“Human lives are at stake because of medical misinformation”

Dr Naresh Trehan needs no introduction. One of the most celebrated cardiovascular and cardiothoracic surgeons of India in an exclusive interview with Deepika Khurana shares his vision for 2020-India’s healthcare, India’s new data policy, role and adoption of Artificial Intelligence in healthcare and dangers of medical misinformation.

Dr Naresh Trehan, Founder Chairman and Managing Director of Medanta – The Medicity is one of the most celebrated cardiovascular and cardiothoracic surgeons in India.

He has not just performed death-defying procedures on numerous ‘beating hearts’ but has also played a pivotal role in reshaping India’s ailing healthcare system.

At 73, Dr Trehan has the same zeal and unwavering commitment, as he had when he moved to the US in 1969 to study heart surgery.

But, after living for about two decades abroad, he decided to move back to India. “I wanted to provide the same standard of cardiac care in India as was available across the globe,” he said.

And, Medanta – The Medicity is perhaps, the realisation of his long-held dream. Today, Medanta is India’s most famous super-speciality hospital and recently, the hospital chain has opened 1000-bed hospital in one of India’s poorest state, Uttar Pradesh.

With over 50,000 successful open-heart surgeries and numerous scientific papers to his credit, Dr Trehan has won just about every award and honour by the Government of India for his distinguished service and contribution.

According to him nothing in life comes easy. “It takes audacious ideation, meticulous planning and obsessive execution to be an achiever,” said Dr Trehan.

In India, there is one government doctor for every 10,189 people and the nurse: patient ratio is 1:483. This implies a shortage of an estimated 600,000 doctors and 2 million nurses.

But despite India’s paucity of doctors, Dr Trehan, a pioneer in the field of minimally invasive heart surgeries is still very bullish about the future of healthcare in India. He believes that AI has advantages in all dimensions of healthcare. “The only way out is the adoption of science and technology.”

In an exclusive interview with Health Analytics Asia, Dr Trehan talks about how India’s new national health protection scheme has been re-defining healthcare access as well as delivery, the role of big data and AI in healthcare and how medical misinformation can have real-life consequences.

Here are excerpts from the interview:

What is your vision for healthcare in 2020?

In this new decade, I see the healthcare sector moving faster and further towards its goal of accessible, affordable, quality healthcare for all. If we widen the aperture to include ancillary sectors, the promise increases for the medical devices industry, high-end diagnostic services and the rest.

Indian healthcare is going to be much more diversified with opportunities in every segment – providers, patients, and medical technology. I see an increased success rate of Indian companies in acquiring Abbreviated New Drug Application (ANDA) approvals, vast opportunities in R&D as well as the growth of medical tourism.

Strong demand, rising manpower and policy support that drive healthcare sector in India will be accentuating factors in 2020 and beyond. In tandem with this, rising awareness, growing incomes, the incidence of lifestyle diseases and increasing access to health insurance are the drivers of demand for quality healthcare.

The number of doctors is on the rise, as is the number of specialities. This resonates in the dual burden of disease, with non-communicable, lifestyle diseases creating a domino healthcare burden.

At the same time, India’s national health protection scheme Ayushman Bharat has been re-defining healthcare access as well as delivery. The country’s competitive advantage lies in its growing pool of well-trained medical professionals.

Personally, I also see significant scope for enhancing healthcare services considering that healthcare spending as a percentage of Gross Domestic Product (GDP) is rising. The Government is planning to increase public health spending to 2.5 per cent of the country’s GDP by 2025.

In fact, the government has already taken some great initiatives to promote Indian healthcare industry: the Pradhan Mantri Jan Arogya Yojana (PMJAY), to provide health insurance worth Rs 500,000 to over 100 million families every year is worth mentioning.

Buttressing this is Mission Indradhanush that aims to improve coverage of immunisation in the country. However, the need of the hour for the healthcare system is to work towards a future where the focus is more on the prevention and early intervention, than the treatment itself.

How about the adoption of innovative solutions by hospitals?

The healthcare sector in India has been growing at a brisk pace, thanks to its improved services, coverage, and effective usage of technology. Besides, the healthcare sector has been effectively moving towards artificial intelligence (AI) solutions.  However, with more exposure to data and technology comes the vulnerability to cyber threats as well. Internationally, 2019 witnessed more than 4.1 billion data records exposed in known data breaches. Out of which, 89 per cent were from the healthcare sector alone. That said, in 2020, the adoption of innovative solutions by hospitals is expected to increase even further.

