Planning for the Future (1948-1965)
organisation for the promotion of medical research in the country. Since I was
assured of funds at least to make a beginning and since Dr Strode was showing
some interest I explained to him what I had in mind. To start such an endeavour,
I explained, it is essential to have a nucleus of trained personnel. It is the usual
practice to select promising young scientists and send them abroad for training,
and then on their return to build round them. This was a slow process I felt.
Would it not be better to import a teacher, start the centre, recruit personnel of all
categories, and give them the opportunities for getting trained? They would not
only be trained under local conditions but also on problems of national interest.
Those who would make the grade could then be sent abroad for further training.
We discussed these ideas in detail and then I made my specific proposals to Dr
Strode.
I suggested that the ICMR should establish a virus research centre with special
reference to study arboviruses. This was done for two reasons, viz. (a) little was known
about the prevalence of arthropod-borne viruses in India, and (b) because this
discipline would facilitate training in all essential fields of virology, viz. techniques
of virus isolation, their identification, entomological research, epidemiological
research through field surveys and, of course, tissue culture methods. It was felt
that anyone trained in the institution would be able to undertake research in any
aspect of virology.
The role of the Rockefeller Foundation would be to provide for the services of
two experts—in virology and in entomology and provide the necessary equipment.
The salaries of the staff of the Foundation would be borne by the Foundation and
the salaries of the Indian staff and maintenance of the equipment would be the
responsibility of the ICMR. It was envisaged that once the Indian staff was fully
trained, the Rockefeller personnel would be withdrawn, on a mutually agreed date
and the institution would be run as full-fledged unit of the ICMR. Dr Strode was in
general agreement with these ideas. The question of the location of the centre was
to be decided later. We discussed few other matters, and by the time we arrived in
New Delhi, the plane journey used to take three hours during those days, our plans
for the Virus Research Centre were ready. I acquainted Rajkumariji with these
developments and she fully approved the scheme.
The Foundation then deputed, at my request, Dr Theiler, the Nobel laureate,
to discuss with me the location of the Institute. The location was important in
many ways. Climate was important so that breeding and maintenance of a mouse
colony would not pose serious problems. The centre should be readily accessible
by air and rail to facilitate investigations of viral epidemics occurring in different
parts of the country without undue delay. I stipulated only one condition. It should
be in close proximity to a medical college, so that the staff and students of both
the institutions could mutually benefit by this association. Dr Theiler visited many
centres and finally suggested Poona for the location of the Centre.
My World of Preventive Medicine 237
Planning for the Future (1948-1965)
National Institute of Virology, Pune
238 My World of Preventive Medicine
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My World of Preventive Medicine 239
Planning for the Future (1948-1965)
I must relate here an amusing incident. Dr Theiler had a South African passport.
His father had worked in South Africa. In Bombay we had booked his room in the
Taj Mahal Hotel. As soon as we entered the hotel, we saw a notice board which said:
“South Africans and Dogs—Not allowed”. This was rather embarrassing. However,
the problem was solved with mutual goodwill since Dr Theiler was residing in the
USA. Theiler too had a good sense of humour!
Poona was chosen as a venue for the centre. But where would I find
accommodation for it? The problem was, however, readily solved through the
courtesy and active help of Dr B.B. Dikshit who was then the Surgeon General with
the Government of Bombay. He suggested that I should take over a two storeyed
building adjacent to the proposed Lady Students hostel. The building used to
house the Physiology and Pathology departments of the College. The building
was empty since a new building for the college had come into being. Dr Desai, the
Principal of the College was also most helpful. The Maharashtra Government too
readily agreed to the proposal with a rent of a rupee per year. Unfortunately I made
one mistake. I did not have the decision in writing since Dr Jivraj Mehta, who was
then the Finance Minister, said that the arrangement could be finalised at a later
date. This was not done. This proved to be a costly slip which, as subsequent events
had shown a few years later, almost threatened the existence of the Centre.
The Rockefeller Foundation appointed Dr Austin Kerr as the Director of the
Centre. He arrived in New Delhi in October, 1951. It was necessary to remodel the
building suitably to provide accommodation for the various sections of the Centre
on the ground floor and make suitable arrangements for housing the mouse
colony on the first floor. The task was entrusted to the PWD of the Bombay State.
It was not an easy job, what with the arrangements to be made for placing the
necessary funds at the disposal of Dr Kerr and such other matters.
In due course the necessary modifications were made. While the cost of these
alterations was borne by the ICMR, the State Government also levied the so-called
‘centage charges’, about forty thousand rupees as stipulated by the PWD. I asked
the Government to waive the charges but Dr Jivraj said that according to rules the
amount had to be paid by the ICMR. Of course, I did not argue thereafter, but I knew
I would be hard pressed to find the money from my current budget. Eventually,
after much correspondence the amount was paid. However, I thought there was a
way out. At the formal opening of the Centre by Rajkumari Amrit Kaur, I requested
Dr Jivraj to be present. The function was in the afternoon. I had invited him to
lunch. There I asked him if it would be possible for him to announce a donation of
Rs. Forty thousand as a gesture of goodwill of the Bombay Government. “Is that the
game, Pandit?” I said it would be a fitting gesturer on behalf of the Government.
He smiled, put in a call to Bombay, talked to his secretary, and later announced the
donation at the formal function.
240 My World of Preventive Medicine
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However, to recruit the technical staff for the Centre was no easy matter either.
Dr Kerr took the opportunity of visiting many institutions in India to scout for suitable
talent for the VRC. Initially, on the recommendation of Dr Dikshit, we recruited one
young medical graduate, Dr Shah, to start work at the Centre. Ultimately when the
equipment arrived from the USA, the Centre started functioning.
The first task was the immunity reconnaissance survey to get an idea of the
spectrum of virus antibodies present in the country. I also suggested that the
Centre should run a sort of training course in virology. My idea was to ascertain
who would be interested in virology, particularly from the staff of different medical
colleges in the country. It was envisaged that after training they would start their
own ‘cell’ in virology in their respective institutions. I found, however, that Dr Kerr
was not too enthusiastic about starting such a course probably because he thought
it would be too early to do so since the Centre had not fully developed for such an
effort. Indeed, he made no secret of his views for he often told the students, as I
learned later, that he was essentially a ‘mouse breeder’ and not a teacher! Perhaps
there were other reasons. While talking to him I found that he had the impression
that the Virus Research Centre in Poona would only be a temporary organisation
and when the All India Institute of Medical Sciences comes into being in New
Delhi, the Centre would be transferred to Delhi! Of course, I had never thought
about it in this way, and I had to set his doubts at rest by writing to him that the
Virus Centre was a long-term project and that the ICMR would continue to finance
it for a number of years!
Anyway the course was started. The first batch consists of students, selected
from various institutions. The course was appreciated by them!
Those days I did not like to miss an opportunity to be present when field
investigations outside Poona were undertaken by the Centre. One such assignment
for the Centre was the investigation of an epidemic of encephalitis in Jamshedpur.
It was considered at the time to be of arbor-virus origin. I had paid a number of
visits to Jamshedpur to acquaint myself with the work and I was rather impressed
with the efficiency with which the work was carried out. When mosquitoes were
considered to be involved in the transmission, the team adopted anti-mosquito
measures in half of the town and then studied the occurrence of cases in both
the parts. Ultimately, the arbovirus aetiology was abandoned and attention was
devoted to enteroviruses as possible causative agents. The team did succeed in
isolating a virus—the “Pushpalata” virus, named after the patient. Even so, its
aetiological role could not be determined.
As Director of the ICMR, I brought about a comprehensive report on the work
done to serve as a reference document for further work. As events turned out, the
epidemic encephalitis became a major problem later involving other cities, e.g.
Nagpur and Lucknow. The ICMR did arrange investigations in these areas, but in
spite of lot of effort the precise nature of the disease and its aetiology could not be
determined. This was the situation till I retired!
My World of Preventive Medicine 241
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The story of the Kyasanur Forest disease (KFD) virus
When the Centre was busy investigating routinely the problem of Japanese
B encephalitis in Vellore and conducting serological surveys elsewhere, it received
information which to my way of thinking, was a bombshell! Dr Ramachandra
Rao who was touring the Mysore State in connection with the malaria situation
there brought the information that there were reports of monkey deaths in large
numbers in the Kyasanur Forest region. It was, I think on a Saturday afternoon
that Dr Telford Work telephoned to me about it. We both decided that the cause
or causes of monkey deaths in that region must be investigated on a priority basis
for, according to our knowledge then, the only infection which could do this was
the yellow fever virus!
On the phone we worked out the strategy. Dr Work asked the Unit working on
JE in Guntur area to proceed to Shimoga district. I was to join the Party, Dr Work
and Dr Trapido, in Poona, and we were then to proceed to Bangalore by car.
