poor. Only those who die in the hospitals have a death certificate, but majority of rural people die at home and so they do not have a proper death certificate. Unless doctors are trained to certify deaths, things will not change. If you look at causes of death, the majority will say, “Old age or Cardio-respiratory arrest.” That are not causes of death. Causes of death are conditions like heart attack, stroke, renal disease, pneumonia, tuberculosis”, says Associate Professor Joshi, who is associate professor at University of New South Wales and holds an honorary appointment at the University of Sydney’s Medical School.

She feels health information systems, especially around the most vital events in life – counting births, deaths and identifying causes of death, need to be improved as without this basic data, health programs cannot be planned, monitored or evaluated appropriately.

ROLE OF NON-PHYSICIANS IN CHRONIC DISEASE CONTROL: The Institute’s follow up survey showed that only five percent of the people, who had a heart attack or stroke, were on cholesterol-lowering medicines like Statins. The treatment levels were really poor. While physicians were not readily available in villages, non-physicians were.

The Institute’s Professor Bruce Neal, Professor Clara Chow and Associate Professor Joshi started the Rural Andhra Pradesh Cardiovascular Prevention Study [RAPCAPS] in 2006. They began training community health workers to screen people in the community, provide information on lifestyle-related risk factors and guidance on treatment adherence. This freed doctors’ time to prescribe and manage medication.

Their 2011 study demonstrated that non-physicians like community health workers can be trained to screen, refer and advice appropriate lifestyle advice and follow-up individuals at high risk of chronic diseases.

“If we train Accredited Social Health Activists [ASHAs], supervise them within the correct framework, and evaluate their training, they actually feel very motivated and empowered to take on this new task of controlling chronic diseases – high blood pressure, diabetes, strokes and some cancers. We are exploring the capacity and role of non-physician workers like ASHAs and Auxiliary Nurse Midwives [ANMs] for the control of chronic diseases in India and factors that motivate them to stay within the job”, she adds.

CULTURAL CHALLENGES AND SYNERGIES: Associate Professor Joshi says, “The George Institute is an academic organisation with high research ethics and standards, but some organisations we work with are focused on service delivery, so finding that balance between research and service delivery is a challenge”.

She does find a lot of synergies between India and Australia. “The lessons we have learnt from our work in India can be applied to rural and remote Australia and vice versa. The concepts of task sharing or task shifting between physicians and non-physicians work well in high, middle and low-income countries. The Institute needs to move into the space of translating research into policy and scaling up research projects and collaborate with state and national governments to implement and evaluate programs for chronic disease care”, she adds.

Note: This interview is part of the 10th anniversary of The George Institute for Global Health in India booklet.

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