How data is transforming the healthcare landscape in India?

With data at the centre, there are three important stakeholders in the healthcare ecosystem: patient, hospital and innovator.

Each of them will achieve a lot by partnering. The hospital can keep a portion of earning for CSR and R&D, the patient may get differential pricing model and the innovator can develop the solution faster.

Hospitals with the help of innovators can leverage de-identified patient data for several uses: leveraging technologies like AI, IOT, virtual reality and machine learning.

There is a potential synergy because hospitals don’t have the expertise to develop solutions and on the other hand, innovators have the solutions but they lack the real patient data to validate the solution. This could be used in the prediction of outbreaks, ICU supervision, preventing premature deaths, drug efficacy, remote patient monitoring, chronic disease management, predictive surgical outcomes and preventive healthcare.

What is your take on India’s new data policy? 

There is a nationwide push for data standardisation and data interoperability across the healthcare value chain (primary healthcare clinics, diagnostic centres, pharmacy, hospitals, insurers etc.). For patients, data standardisation provides the freedom to digitally share medical records. Sharing can avoid duplicate tests, reduce medication error, minimise readmission and most importantly, empower patients to choose their caregivers.

The new data policy is conceptualised for planning, development of strategies and general awareness at the national level. Healthcare data sharing will also help in setting the foundation for a nation-level health registry. This is a long-desired goal for effective execution of various public health programs like the Ayushman Bharat.

Hospitals are aware of the potential benefits of data sharing and exploring how to securely exchange information in the value chain. There are, however, challenges related to its implementation, which are relevant globally.

Specific to the India environment, the challenge in most of the hospitals is the non-availability of even digital health records. Running a hospital is not cheap and hospital administrators have to take a tough call on multiple priorities, for instance, either to procure robotic surgery equipment or add new staff for service excellence.

What are the key healthcare challenges in India that you foresee? 

I view the challenges from a simple question: how aware is the Indian population about important issues regarding their own health? Studies on awareness are many and diverse, but lacunae in awareness appear to cut across our country. Answers may lie in low educational status, poor functional literacy, low accent on education within the healthcare system, and low priority for health, among others. What is encouraging is that efforts to enhance awareness levels have generally shown promising results.

Barriers to access in the financial, organisational, social, and cultural domains can limit the utilisation of healthcare services, even in places where they are available.

Another layer is the fact that almost 75% of healthcare expenditure comes from the savings of households, and catastrophic healthcare cost is a cause of impoverishment. The healthcare exosystem and ecosystem have come under stress, with the patient-provider axis being the most affected.

While unreasonable expectations may be at the bottom of much of the stress, it is time for us to recognise that the first step on the way forward is the recognition of the problem and its possible underlying causes.

Among the long list of challenges also lie overpopulation, inadequate infrastructure and chronic nature of many issues which have been festering since long and will take disproportionate effort to resolve.

Our healthcare infrastructure is underfinanced and often short-staffed. The doctor-patient ratio is 1:1700, there is a severe shortage of doctors in the rural areas and the overall healthcare delivery mechanism is seriously flawed.

The country’s contribution to per capita healthcare insurance is also extremely low. Over 76% of the country’s population does not have health insurance. There is a 200% shortage of primary healthcare doctors in rural/semi-urban India. In addition to communicable diseases, we have the double burden of lifestyle diseases.

These are some of the most obvious challenges. As we get ready to face a future full of possibility and uncertainty in equal measure, let us recognise these and other challenges and prepare ourselves to meet them, remembering that the fight against ill-health is the fight against all that is harmful to humanity.

Despite the improvement in diagnostics, India has witnessed an alarming rise in the number of deaths owing to heart diseases. So where do you think we are going wrong?

A combination of factors are at play. Genetics, diet, lifestyle triggers, lack of prevention, lack of treatment, and/or delayed treatment, all converge to create the situation. South Asians tend to develop high blood pressure, high triglycerides, abnormal cholesterol and Type 2 diabetes at lower body weights than other groups. South Asian men are also prone to higher levels of coronary artery calcium; a marker of atherosclerosis that can be an early harbinger of future heart attacks and strokes. This genetic fact plays out in dietary behaviour.

The majority of Indians are vegetarian, a common practice that is widely regarded as heart-healthy. But vegetarians who eat traditional South Asian foods like fried snacks, sweetened beverages and high-fat dairy products are found to have worse cardiovascular health than those who eat what the researchers call a “prudent” diet with more fruits, vegetables, nuts, beans and whole grains (and, for non-vegetarians, fish and chicken).