In Bangalore, we first met Shri P.V.R. Rao, ICS, the Chief Secretary of the State.
We were good friends. We explained to him the purpose of our visit and what
was at stake and what we wanted to do. We wanted permission to shoot normal
healthy monkeys in the forest region, since there was a ban on shooting monkeys.
We also explained that our unit would be reaching Shimoga that day and would
be working in the forest area to investigate the cause of monkey deaths and study
cases of illness in the locality. We, of course, apologised profusely for having gone
to the forest without prior permission of the Government. We wanted immediate
action, since we were proceeding on the hypothesis that the cause of death in
monkeys might be the yellow fever virus! Shri Rao was most sympathetic and
promised all support. He was going to send a wireless message to the police
regarding shooting of monkeys, and for rendering all help that was necessary.
We were in the Kyasanur Forest the next day. After a little inspection, we
selected a site to build “machans” in the forest on suitable trees to trap mosquitoes
at different heights. We were standing at the foot of the trees all day till a heavy
shower in the evening which necessitated our return to Shimoga.
However, the day had its own adventures. A villager brought a dead monkey
for our inspection. Post-mortem was performed immediately by Dr (Miss) Sharda
Paul on the forest floor! The specimens were collected and transported to our field
station at Vellore where Dr Dandawate (Sub-Asstt Surgeon) was in charge. After
preliminary testing, the material was transported to the Centre in Poona for final
studies. This arrangement was made for expediting despatch of material to Poona
under proper conditions of storage.
As we were about to leave the forest, we were accosted by the police for
infringing rules about shooting monkeys. We had to hold a conference to explain
all the facts. They had not then received the wireless message from Bangalore.
242 My World of Preventive Medicine
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The Kyasanur Forest Disease (KFD) virus: From discovery to 243
making vaccinMey.World of Preventive Medicine
Planning for the Future (1948-1965)
As we reached the Shimoga guest house in the evening we were horribly
surprised to find that we were covered all over with tick bites. In our discussions
that night we did express our apprehension that the disease might turn out to
be due to tick bites! We discussed the steps to be undertaken for the study of the
disease in toto, including the establishment of a small hospital for the treatment of
patients and such other matters. Next morning I returned to New Delhi.
Within two or three days after my return to Delhi, I received the message
from Dr Work that three of the technicians working in the forest had gone down
with the disease! This was bad news for there was the fear that others might also
get the infection. It was decided, therefore, to call a Conference of workers in the
field and explain to them the situation, emphasising till the nature of the infection
was known, it would not be possible to take any satisfactory control measures. In
the circumstances, they should decide if they would volunteer to work. We were
very happy to note that all of them agreed to work irrespective of the dangers
involved! they said they would not let their colleagues down who had suffered
from the disease. Within another two or three days, Dr Dandawate caught the
infection while working in the laboratory in Vellore. He had a severe illness and
had to be hospitalised. He made good recovery and since he had recovered from
the infection, and could, therefore, be immune to it, he became a key figure in the
investigations.
I reported these developments to the Ministry and suggested that those who
had worked under these trying circumstances should be rewarded in some way,
possible by giving them two advanced increments, sort of ‘battle field promotions’!
The Ministry did not agree. It was suggested that the Ministry would write personal
letters of appreciation to each of the workers. However, being annoyed, I did not
pursue the matter further.
In the meanwhile, the workers at the VRC succeeded in isolating the virus
which turned out to be one akin to the “spring summer encephalitis virus” isolated
by Russian scientist. This was, I think, the first time the virus was isolated and
identified within a short period of time, i.e. only 11 days since first information
was received about the disease. This was possible not only because the work was
organised meticulously but also because of the availability of necessary antigens
for serological tests and above all the presence of trained staff in situ which could
process the material with competence!
While these investigations were underway, Mr. Dean Rusk who was the
President of the Foundation at the time came to Delhi. He expressed the desire
to visit the Poona Centre and acquaint himself with its working. I made the
arrangements and suggested that he should visit alone and form his own opinion.
He came back to Delhi. Rajkumari Amrit Kaur had arranged a lunch at the
Delhi Gymkhana Club. I was also invited to meet him. Unfortunately, I was a
244 My World of Preventive Medicine
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bit late in reaching the Club. The guests were seated on the lawn. As I walked
towards the guests, Dean Rusk spotted me and came to meet me. He expressed
his satisfaction at the work which was being done and said that while the staff
was working throughout the night, they had to come long distances from their
residence to work. “Why can’t you provide residential accommodation nearby?”
he asked. I explained to him the situation. I did not have enough funds at the time
for purpose. “Supposing we build it for you, would you agree?” he replied. I said, I
would, but it would be better if we consulted Rajkumariji in the matter. We walked
towards where she was sitting and explained to her our proposal. She readily
accepted the offer! However, the question of finding a suitable site for constructing
the building was always there. I had an eye on the plot of land opposite the
Ladies Hostel. It was, I was told, reserved for the Principal’s bungalow. It was big
enough and I thought that if a small corner adjacent to our laboratory was given
to the Centre, there would still be a fair sized plot suitable for constructing the
bungalow for the Principal. I had to run again to Dr Jivraj, and again he obliged
me by releasing a portion of the land for the Centre’s requirements! A building
housing four flats, was duly constructed with provision to build two more on 2nd
floor. The flats were spacious. Since the Health Ministry in Delhi was rather uneasy
that such accommodation was made available to the comparatively junior staff, I
had to point out that the same staff junior today would be senior tomorrow, and
would continue to occupy them!
Once the virus was identified as that akin to the Russian spring summer
encephalitis virus, the question arose as to how that virus was introduced into
that region so far south in the forest of Mysore State! It was considered “logical”
to assume at the time that it might have been introduced into the country by the
migratory birds from Siberia!
The role of bird migration is indeed interesting. We owe much of the
information in this regard to Dr Salim Ali who has studied the problem in some
detail. The birds do not cross over the Himalayas, but take a detour and reach the
adjoining area of the Rann of Kutch and Saurashtra. As stated by Salim Ali, “The
current of migratory birds passes over the northwest frontier province, Afghanistan,
Baluchistan and Sind, beyond across the Arabian Sea and over southern Africa.
Most of the African wintering species pass over Kutch during September and
early October. They come in great waves during their temporary sojourn and are
completely gone again within the course of few weeks. Kutch is a veritable cross
road for all these migrating streams”.
It would be interesting here to record here that Drs Kerr and Gatne carried out
serological investigations of random samples of blood of residents in Kutch and
Saurashtra and found the presence of antibodies to the Russian spring summer
encephalitis virus! The finding was further confirmed later by Dr Work at the Virus
Research & Centre. As I look back, I must confess that this hypothesis of the role of
My World of Preventive Medicine 245
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migratory birds did dominate our thinking for some time. If the migrating birds
could be implicated in the introduction of infection, then the local bird fauna
could also be involved in the transmission of infection within the region and even
beyond the local forest area. There was also the finding that the area involved
initially as the main focus of infection was gradually extending. Hence it was
considered necessary to think about measures which would contain the infection.
There were no recognised methods of tick control. One member of the staff, Dr
Trapido, the entomologist of the Rockefeller Foundation suggested burning of the
undergrowth in the forest. Dr Work tended to agree with the suggestion. However,
there was the risk of some trees in the forest also being affected. According to
them, the risk was worth taking, and “there was the need to act quickly”, they
argued. Otherwise, it might be too late. “What is the use of bolting the stable door
after the horse has bolted?” they argued.
Of course, one could not adopt, or even suggest such measures without
consulting the Government of Mysore. Hence it was decided to call a meeting of
officials concerned to discuss the issue.
This was done. The meeting was presided over by the Health Minister of
the State and lasted for three days. A comprehensive agenda was drawn up for
discussion. At the end of the meeting, I summarised the whole proceedings.
I had to point out what was at stake. If the infection was not stamped out in
the comparatively small area of the forest affected, there was the likelihood of its
spreading, not only throughout the forest, but also all along the Western Ghats, and
may ultimately reach the neighbourhood of Poona! Indeed, we were apprehensive
of that happening, for as the days passed the affected area was enlarging as was
evident from reports of monkey deaths occurring in them. Indeed in early 1957, the
disease was confined to an area of one square mile. By about April it had enlarged
to 130 square miles, and by August to 471 square miles!
The meeting, however, only helped the Government to appreciate what
was involved but no final decision could be taken. The cost of burning the
undergrowth was considerable. When the estimates were drawn up, there were
further discussions in Delhi. “Would you guarantee that the proposed measures
would succeed?” they asked. I could give no such assurance and the proposal was
dropped.
