Indian Medical Story- 25 years, 36,000 postcards

Is India a healthy nation? It is an uncomfortable question, particularly so when it is directed at a nation known for its back-breaking burden of diseases. The question might even be dismissed as an irrelevant one, but that would be a mistake. The issue it raises is very real, but the search to answer that question leads us to the revelation that India is ready to develop an acceptable answer regarding population health.

So perhaps we should rephrase the question: Is India making a determined bid to tear down restrictive, conventional barriers and emerge as a healthier nation? The answer to that question is an unequivocal “yes”.

What should be the focal point of India’s future health strategy? As a starting point, it is absolutely imperative to address a health issue that has been escalating for some time and cannot be ignored any longer. India, along with most other nations on the planet, has fallen victim to a modern-day health threat – non-communicable diseases (NCDs). These are an array of debilitating and deadly afflictions – cardiovascular diseases, cancers, chronic respiratory diseases, diabetes, to name a few – that could cost the world $47 trillion in lost economic output from 2010 to 2030 if urgent action is not taken to prevent and treat them, say experts.

And India’s condition is particularly serious. NCDs are estimated to account for a disturbing 60 percent of all deaths in India, making them the leading cause of mortality ahead of injuries and communicable diseases as well as maternal, prenatal, and nutritional conditions. Furthermore, NCDs account for about 40 percent of all hospital stays and roughly 35 percent of all recorded outpatient visits.

NCDs not only affect health, but also productivity and economic growth. The probability of dying during the most productive years (ages 30-70) of one’s life from one of the four main NCDs is a staggering 26 percent. Moreover, an ageing India whose population is growing more susceptible to NCDs is likely to find the burden even heavier and more destructive than is the case with other nations.

The situation, however, doesn’t have to be as bleak as it looks right now. NCDs are preventable.

Overconsumption of salt, sugar and trans fats combined with lack of physical activity are contributing factors to many NCDs. Increased production of processed food, rapid urbanization and changing lifestyles have led to a shift in dietary patterns. People are consuming foods high in energy, saturated fats, trans fats, free sugars or salt/sodium, while not eating enough fruit, vegetables and dietary fibre such as whole grains. There is sufficient global evidence suggesting reducing salt, sugar and trans fat in the diet can prevent major NCDs and lower disability and mortality rates.

Options exist for actions that policy makers can take today. Businesses may contribute as well through workplace health programmes aimed at prevention, early detection, treatment, and care. Are we prepared to take up this challenge? This is an important question, given India’s healthcare track record.

The clear warnings regarding population health that are resonating across the country have not been able to shake off the indifference of the policymakers vis-a-vis NCDs. They remain heavily focused on communicable diseases and classic “diseases of poverty”, paying scant attention to these emerging health threats, even the most virulent ones. So while NCDs now constitute the bulk of the country’s disease burden, national health programmes to tackle and treat these are very limited in coverage and scope.

India needs a smartly planned, adequately financed and efficiently administered public healthcare system, one that earmarks a major portion of the annual healthcare budget towards addressing NCDs. This will mobilise adequate funds for the delivery of public health interventions, medical services, and counseling of patients.

This system should also explore public and private collaboration to develop innovative financing models, including both public and private insurance that can reduce individuals’ out-of-pocket expenses.

It is imperative to increase spending on preventive care and encourage individual interventions including regular health check-ups, curbing tobacco and harmful alcohol use, reduction of salt/sugar intake and promoting physical activity. All this will limit disease progression and the need to spend significant resources on expensive treatments. Efficient health teams, including nurses and paramedical professionals, also play a critical role here and would respond to the needs of patients with chronic diseases. Investment should, therefore, be made in training of paramedical staff and physicians to detect early signs of illnesses.

Based on latest reports, we are seeing promise for positive change on this subject. The National Democratic Alliance (NDA) government, as of this writing, plans to increase public investment in health from 1 percent of GDP (gross domestic product) to 2.5 percent by 2020, with 70 percent of this being dedicated to primary healthcare.

In other words, under this new national health policy document that is being drafted, the government will ensure that it spends an average 3,800 rupees per capita annually on health as compared to less than 1,000 rupees being spent at the moment at current prices.

This latest draft health policy may not be fully what the doctors and the medical community ordered, or hoped for. Not by far. But it has managed to reach closer to the target than ever before and demonstrates considerable progress. One can hope that these decisions are an indicator that the government is listening to our concerns about India’s greatest health challenge.

In all, he wrote around 36,000 postcards to patients, acquaintances and strangers—explaining basic habits like boiling water and washing hands, and how to prevent commonplace ailments like diarrhea.

“Eighty percent of diseases in India are waterborne and airborne, and can be easily prevented,” Ramayogaiah told Rahul M, a freelance journalist, earlier this year. “All that one needs to do is have clean surroundings and drink boiled water.”

Ramayogaiah emphasised on “preventive aspects rather than curative,” said Rama Devi, who works at Jana Vignana Vedika, an organisation working for the popularisation of science, in Andhra Pradesh, and is a doctor at Gandhi Medical College and Hospital in Hyderabad.