People who eat a Western-style diet with red and processed meat, alcohol, refined carbohydrates and few fruits and vegetables are also found to have more metabolic risk factors. In fact, much of the country is also adopting a Western lifestyle. Therefore, sedentary lifestyle and occupation — coupled with a diet in which high-calorie, low-nutrient foods are common — are creating a situation in which non-communicable diseases (NCDs) such as heart disease and cancer are common. This is exacerbated by a proliferation of risk factors such as obesity. We attribute many of the deaths related to heart disease to preventable factors such as those mentioned previously.

In addition, alcohol and tobacco are the potential risk factors that can be entirely removed. If mortality related to heart disease is to be addressed, a system must be put in place to encourage the public to reduce preventable risk factors. Also, screening for those deemed to be at risk must be made more accessible. Only through a combination approach to addressing these issues is the problem likely to be managed and potentially overcome.

Do you see a big role of AI (Artificial Intelligence) in healthcare?

In healthcare, AI has advantages in all dimensions be it – OPD, diagnosis or IP settings. Since the inception of Medanta, we have been using robots for surgeries and in the near future, AI-enabled robots will further assist physicians to deliver better surgical interventions. Care providers have to understand that AI is not replacing them but rather empowering them to make a better diagnosis and better decisions.

According to the data provided by the National Organ and Tissue Transplantation Organisation (NOTTO), there have been nearly 300 heart transplantations across India in past two years. Though the increase is tenfold, still if we look at the need, this is just a drop in the ocean. Where do you think we lag?

Roughly, five lakh people die annually in India due to lack of an organ donor but with less than one per million people opting to donate, the organ donation rate in the country is one of the lowest in the world. There is an extreme shortage of organ donation even when people are at end-stage organ failure.

Even though India has the largest population in the world, the ratio of organ donation stands less than one per million population. Contrast this with Spain. It is at the top with a mere 50 per million population.

As a country with high levels of illiteracy and lack of awareness, India might not yet be ready for shifting to an ‘opt-out’ system. This argument does hold ground, especially given the fact that religious beliefs are strongly associated with the dead. Religious beliefs of some communities consider even a post mortem as a desecration of the human body. There are also myths associated with organ donation. To be fair, no such initiative can succeed unless accompanied by adequate awareness among the masses.

It is important to involve influential people such as popular celebrities, sportspersons as well as religious leaders as part of the awareness campaigns. Education and initiatives are the keys. For instance, in 2018, the government-mandated a change in the format of driving license to display whether the individual has pledged his/her organs in case of brain death. Much like the driving license mentions the blood group of the individual; it will also now include a column stating whether the individual consents to become a donor. We need more such measures, on a far wider scale.

I think awareness, education, sensitisation and facilitation are the answer.

With the coming of social media in recent years – fake news and medical misinformation have gained unprecedented amplitude. How do you think we can counteract medical misinformation? 

In the age of Dr Google, we live in a world of unprecedented growth in online media outlets. As a result, news consumption habits have fundamentally changed.

On the one hand, the news cycle has become 24/7, and on the other, social media has blurred the line between truth, facts and fake or distorted news. In addition, quality controls which functioned in the traditional media structure (e.g. editorial boards) have become obsolete in the online world.

Fake news thrives not just because it has the ability to reach millions of people, but because it is easy to relate to. Hard facts do not stir up emotions, fake news, on the other hand, does. In my understanding, the best solution for social media companies is tailoring their algorithms to bury disinformation, or in other words show it to the least users possible. Moreover, deleting well-known extremist accounts spreading disinformation and conspiracy theories could contribute to slashing the supply of manipulative narratives, which has to be done in smaller geographical settings as well.

The spread of bad information has had dire consequences. This is true even of developed countries. In the United States alone, a fear of vaccinations has led to a nationwide measles outbreak: From January 1 to April 29, 2019, 704 individual cases of measles have been confirmed in 22 states, according to the Centers for Disease Control and Prevention (CDC), and the number of cases continues to rise. This is the greatest number of cases reported in the United States since measles was eliminated in 2000. Doctors must work to combat this phenomenon on multiple platforms. We must sound the alarm that “human lives are at stake” because of medical misinformation.

Medical schools and teaching hospitals must also make efforts to combat misinformation.

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