The only approach for the prevention of the disease in the population was
the use of a vaccine. The problem was, in a sense limited, in that only those who
had to work in the forest had to be protected. The use of the Russian vaccine was
not considered feasible, and it was ultimately decided to make the vaccine from
the local strain. The Rockefeller Foundation suggested that they could arrange to
make it at the Walter Reed Institute in Washington. While we agreed to do so, we
felt it was essential that an Indian member of the staff should be associated with
the production so that eventually it could be made in India.
246 My World of Preventive Medicine
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The problem was, whom to depute for this purpose. We knew that to work
with the virus was hazardous. The person to be sent must be immune to the
infection. The only person at the time who was suitable was Dr Dandawate, who,
while in Vellore, as stated earlier, had contracted the infection and had recovered.
He was to be sent on a fellowship. But the rules of the Foundation did not permit
his selection since he was not of the required grade. To get over the difficulty I
revised his grade and sent him on the fellowship!
Investigations on the Kyasanur Forest disease have been continued ever since.
The role of birds, cattle, small forest animals and the like was investigated. The life
cycle of the bat involved has been worked out; yet no satisfactory control measures
have been developed. The vaccine originally prepared did not appear to have
adequate immunising value. In the meanwhile, the disease is slowly spreading and
now the affected area occupies 1600 sq. kilometres! The only hope lies, so far as I
can see at present, in the development of a suitable vaccine.
While these investigations were in progress, and also other problems that
were brought to the notice of the Centre, there were some changes in the staff. Dr
Kerr returned to America and Dr Work was appointed in his place. I had excellent
rapport with him and had frequent discussions with him both in scientific and
administrative matters. When he went back to the States Dr Anderson was
appointed as the Director. However, in the meanwhile, the Rockefeller. Foundation
suggested that I should take over the Directorship of the Centre. The Foundation
wrote to the Ministry of Health to that effect, and offered to meet my salary also.
I declined the offer. Then Dr Morrison of the Foundation met me in my office
to discuss the proposal. He pointed out that it would be advantageous in many
ways and that I should accept the post, since eventually I was thinking of retiring
in Poona in any case. I explained to him my point of view and finally said that
since I had planned the institute, I would not like to be the beneficiary of my own
planning! When he tried to discuss the matter further I had to intervene by saying
that an ‘article of faith was not open to discussion’. So that was that.
I am happy to state that before I retired from the ICMR, the Foundation had
ceased its association with the Centre, as was envisaged in the original agreement,
and the Centre is now being run entirely by the ICMR.
My World of Preventive Medicine 247
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II
Establishment of a Centre for research in poliomyelitis
In December 1947 I was in New Delhi in connection with the IRFA meetings.
When I called on Dr Jivraj Mehta, he informed me that there was a severe epidemic
of poliomyelitis in the Car Nicobar Islands in the Bay of Bengal and the mortality
rate was very high. Subsequent investigations had shown that there were about
800 cases in a population of about 10,000. “Was there not the possibility of the virus
being introduced into India?” he asked. I was not acquainted with the poliomyelitis
problem in the country. I did not have to deal with it in the Madras Province. True,
cases of poliomyelitis were being reported occasionally, but I did not know the
magnitude of the problem and had not the faintest idea, which type or types of
the virus were responsible for the disease in the country. I felt this was a good
opportunity to start looking into the problem.
I, therefore, suggested to Dr Jivraj that steps should be taken to investigate
the epidemic in Car Nicobar, and suggested that it would be preferable to
send a team from the Army for the purpose. However, I also suggested that an
orthopaedic surgeon should be included in the team. It would appear that the
main occupation of the inhabitants of the Island was to gather coconuts which
meant that the people had to climbe the coconut trees. It was obvious, therefore,
that for any rehabilitation programme, inclusion of an orthopaedic surgeon could
be an advantage. I knew Dr M.G. Kini, Professor of Orthopaedics in the Stanley
Medical College, was interested in the problem and suggested that he be included
in the team if he was willing to go. Fortunately, Dr Kini readily agreed to be a
member of the team. It was also agreed that I should send a technician from the
Institute to collect samples of stools for the isolation of the virus in the laboratory.
Dr Mehta readily agreed to these suggestions. He also arranged to send an iron
lung from the medical stores depot in Calcutta to treat paralytic cases if such a
procedure was needed. The team did excellent work.
From the material brought to the King Institute, I could isolate the virus by
the intranasal inoculation in monkeys. I believe this was the first attempt in India
to isolate the virus. Started in this way, it would sound as if it was a big discovery.
Needless to add that anybody could have done it if only he knew when and what
to observe in monkeys after intranasal inoculation of the material, for in every case
frank paralytic symptoms need not appear.
When Dr Kini returned to Madras we decided to study the polio situation in
the city. Dr Kini analysed the material available in hospital records and it was noted
that there were over sixty cases of paralytic polio admitted to the hospital during
the year! Later from a newly admitted case in the hospital, I could isolate the virus.
The virus so isolated, went through many passages in monkeys. Unfortunately we
248 My World of Preventive Medicine
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could not proceed with the work as I left for New Delhi in 1948 to take up the
appointment of the Secretary of the Indian Research Fund Association. This was,
however, the beginning of my association with the polio problem in the country.
Soon after, there were reports of increased incidence of poliomyelitis in Bombay.
They called it an epidemic, since over 200 cases had been reported during the year.
I felt there was need to organise a comprehensive investigation into the problem
by establishing a research unit for the purpose. I also felt that the Haffkine Institute
was the proper place for the purpose. When I wrote to Gen. Sokhey, the Director of
the Institute, in the matter, I found to my surprise that he was very lukewarm about
the proposal. It was an infectious disease, and since the Institute was involved in
the manufacture of biologicals, it would not be proper, he felt, to have the unit
located in the Institute!
Since I was keen to have the unit in Bombay, I decided to discuss the matter
with Dr M. D. Guilder who was then the Minister of Health of the State. He received
me cordially and expressed his full agreement on the need to have the unit in
Bombay. I suggested the Pathology Department of the Grant Medical College
as a suitable place to locate the unit. “Have you discussed this question with Dr
Gharpure?” he asked. I said I would do so, if I had his concurrence.
He immediately got in touch with Dr Gharpure and asked him to come
immediately to his office to see him. As soon as he arrived, Dr Guilder said, “Dr
Pandit is here in connection with the polio epidemic in Bombay. He wishes to
establish a unit in Bombay to investigate it. I am fully in agreement with the
proposal, and I think it could be set up in the Pathology Department of your
college under you. He will provide the staff, of course, but Government will also
give further assistance, if required”.
Dr Gharpure readily agreed to the proposal. However, I was a bit embarrassed
at this for I felt guilty in not having discussed the question with Dr Gharpure before
seeing the Minister. However, Dr Gharpure and I had been good friends ever since
our college days and I knew he would not only not misunderstand me but would
also wholeheartedly support me.
Dr Gharpure plunged himself wholeheartedly, indeed with the zeal of
a fanatic, into the affairs of the unit. He appointed Dr Dave on the staff of the
Unit. Government of Bombay kept its words and gave all the necessary help.
On retirement from the Grant Medical College, Dr Gharpure took the Unit to the
Haffkine Institute. The ICMR owes a lot to these two workers in making the Unit
one of the most successful units of the ICMR. It was because of their efforts that the
Government of Bombay approved of the idea of manufacturing polio vaccine in the
Haffkine Institute — a proposal initially supported by Dr Sabin, the discoverer of the
oral polio vaccine. Later, however, he suggested that since Conoor had developed
all the facilities for the purpose and was ready to commence manufacture, a
second centre in Bombay would not be necessary. I must confess that, at the time,
My World of Preventive Medicine 249
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I was inclined to support Dr Sabin’s view and felt that the contemplated building
for the manufacture of polio vaccine in Bombay could as well be used for the
manufacture of other virus vaccines, e.g. the measles vaccine. Alas, how wrong I
was, as the subsequent events have shown. If the Haffkine Institute today is in a
position to manufacture polio vaccine, it is entirely due to the pioneering work of
these workers, Dr Gharpure and Dr Dave.
I may mention here that while the arrangements for the establishment of the
Unit in Bombay were being finalised, I reported the developments to Dr K. C. K. E.
Raja who was then the Chairman of the Scientific Advisory Board of the ICMR. He
suggested that I should prepare a Memorandum on poliomyelitis indicating the
present state of knowledge about the disease for the guidance of the public health
workers in the country, with special reference to vaccine prophylaxis since vaccine
for its prevention had just been introduced by Salk in USA. The Memorandum was
prepared jointly by me and Dr Ramalingaswami who had joined my staff as Assistant
Secretary. The Memorandum was published in 1955. In that Memorandum, we
gave our views, based on existing knowledge, regarding the use of the vaccine for
the prevention of the disease in the country. Some relevant extracts are given here
for record.