The activist doctor.(Rahul M)

“He often joked that if doctors in India were to go on a strike for 10 to 15 days, the mortality rate during that period would decrease because doctors wouldn’t be writing prescriptions,” she told Quartz. “He would say doctors are creating iatrogenic (caused by treatment) diseases. First they give medicines, that causes side-effects, so more medicines…and that’s a vicious cycle.”

In a column for The Hindu newspaper in 2011, Ramayogaiah wrote:

We, doctors, know for sure from our long years of gruelling studies that most of the symptoms are self-limiting, most others are trivial and very few are serious. In the name of evidence-based medicine and defensive medicine, we order a battery of investigations even for trivial symptoms… Unnecessary tests are a loathsome burden on patients and, at times, result in false positive results leading to unscientific treatment.

“Health is to do with water, nutrition, environment and good sanitation,” Devi said. “Doctors come into picture when a disease takes place. So why do people say that doctors give health, he would say.”

Educating mothers

From 1990 till 1998, Ramayogaiah worked in the paediatric ward of Chittoor’s Government Headquarters Hospital, from where he wrote his first postcard.

At the hospital, he was also connected to the Breastfeeding Promotion Network of India, an initiative to encourage women to breastfeed infants. Roughly 2,500 women used to deliver babies every month, and typically, they would return to their homes in the nearby villages after the delivery.

A postcard on breastfeeding.

“He started thinking how do we know whether the child was getting vaccinated properly, and according to the date,” A. Naga Sujana, Ramayogaiah’s daughter, told Quartz.

Eventually, he decided to collect the addresses of these new mothers from the hospital’s gynaecology department and write to them directly.

“So in a postcard, he would list all the vaccinations, the dates when they were due, and at what age of the child,” Sujana recalled. “He would then sign it with a ‘wishing you good health’ and post it.”

The doctor also ensured the postcards were sent from the hospital he worked at. “That way when women receive these postcards they would take them seriously as they look official,” Ramayogaiah said in an interviewearlier this year.

His idea worked. Women would often return to the hospital for the vaccinations and profusely thank him.

“These were mostly uneducated women. So the postmaster who would be delivering the letter would read them aloud for them,” Sujana said. “At that time, he sent some 1,500 postcards.”

During his next posting, in Guntur, Andhra Pradesh, he sent out another 2,500 postcards on polio vaccination. “He had fallen very sick, and he could not participate in the Pulse Polio campaign, so he wrote postcards and sent them to villages,” his daughter recalled. Pulse Polio is an immunisation programme by the Indian government to eliminate polio. In 1995, the campaign was scaled to cover all of India’s population.

A villager for villagers

Ramayogaiah was born in Mundlapadu, a tiny village in Andhra Pradesh’s Prakasam district, in 1950. He studied medicine at Kurnool Medical College, before graduating in 1968 and then reading for a diploma in child health.

At 27, Ramayogaiah became a government doctor, eventually spending many years at major primary health centres and several posts in the state government.

Araveeti Ramayogaiah.

In 2005, during the twilight years of his practice, he moved to Hyderabad, where he held various posts, including the state malaria officer and medical consultant at the Indian Institute of Health and Family Welfare. He was also the state coordinator for the Breastfeeding Promotion Network of India, and additional director of health, Andhra Pradesh.

“He had no possessions like a house or a car,” Devi said. “He was way too simple.”

Ramayogaiah retired in 2008, but his postcard campaign didn’t. He actually took writing postcards full time.

Soon after, he started a non-profit body, called the Organisation for Promotion of Social Dimensions of Health, and used his pension to collect addresses, write postcards and dispatch them.

Ramayogaiah also launched a blackboard campaign, in which he created 170 health boards containing health tips and information about diseases in easy-to-understand pointers.

These health boards were then sent to schools, colleges and village panchayats.

“Volunteers or school headmasters were supposed to write the health tips on the blackboard in their own handwriting. That would make children curious, and they would read them and learn. That would stay for, say, two or three days. After which, he would send another set of health tips,” Sujana explained.

Last few months

A couple of months ago, Ramayogaiah was found to be suffering from a deadly brain tumour. He was admitted in a private hospital in Hyderabad, but he wouldn’t take any of it.

“When I went inside the ICU (intensive care unit), he told me, ‘We fought all our lives against these corporate hospitals, so this is not right. It’s not necessary, so let me go’,” Devi recalled.

After much deliberation, he was brought to his daughter’s home from the hospital. “I have lived my 65 years happily, I am satisfied with that,” he said during Rahul M’s visitto his daughter’s home in Hyderabad.

A postcard by Ramayogaiah to Rahul M before they met for the first time. Rahul M had found about him through his father, who was Ramayogaiah’s junior in medical college. When Ramayogaiah heard Rahul M was interested in his campaign, he sent one of his trademark postcards to his Delhi office.(Rahul M)

Ramayogaiah passed away on Sept. 06. Now, the volunteers will be using the health boards to write letters and post them on his behalf.

“Nothing will change. Only his signature will be missing,” his daughter said.