Pages 29
“...Is the problem of poliomyelitis in India of such magnitude as to warrant
the institution of a mass control programme with the expense and effort involved
in instituting it? Existing evidence, as recorded above, is hardly in favour of such
an undertaking, especially when there are many more pressing problems which
require urgent attention in the country”.
Pages 30-31
“While the importance of gathering further knowledge before embarking
on a vaccination programme on a country wide basis has been stressed above,
situation might arise where it might be contended that the use of the vaccine
even now in some areas would be justifiable, as for example, in the presence of
periodic severe epidemics. Protection of susceptible children in the age group 6
months to 3 years will have to be undertaken to meet such situations. This would
imply that the above mentioned age-group would behave more or less similarly
so far as the production of antibodies is concerned to the older age-group of
6-9 years in whom the efficacy of the vaccine has been demonstrated in the
USA. Specific information on this point is not available. In general, it is perhaps
true to say that the immunological response of very young children to active
immunisation of any kind is rather irregular and of a lower magnitude than that
of the higher age-groups. It must also be remembered in this connection that
the size of the infective dose may vary between India and the USA in view of the
different hygienic conditions prevailing there. Since immunising dose has some
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relation to the infective dose, the American experience so far available may not
be totally applicable to Indian conditions. Further, if a vaccination programme is
instituted, the question would arise whether it would affect adversely the general
picture of poliomyelitis in India.
It is presumed, of course, that environmental conditions present in such areas
will not be altered materially in the next few years violently disturbing the ecology
of the natural infection which today favours the widespread dissemination of
the virus in the community and consequent continuous immunisation of its
members. It should be remembered in this connection that the number of non-
paralytic and abortive cases of poliomyelitis in the community will not be reduced
as a result of vaccine prophylaxis and that they still continue to excrete the virus.
In these circumstances, the expedient immunisation of susceptible individuals
will not be expected to alter the pattern of immunity of the various age-groups in
the population concerned. Whether such a procedure could be within the means
of any local authority, from the point of view of the cost involved in organising
such a campaign, is no doubt a matter for that authority to consider. Lastly, the
question of importing the vaccine for such trials has to be considered. Obviously,
the vaccine, if imported from abroad, must confirm to the rigid standards with
regard to safety which have been recently prescribed by the USA Government.
The ultimate safety and the efficacy of the new vaccine has yet to be assessed.
IN VIEW OF ALL THESE CONSIDERATIONS, ONE CANNOT ESCAPE THE OVERALL
CONCLUSION THAT IT WOULD BE WISE TO ADOPT A JUDICIOUS AND EVEN A
CONSERVATIVE ATTITUDE AT THIS STAGE TOWARDS THE WHOLE PROBLEM OF
VACCINE PROPHYLAXIS UNTIL MORE KNOWLEDGE HAS ACCUMULATED ON THE
MANY QUESTIONS POSED ABOVE.”
How valid are these views today? The situation must have changed
considerably. The Polio Unit in Bombay had gathered a lot of information on
various aspects of poliomyelitis in India. Besides many other investigators
had also published their findings on different parts of the country. In view of
the information thus available, I had suggested to Dr Gharpure to revise our
Memorandum and bring it up to date. I wanted the Memorandum to be a
comprehensive one summarising the work done by several investigators in the
country. This, I thought, was necessary in order to define our policies regarding
the use of vaccine in the country. As I have said on one occasion, in all human
endeavours, it is necessary to ‘pause, ponder and then proceed’. Unfortunately, Dr
Gharpure could not complete the work before he died.
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III
Establishment of Tuberculosis Chemotherapy Centre
The idea of establishing a centre, in India, for the study of effectiveness of
chemotherapeutic procedures in the treatment of tuberculosis originated with
the Ministry of Health and the WHO. I quote from the report of the WHO (Ref :
“Twenty Years In South East Asia” 1948-1967, pp 156-157) :
“The discovery of isoniazid in 1951 made it possible to consider the use of
anti-tuberculosis drugs in a public health programme of tuberculosis control.
For a community wide tuberculosis control programme it is, in most countries,
necessary to organise domiciliary drug treatment. In countries of South-East Asia,
with an enormous shortage of hospital beds, it was beyond all possibility to provide
institutional treatment for all tuberculosis patients, and domiciliary treatment
was the only hope. However, there were important considerations in domiciliary
chemotherapy which needed investigation. The main elucidation required was
whether such treatment would be as effective as institutional treatment with
the same drugs, and whether domiciliary treatment of tuberculosis patients on
a large scale would end anger the health of the community in which they lived”.
The ICMR was entrusted with the task of collaborating with the WHO. When
the question of the location of the centre was discussed I voted in favour of Madras.
In the study of the type envisaged, active collaboration of the people was essential,
and in view of my working in the State for a number of years, I knew that such
cooperation would be readily forthcoming. The Indian complement of the staff was
chosen by the ICMR, while the Medical Research Council of the United Kingdom
assumed the responsibility, on behalf of the WHO, and lent several of its personnel
who had experience of tuberculous chemotherapy trials, to guide the research.
The project was an outstanding success and the Centre had earned an
international reputation. The results obtained during the first ten years of its
working were extremely interesting. I quote from the WHO report:
“The first report was published in 1959. It indicated that domiciliary
treatment was just as effective as sanatorium treatment, in spite of the fact that
latter provided both bed rest and diet, which was far superior to that of patients
under treatment in their own, predominantly very poor”. “...It was proved that
the patients treated at home were not exposed to special risk of infection when
compared with the sanatorium patients”. “One of the remarkable achievements
of this project was that the patients and contacts were followed up successfully for
five years. One hundred per cent of the surviving patients admitted to the study
and 98 per cent of the surviving contacts were kept under examination during the
whole of this time, and later findings gave no cause to amend the first conclusion
that domiciliary chemotherapy was as efficient a method of tuberculosis control
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as was sanatorium treatment. The domiciliary chemotherapy was, of course,
much cheaper, and also free from the drastic dislocation of the family caused by
prolonged admission into sanatorium or in hospital with the resulting problems
of rehabilitation”.
The association of the WHO with the project ceased in 1966, and the centre
was fully taken over by the ICMR. Even before this, I had raised the question of the
centre being made permanent since there were still many facets of the problem
which needed investigation. It was also necessary to ensure permanency of service
to staff members. When the proposal was submitted to the Ministry of Health,
the Minister for Health, Shri Karmarkarji expressed the view that while he had
no objection to make the centre permanent, it should be moved from Madras to
Ghataprabha and should work in association with the set up created there by Dr
Hardikar, a patriot and founder of the Health Institute there. I knew Dr Hardikar
well, who was, while in Delhi, an occasional visitor to my office in the ‘P’ Block. I
had to point out that Ghataprabha was not a suitable place for locating the centre,
since other essential facilities necessary for the conduct of work were not available
there, and any move from Madras would dislocate the work of the centre in many
ways. I also explained that the move would be resented by the Government of
Madras which had invested considerable funds in financing the project. In spite of
my periodic requests no decision was taken for over a year. He ultimately agreed
to retain the centre in Madras, but not before telling me what he thought of me
and my work! I did feel very bad that evening though I knew that essentially he did
appreciate what I was doing!
IV
Establishment of the Cholera Research Centre, Calcutta
The problem of cholera had always been with us in spite of extended
researches carried out during the earlier two decades. There were severe epidemics
of cholera in the late fifteen which prompted the Government of India to appoint
a committee to suggest ways and means of controlling them effectively. I was
the Chairman of the central committee. Similar committees were appointed by
the States. The central committee, in consultation with the States committees,
forwarded recommendations for the control of cholera in India.
In the course of the deliberations of the committee many gaps in our
knowledge of cholera came to light, particularly in the epidemiology of the disease.
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We had no precise evidence on how the infection persists during inter-epidemic
period. The efficiency of cholera vaccine was also not fully determined. Though we
had provided evidence that the protection after a single dose of the vaccine lasts
for a period of six months, our findings were not regarded as conclusive since they
were not based on ‘controlled’ field trials’.
Again, the patho-physiology of cholera had not been fully elucidated. These
and similar problems were also being debated in the Cholera Advisory Committee
of the WHO, of which, I was also a member.
In view of these lacunae in our knowledge of the disease it was considered
essential to embark on a comprehensive programme of research in this field.
Most of the research workers interested in cholera were working at that time in
Calcutta. I thought it advisable to call a meeting of such experts and then to form
out projects individually between them. Dr Venkatraman, who was the Serologist
to the Government of India working in Calcutta, was entrusted to proceed in the
matter. However, nothing worthwhile came out of this endeavour.
Originally it was my idea to establish this centre in the campus of the Infectious
Disease Hospital. It was contemplated that in due course, the centre could also
undertake research in the other communicable diseases, in which case the
proximity of a hospital would be an advantage. Indeed, the Government of West
Bengal had welcomed the idea and had indicated their willingness to cooperate
fully in establishing the centre.
However, the Director General of Health Services in New Delhi, suggested
that it would be advisable to locate the centre in the building which was nearing
completion in Kyd Street. This was agreed to. The Centre came into being in 1962.
In a way this was just as well for soon after that WHO decided to undertake
controlled field trials in Calcutta, to determine the efficacy of cholera vaccine.
Facilities were thus readily available in Calcutta, and the first task of the Cholera
Research Centre was to participate in this undertaking.
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CHAPTER X
EPIDEMIC OF INFECTIOUS HEPATITIS IN
DELHI
Delhi experienced a very severe outbreak of infectious hepatitis during
December 1955 and January 1956. The ICMR decided to investigate the
epidemic in all its aspects and constituted a group for the purpose under
the overall guidance of Dr R. V. Vishwanathan. Many agencies in Delhi cooperated
with this effort and the results were published as a supplementary number of
the Indian Journal of Medical Research, Vol. XLV, in 1957. Over 7,000 cases were
recorded during the period. However, a sample survey indicated that the total
number of cases could have been in the neighbourhood of over 29,000!
As was to be expected, the Government had appointed a committee to
determine the cause of the outbreak. It concluded thus:
“The evidence analysed by the Committee shows that the outbreak of jaundice
in Delhi is viral in origin, that the causative virus was disseminated through the
pipe water supply from the Wazirabad Pumping Station, that the water from the
Yamuna river contaminated with sewage from the Najafgarh Nullah near the
pumping station was drawn into the waterworks at Wazirabad Pumping Station
for about a week from 14th to 16th November 1955 and that such contamination
was fully responsible for the epidemic which occurred in Delhi in December 1955
and January 1956”.
The epidemiological team of the ICMR had made further observations. I quote
from their report published in the IJMR referred to previously:
“There is a depression near the town of Najafgarh where water from the
western side of the ridge accumulates during rainy season and forms what is
known as Najafgarh Jhil (Lake) …… From the lake an escape has been constructed
to carry off the superfluous water during rains to the river Yamuna which it joins
just above the village of Wazirabad. This escape, popularly called the Najafgarh
Nullah, has a drainage line for a catchment area of more than 200 sq. miles. It
meets Yamuna river at a distance of only 700 feet on the downstream side of the
Wazirabad Pumping Station. It is about 30 miles in length. A portion of the Nullah
receives sewage and shit from the colonies located on either side of it which have
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come into existence since 1947 for housing the displaced persons. What was
a storm water drain before 1947, has been converted into an open drain which
carries pure sewage and sillage which are discharged into the Yamuna river in
the dangerous propinquity of the main pumping station which supplies drinking
water to over 90% of the urban population. Wazirabad Waterworks is at the north
end of the city”.
Referring to the events prior to the outbreak, the report further stated:
“Floods occur every year on the river after rains. The river is prone to shift
its course from one bank to the other after floods. Every year channels are dug
to divert the water towards the intake points. When the flood waters subside
and the river changes its course towards the opposite bank, reverse current is
occasionally produced near the Wazirabad bank of the river, facilitating thereby
the sucking in of the discharged contents of the Najafgarh Nullah towards the
intake point. ..During the critical period “there was sucking action of the pumps.
The contents of the Najafgarh Nullah began to go upstream towards the intake
points. A time was reached when the level of water at the intake point and the
mouth of the Nullah was the same”.
As this knowledge became available, the Ministry of Health began to consider
what steps should be taken to prevent such occurrences in future, and I got
involved in the discussions. One day Rajkumariji decided to pay a visit to the
Wazirabad Pumping Station and asked me to accompany her. The river, at the
time, had changed its course, and channels were being dug to divert the water
towards the intake point. When we visited the site there was no evidence of any
activity, and a solitary cow was grazing near the pumping site. Rajkumariji was
rather annoyed that no steps were being taken to prevent the animals from
grazing near the pumps as this contaminates the site. I said, “Madam, the cow is
here because perhaps she came to know that the Health Minister was visiting the
site and wanted to see her!” Rajkumariji could always appreciate a joke!
Soon after, the Superintendent of the Waterworks, Shri Mehta arranged a
meeting to consider the problem. One of the proposals was that the Najafgarh
Nullah should be moved so that its contents flowed downwards in the Yamuna
away from its present site of discharge. It was pointed out, however, that in that
event, water near the bathing ghat, situated not too far away from the exit point
of Nullah, would not be suitable for bathing. The meeting was attended, among
others, by member of the Delhi Corporation. He was emphatic that facilities of
bathing should not be disturbed. I said in reply that it was for the Corporation
to decide whether the bathing facilities for the few were more important than
the provision of a safe water supply for the Delhi public! However, I stated that
instead of discussing this question academically, it would be quite possible to
gather relevant data by examining water samples all along the route from the
outlet of the Najafgarh Nullah to the bathing ghat and thus determine the extent
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of pollution at source and the degree of purification evident at different places all
along the way to the bathing ghat. I indicated the methodology for collecting the
samples and tests to be done on the samples. The suggestions were accepted.
Four days later, the Health Ministry called a meeting of the concerned officials
to discuss the question further. The meeting was attended, amongst others, by the
Chief Engineer of the Corporation and the Director of the River Research Station at
Khadakwasla, Poona (I think, Shri Godbole). I was asked to attend. As I was entering
the room, I was given the results of tests suggested above. Rajkumariji presided
over the meeting and explaining the purpose of the meeting and giving a brief
account of what had happened, called upon me to open the discussion. This was
a bit embarrassing. However, I expressed my views based on the information I had
gathered. I pointed out that solution to the problem would lie in two directions, viz.
either to move the pumping station further beyond upstream, so as to increase the
distance between the mouth of the Nullah and the pumping station or move the
outlet of the Nullah downstream to achieve the same purpose. The first alternative
was not feasible, the river had taken a turn or had a bund a little beyond, and
the engineers had thought it inadvisable to have the pumping station close to
it. Besides such a step would not in any way alter the situation created by floods
every year.
Regarding the second alternative, i.e. moving the outlet of the Nullah
downstream, there were certain difficulties. It was suggested that in that case,
water near the bathing ghat downstream would not be suitable for bathing. In
order to clinch the issue, a few tests were done on samples of water at different
points downstream. The results which were just available to me confirmed the
situation. The water at bathing ghat would certainly be not suitable for bathing.
It was also not ascertained how far the pollution would reach beyond that point.
I also pointed out that authorities in the past had also considered the feasibility
of providing safe water through infiltration gutters in the river bed but had
dropped the idea on account of the particular size of the river sand. In view of
these considerations some other solution would have to be considered to meet
the situation.
In this connection, it was necessary to remember, I said, that during the
critical period when the maximum contamination was occurring, “a time was
reached when the level of water at the intake point and the mouth of the Nullah
was the same”. If it was possible to prevent such occurrence in future, the position
could improve. This could be achieved, it was felt, if a bund of sufficient height
was created right across the river, between the intake point and the mouth of the
Nullah, i.e., in other words, to create an artificial reservoir which would prevent the
contamination of water with sewage through the sucking action of pumps. It was,
of course, for the engineers to consider if the suggestion was feasible.
To my surprise, the Director of the River Research unit in Poona stated that as
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a result of his studies he had come to the same conclusion. The Chief Engineer also
stated that technically the suggestion was feasible.
Thus the meeting ended. When some of us met the Minister in her office
after the meeting, I was congratulated by her and by the Health Secretary, Shri
V.K.B. Pillay, for my contribution at the meeting. I was, indeed, very happy that
the experience I had gained while dealing with the water supply problems of the
composite State of Madras and Andhra Pradesh came in so handy!
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CHAPTER XI
VISIT TO THE SOVIET UNION (1953)
In 1953 I was a member of the Indian delegation led by Rajkumari Amrit Kaur,
to the annual session of the World Health Organisation in Geneva. At the end
of the meetings Rajkumariji had planned to visit Soviet Russia as the guest of
our ambassador Shri K. P. S. Menon, I was asked to accompany her. I was, indeed,
very happy at the idea, for not only would I have the opportunity to see something
which the Soviets were doing in the medical and health fields, but I would also
have the opportunity of spending some time with my daughter and son-in-law
Shri Ram Sathe who was then the First Secretary in the Indian Embassy in Moscow.
Apparently, there was some delay in completing the necessary formalities about
the visit, but ultimately after spending two days in Prague, we reached Moscow
on May, the 25th . We were graciously received at the airport by Madam Kovrigina,
the Deputy Minister of Health. She suggested that we should be the guest of
the government. We, however, politely regretted our inability to accept the offer.
This was just as well, for as the guests of our ambassador, we could meet and
discuss with other diplomats, all that we saw and learnt during our visit, and who
were equally anxious to hear our impressions since they did not have the same
opportunities to see things as we had!
The next day we met the Deputy Health Minister in her office who assured
us at the outset that every opportunity would be provided to us to visit whichever
institutes we liked in any area of the Union. “Put your finger anywhere on the
map and we would take you there”! Of course, we were ourselves ignorant of
where we would like to go. Ultimately, it was decided that we should visit certain
representative institutions in Moscow and Leningrad, and also pay a visit to one of
the Central Asian Republics, e.g. Tashkent in Uzbekistan and Sanatoria in Sochi on
the Black Sea coast.
To start with, we were given a document entitled Public Health Service in the
U.S.S.R.’ to acquaint ourselves with the aims and objects of the Soviet policy in
matters of health and the general organisation and structure of the Ministries of
Health in the Soviet Union. The memorandum stated that the Soviet Union was a
country of 100% literacy. There were over 3 million students studying in colleges
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and vocational schools in the country; while in 1917, there were only 20,000 doctors
in Soviet Russia, today over 20,000 doctors graduate from medical colleges.
The Ministry of Health alone employed over 250,000 doctors! In Uzbekistan
there was one doctor for 895 persons, in Azerbaijan one for 490, and in Georgia one
for 373 persons. There were over 300 research laboratories with new discoveries in
preventive medicine, and over 25,000 research workers were working in them.” A
special system of rural medical service has been set up in the country. Each rural
district has two or three hospitals with specialists on their staff able to render
any kind of medical aid. In case the local physicians have the need to engage
the advice of their more experienced colleagues, they may invite professors from
nearby towns by cable, telephone or radio. A medical aviation plane would take any
specialist at any time to any distant rural district. Medical emergency air service
stations are available in any regional or republican centre.”
There were many other items of information and interest in the memorandum,
particularly regarding arrangements made for the welfare of women and children.
It stated: “The mother of many children is surrounded with constant care and
honour. Mothers of five and more children secure the “Motherhood Medal”, and
the Order of “Mother Glory”, and a mother of ten children receives the honorary
title of “Mother Heroine” and is awarded the “Gold Star”. Our country worships
mother’s heroism, reveres the women who has fed and brought up her children,
the new generation of our fatherland”. Finally, the memorandum ended with the
following statement:
“...We want to live in peace and friendship with the great Indian people.”
Georgi Malenkov, the Soviet Prime Minister, voiced the opinion of all Soviet people
when speaking at the Fifth Session of the U.S.S.R. Supreme Soviet when he said:
“We hope that relations between India and the Soviet Union will become stronger
and will develop in a spirit of friendly cooperation.”
During the course of our visit to various institutions in Moscow and in the
central republics, we had ample opportunities to verify some of the statements
made in the memorandum. In discussing the structure of the Ministry of Health
we were told that ministers of health both in the Centre as well as in the Republics
were men of high professional standings. These are appointed by the Supreme
Soviet and hold their office as long as they enjoy the confidence of the Supreme
Soviet. Again officers serving in the ministry are not necessarily engaged all the
time in administrative work in the ministry, but many of them have assignments
for scientific pursuits in revolver medical institutions in the country. Indeed, my
interpreter who was a medical man was surprised when I told him that my minister
was not a doctor! Again health and higher education were the direct responsibility
of the Central Ministry of Health and not of the corresponding ministries of the
constituent republics.
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Admission to the medical institution was on the basis of an examination.
Knowledge of one foreign language was compulsory, and we were informed
that 70% of students learn English! We could verify this when we visited a girls’
school. We were surprised to learn that amongst the students admitted 65% were
women and the percentage was even higher previously. “Can anybody take to
medicine?” I asked my interpreter. “Certainly”, he replied. “How come, then, the
large percentage of women?” I exclaimed. My interpreter just smiled. Obviously,
this was soon after the war which had resulted in tremendous loss of manpower
and women had to be drafted for such occupations. Indeed, at the time of our visit,
heads of most institutions were women. Seigerist had the following explanations
to offer: “But industry came first, particularly heavy industry, which had a prior
claim on manpower and material. It would have been impossible to increase the
number of physicians substantially if women had not enrolled in the medical
schools in increasingly large numbers. There was a time when 75% of all medical
students were women!” This was, of course, “planning”! Later when the question
of ‘standards’ was considered, it was decided to extend the medical course from
five to six years, but not by decreasing the number of admissions to medical
institutions!
When we visited Leningrad we had occasion to see the Institute of Paediatrics
there. It was established in 1918 as the Institute for the care of ‘Mother and Children’.
About 450 students were admitted each year, most girls students. Emphasis was
on children’s diseases though a study of diseases of adults was not neglected!
There were more than a thousand beds, mostly for children up to the age of 16.
One interesting feature of this Institute, which we had also seen in one of the
maternity centre was the existence of a ‘milk bank’. The stock of mother’s milk was
maintained through milk donors! This concept of training of pediatrician, quite
independently of any other general training in medicine was, indeed, a novel one
to us! We were told that during the war they had functioned to a large extent as
general practitioners!
Visit to the Institute of Experimental Medicine in Leningrad was equally
interesting. We could not spend much time there was some members of the
staff were away attending a conference. However, we could spend sometime in
Pavlov’s Laboratory. It was maintained exactly in the same state as he had left it on
the date of his last illness. All his personal belongings, i.e. books, and even candy,
were there! The dogs with salivary fistulae were there and we were shown how a
stimulus applied to the tongue induced the flow of saliva from one salivary gland or
another. It was interesting to note that whether in medical relief, medical research
or in health education the ‘Pavlovian concept of conditional reflexes’ always
predominated. As explained in the pamphlet on Health education, produced
by the Institute of Health Education, Moscow “of immense importance in the
development of theory and practice of health education, as far as Soviet medicine
as a whole, is the teaching of the great Physiologist Ivan Pavlov, on the integrity of
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the organism, the inter-relationship of the organism and the surrounding world,
the dominant and decisive role of the Central Nervous System, and especially of
the Cerebral Cortex, in the life of the human organism”. This concept was applied
in the development of therapeutic procedure in certain diseases, as for example, in
ensuring painless delivery, or in the treatment of peptic ulcer. Indeed in an article
in the ‘Pravada’ criticising the actions of some the Health Ministers, the following
paragraph occurred:
“The development of Soviet Public Health Service rests upon the granite
foundation of advanced science, on the remarkable scientific heritage of S.P.
Botkin and L.P. Pavlov, the glorious founders of scientific medicine of our country.
The Soviet medicine and health services have been raised to the high level by
the brilliant teaching of I.P. Pavlov by means of which it has been possible to
explain correctly the origin and nature of diseases and to outline the ways for
their rational treatment and prevention”.
To quote Henry Sigerist again:
“Yet this attitude is understandable. The great masters of Physiology in
Germany were Ludwig, Du Bois Raymond and Helmholtz. They had many
Russian students who later created a School of Physiology in Russia. Of all
the medical sciences Physiology appealed to Russians most; it had a fruitful
development in Russia. This certainly did not happen by chance. Physiology is
the most philosophical of medical sciences. It could not help but appeal to the
philosophical Russian mind, and from the beginning Neuro-Physiology was a
highly cultivated field”.
Whenever we discussed the nature of work done in the Institutes, we were rather
amused at the tendency of the Russian scientists to attribute the major discoveries
to Russian scientists. We had already been told that the Soviet Professor who had
discovered the ‘painless delivery method’ and introduced it into medical practice
was awarded the highest order of country The Order of Lenin’. Previous to the days
we were going to visit the Institute of Tuberculosis in Moscow, we had heard on the
radio of a new discovery in that Institute - new drug ‘phtirazıd’ for the treatment of
tuberculosis. On enquiry it turned out to be the same as ‘isonicotinic acid hydrazide’.
I would like to relate an amusing incident relating to this. We were visiting a girls’
school when an oral examination in physics was scheduled to take place. The girls,
mostly aged between 12 and 14 had assembled in the classroom. The two external
examiners were seated at a table with a number of slips beside them. On a nearby
table number of instruments, apparatus etc. were neatly arranged. Each Slip carried
one question. The girls were asked to pick up any one slip and study the question.
When ready to answer, each one was called to the table to answer the question. The
class teacher was standing to attention by the side of the examiners.
One girl had to explain the laws of gravity. She did this remarkably well. She
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assembled the apparatus on which was located a pebble. With the turning of
the switch the pebble fell down and then she calculated the velocity of the fall.
She was then asked how an aeroplane took off and landed. She explained this
remarkably well too. We were really surprised at the ease and confidence with
which she answered all questions. Finally she was asked who discovered these
laws? She named a Russian scientist! I could not help asking my doctor interpreter,
whether the student knew that Newton ever existed and, as usual he smiled!
While we were thus impressed with the standard of education given to
children in Moscow, we did not know that the same high standard existed
elsewhere, particularly in the constituent Soviet Republics. In Moscow we had
occasion to visit what were known as ‘Palaces of Pioneers’, a sort of children’s
clubs housed in the palaces of noblemen during Czarist times. The Pioneer houses
were really aids to education where children from 10 to 15 years of age acquire an
immense amount of general knowledge. They are taught to use their hands in
carpentry, gardening, model making, they are taught to observe nature, and know
about the Earth, the Sun, moon and stars, the sea, the mountains, the mineral
wealth of their own country, their other resources and the geography of their own
town or village as the case may be. Simple devices to explain physical laws and
facts of mathematics are used to impart knowledge in a simple way. There are also
dancing and music classes. These activities are carried out in different sections
and the children decide which section to attend. So popular were these “Clubs”,
that it was difficult to keep the children away from them as some parents stated.
One could go on and write what we heard and saw about other aspects of
medicine and public health such as medical relief, health education, etc. These
had followed the usual pattern such as the establishment of polyclinics, maternity
centres and hospitals according to the population to be served. The planning was
based on the unit of population, normally of four to five thousand people. The
whole planning was based on the concept that a Soviet citizen will be examined
at least once a year.
It is now nearly three decades since I had visited the Soviet Union. Knowing
the penchant of the Soviets for planning, great advances must have been made
in all fields of medicine and public health since our visit which was just after
the termination of the Second World War. What were our overall impressions?
On return we submitted our report. Though I wrote most of it, the final Chapter
‘General impressions and some conclusions’ was penned by Rajkumariji. I would
like to quote a few extracts from that Chapter:
“From his earliest age the child is taught to love the country, to be proud of
the achievements of its great men whether poets, artists, generals, politicians,
musicians, dancers, scientists, doctors or others. Hero worship had been
encouraged. Everywhere the emphasis is laid on beauty. Parks are well laid out with
lovely flowers and foliage, and trees are planted by the millions every year. Beautiful
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statues, whether on general themes or of famous Russians are seen in parks, and
even along the countryside. No advertisements mar the countryside, but there are
artistic posters every now and again to show the beauty of the countryside, of the
big valley or river projects, or of the heroes of the war, of authors, of great men in
every walk of life.
We were told that party membership has now increased threefold and all
new members are between the ages of 25 and 40. “Parliaments”, whether in the
republics or at the Centre meet once a year. We were told that the budget is never
a deficit one. Once passed by the Supreme Soviet the money allocated goes to the
ministers at the Centre and republics respectively and they are at liberty to spend
it according to their programmes without further checks from any other quarter.
Over the republics there is, however, always supervisory and directive control by
the Centre. “If you want to forge ahead quickly and work out a uniform pattern of
social and other services, you must have central control” was the opinion of the
administrators we met. However, we were told that there was seldom any cause
for interference by the Centre.
To say that the earnings of everyone in Russia are on a par is quite untrue.
There is a minimum level below which no salary goes; 450 roubles a month plus
board and uniform for the nurse was the lowest quoted to us. There is the high
watermark of 30,000 roubles for a ballerina. An academician gets very high pay,
but we could not get exact figures. We never could find out where the ministers
lived or what their salaries were!
The standard of morality seemed to us to be very high. There are seldom any
divorces. Whether this is due in some measure to the equality of status between
men and women, that all women are wage earners, many holding high offices,
and therefore, economically independent, it is not possible to say. In any case,
while no religious training is given anywhere and while the younger generation
aver that they do not believe in God, there is maintained indirectly, as it were, by
the States a high standard of ethical training.
Only good literature is distributed, a spirit of camaraderie and cooperation is
inculcated ab initio educative films only are shown, no jazz is allowed so that there
may be a high standard of music, opera, drama, and ballet, etc. all this makes for
a fairly high level of thought and behaviour and above all of a burning patriotism!
There is fear of the outer world in the minds of all. “The U.S.A. are inimical, the
Western European Nations are arming against us, the Middle East is being
formed against us. We never want war again and we shall never start it” and so
on. It is distressing for them to have this psychology of fear, but it in there. Equally
impressive is the universal desire for peace.
All the achievements of U.S.S.R. have to be measured in terms of what they did
not have 35 years ago. However, the short space of time in which the Soviet Union
have progressed is no doubt remarkable. It must also be remembered that they
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have made this progress absolutely on their own, without any help from anyone.
They have suffered, and I believe they realise they suffer from being cut off from
the outside world as far as scientific progress in medicine and in other spheres is
concerned. If only the veil that divides them from the outer world could be lifted,
they would gain greatly and so might the outer world. The Russians as a people
seem warm hearted and lovable. They are intensely musical and artistic, immensely
proud of their country and extraordinarily enthusiastic about working for it. This
enthusiasm is so infectious that even the ordinary onlooker gets enthused. It
would be wonderful if we could catch this infection in our own homeland!
There is no doubt that there is regimentation of action and thought. The
people have only such food, whether in books, in music, in art, in education given
to them as is considered good for them by the authorities. The Russians from time
immemorial have been used to secret police, to oppression and to poverty, may
be more amenable to such regimentation. How long will they submit to it? Will
they do so once they come in contact with the outside world? The present-day
generation is unaware of the dreadful conditions for workers prevailing during the
Czarist regime which created the communist revolutionaries. Will they continue
to submit to regimentation once they are highly educated? These are questions
which did and must arise in our minds in spite of the natural appreciation of all
they have achieved and all that they have given to a people who were poor and
oppressed and had nothing before the revolution.
We returned to India after visiting Finland and Stockholm and submitted
the report on our visit to the Prime Minister, Pandit Jawaharlal Nehru. He was
apparently interested in the report and advised that it be printed and circulated
to the health ministers in the States as a confidential document. He also wrote a
preface to the report.
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CHAPTER XII
VISIT TO AUSTRALIA AND NEW ZEALAND
In 1956, Rajkumariji received an invitation to visit Australia and New Zealand.
In communicating the invitation, the Australian Government also suggested
that I shall accompany her. I learned later that the suggestion that I should
accompany her was made by Sir MacFarlane Burnet, O.M. FRS who was then the
Director of the Walter and Eliza institute. I had met Sir Burnet in 1932 when he
was working in the National Institute of Medical Research in London. In 1955, he
had visited India and at my invitation he had attended the meeting of the Indian
Council of Medical Research at Nagpur. I was, indeed, very happy that I would get
the opportunity of meeting him again in Melbourne. I was his guest one evening
in Melbourne and after dinner we had some discussion on what I had seen during
our short stay in Australia. I remember he told me that what were beds were not
really for patients who need hospitalisation. People felt it was more economical to
them to be admitted to the hospital, even for ordinary illnesses such as fever, than
to undergo treatment in their own homes. Who would look after them at home,
since domestic help was so expensive. The minimum wage in Australia then was
£12 a week.
We landed on the Australian soil at about 11 PM at Port Darwin. We were
received at the airport by the Administrator of the Northern Territory and after a
cup of coffee and rest in his house, we took off for Sydney at 1 AM and arrived there
at 9 AM. Rajkumariji, being the Minister of Health, was received at the airport by
the Minister of Health, an ADC of the officiating Governor General. I indeed felt
very proud that a representative of my country was being greeted very warmly and
received with affection wherever she went.
During our two weeks stay in Australia, we visited Melbourne and Canberra,
the capital, saw the working of their research institutes and had discussion with
the authorities concerned on the administrative set up of their federal and state
ministries of health. In New Zealand we stayed for a week. We were able to visit
two towns in the North, Auckland and Wellington and two towns in the South,
viz. Dunedin and Christchurch. The whole stay was delightful, for we made the
journeys by car and so were able to see the delightful countryside en route. On
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return to India, I was entrusted with the task of writing on medical matters and
Rajkumariji wrote about her general impression.
Our discussion initially concerned on the relationship between the federal
and state ministries of health. The Government of Australia is federal, but the
states have full authority and indeed call themselves “Sovereign”. We were told
of an amusing incident when the queen visited Australia the previous year. She
landed at Sydney exactly at the same spot where the first settlers had landed. It
became a matter of dispute as to who should receive her, the Prime Minister of
Australia or the Premier of New South Wales. Finally, a compromise was arrived
at whereby the Prime Minister received her in a special launch and the Premier,
when she actually landed on the soil of Sydney.
During the Second World War the Central Government had asked for special
powers during the war years which the states had yielded quite gladly. Now, in
their opinion, the centre should not keep them any longer. Some of the states
were dissatisfied with the attitude of the Central Government; they had actually
filed a suit in their High Court and were eagerly awaiting a decision in their favour.
The population of Australia at the time of our visit was just around 10 million
souls. There is of course the White Australia Policy and immigration is restricted
to them. However, it was interesting to hear that after a three-day debate on
the White Australia Policy of the Government, the students of the University of
Melbourne came unanimously to the conclusion that this policy was wrong and
not in the best interests of Australia.
To serve this population of 10 million there were 9,000 doctors in Australia,
i.e. roughly one doctor to 1,000 of the population. Of these, 65% were engaged
in general practice, 12% were specialists, 13% were working in hospitals, 8% were
members of the public health service and about 2% were engaged in teaching and
research. From the census taken in 1947, it would appear that roughly about 65%
of the doctors were practising in large cities, 20% in towns and about 15% in rural
area. This distribution is understandable since rural areas in Australia were indeed
sparsely populated.
What were the medical problems of Australia? The reply was, first, more hospital
beds. I have already referred to it as mainly due to socio-economic conditions of
the country. The tendency to go to the hospitals is further encouraged by the
provision for medical benefit through the concessions offered by the Government
and voluntary insurance scheme.
Apart from this the major health problems were: tuberculosis and diseases
associated with advanced civilization, such as cardio-vascular disease, cancer and
problems associated with mental health. There was a special committee to investigate
the causes of juvenile delinquency. We were also informed that the problem of
resistance of organisms to antibiotics was assuming considerable importance, and
the indiscriminate use of antibiotics was the essential contributing factor.
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One of the striking developments that have taken place in Australia in
providing medical relief to outlying areas is the institution of Flying Doctors Service.
It was indeed due to the vision of the late very Rev. John Flynn, Superintendent
of the Australian Inland Mission in a far off inland state in the Northern territory.
While organising a mission service there, he saw the need for a speedy medical
services which could give security and allow for the development of home life,
a mantle of safety as he called it. I quote from the report we submitted on the
completion of our visit:
“With the development of air services and of radio communication during
successive years, a network of 12 Radio Base Stations and over 1000 Radio outposts
was established. Special “Radio receiving and transmitting sets” had to be
developed for the purpose. In this manner, medical aid has been brought near to
the people living in a radius of 400 miles of each of these 12 Radio Base Stations.
These radio basic stations were suitably located in different parts of the country
so that it may now be said that most of the outlying areas are within the reach of
active medical advice to patients. Its modus operandi is as follows:
At each of the 12 Bases there is a well qualified doctor in attendance who can
be in direct communication by telephone or radio with outlying posts. Both the
Base and outlying stations are suitably equipped with transmission and receiving
sets, so as to enable the outpost to communicate with each other and also with
their respective Bases. The outposts are equipped, in addition, with suitably
devised medical chest containing many essential drugs, ointments and bandages,
etc. required for the treatment of common ailments as well as emergencies. In
these chests sulpha drugs are included but not antibiotics. When any patient at
any of the outlying posts wants to seek medical advice, he contacts the doctor
at the Base by radio telephone and explains his illness to the doctor. To enable
him to do so a book containing suitable instructions as to how to describe the
patient’s symptoms is also provided. For example, in describing the site of pain the
patient has only to refer to a number which is given on the anatomical chart, and
by any vague description of the site, e.g. pain is at site No. 7 the doctor visualises
the person making the sag in establishing his diagnosis. He is then given the
necessary advice and treatment as to which medicine from the chest should be
utilized and what manner.
We had a demonstration by a gramophone record taken on the basis of the
nature of the conversation that took place between the patient and the doctor,
and the performance was most effective and interesting.
It might be stated that in addition to the above procedure the doctor makes
periodic visits to the states even in unclimatic weather if the medical emergencies
justify them”.
This account is based on what existed many years ago. I have often wondered
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to what extent the service has been extended. Further can we not use the basic
principles involved in the organisation of such a service for our own remote rural
areas, for Adivasis for example, by utilizing the existing network of our state
transport systems as well as by extending our communication system. At least
it might be advisable to make a beginning by linking big hospitals in the cities
with smaller hospitals and primary health centres in the districts. At any rate, such
thoughts did occur to me.
Our one week’s stay in New Zealand was equally interesting. The standard of
medical education and medical relief was very high. New Zealand had at one time a
high rate of mortality. Today it has the lowest. We made special enquiries as to how
they were able to achieve it. The improvement has been brought about by good
observation, good nursing and, of course, good public health. In the first place
steps were taken to provide standard techniques for labour, the second step was to
establish antenatal clinics and the third was the provision of sterilised equipment
for use by domiciliary measures. Special steps were taken for the overall training of
nurses particularly midwives. They were subjected to strict registration and were
also a factor in reducing mortality.
In the discharge of these functions the Director of the division has many
scientific duties to perform. He issues periodically from his office memoranda
on scientific matters which are of special interest to the doctors and nurses, e.g.
steps necessary to avoid skin and congenital sepsis in babies and allied problems.
It might be noted that to prevent the misuse of antibiotics, some antibiotics were
not permitted to be used as routine. These were kept in reserve, as it were, for the
treatment of drug resistant cases.
It might be stated that such scientific service was a feature of most of
the divisions in charge of the directors. Again, there is considerable flexibility
of arrangement in the working of these divisions. The Director of a division is
responsible for initial planning with respect to his speciality. He then consults
the Deputy Director of Health and obtains his general sanction to the scheme
so enunciated. Once such sanction is obtained, he discusses the financial
implications of the scheme with the Deputy Director General of Administration.
The Director of the Division is then free to go to the Director General of Health or
even the Minister of Health, for further discussion, if necessary. Once the scheme
is approved, the financial provision is dealt with entirely by the Deputy Director
General of Administration who processes the request to the Treasury to obtain
final sanction and allocation of funds.
We were particularly impressed with the distribution of functions between the
senior officers of the Ministry regarding membership and chairmanship of various
committees. These functions are distributed over a number of officers so that no
one member is entirely preoccupied with committee work to the detriment of
other pressing demands.
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At the conclusion of our tour, we had one dominating thought that so far as
medical scientific activity is concerned, we had “discovered” Australia and New
Zealand. Research in Australia is not on a big scale, and the number of institutions
engaged in research is relatively small but the quality of work is of a very high
order since Australia had succeeded in attracting persons of eminence to work in
their institutions. We felt strongly that advantage should be taken of the facilities
available in the country for the training of our workers in certain fields of science.
We felt that it was a particularly opportune moment to do so. A few Indian
students who had been sent to Australia under the Colombo Plan had done
remarkably well and the Australian authorities had nothing but praise for the
quality of our students. They were anxious to have more students, and since the
number of students going to Australia would be small, they would certainly receive
a great deal of individual attention.
On our return journey, Rajkumariji raised the question whether it would not
be advisable to have “Scientific Attache” in our embassy in Australia or a “roving
attache” as she put it, who would visit the countries in the region and gather
information of value to us in India. Indeed she said that she had the impression
that our High Commissioner in Australia would strongly welcome the suggestion.
I welcomed the suggestion and I told her of my experience in the United States on
a similar proposal. While on a visit there, the Government of India had asked me
to visit the office of the “Commonwealth Scientific Office” and gather information
about its functions and activities. This office was established during the Second
World War. Each Commonwealth country sent one scientist representing a certain
field. Together they formed a compact team, each one representing a speciality.
They pooled all the information which they could, gather in different fields — mainly
connected with war effort, and the report was made available to the Commonwealth
countries. I had reported that if the Government of India would approach one to
serve in that office he would be received very cordially by that office. I was told at
the time that the activity would be continued even after the war. Unfortunately,
however, the office was closed after the termination of the hostilities.
During our return journey, while we were discussing what we had seen in
Australia and New Zealand, I suggested to Rajkumariji whether we should not
consider adopting some of the procedures in the working of the ministries of
health, particularly in New Zealand, in the matter of delegation of responsibilities
to our officers working in the offices of the Ministry of Health, and the Director
General of Health Services in New Delhi on the pattern we had seen and
appreciated in planning and execution of several proposals in connection with our
health programmes. She welcomed the idea and asked me to put up a note which
could be discussed with the Secretary, Ministry of Health, and the Director General
of Health Services. I did so. A meeting was called and after some discussion we
adjourned. However, we could not meet again. The report we had submitted was,
apparently, read with interest.
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CHAPTER XIII
VISIT TO U.S.A.
In 1954, Rajkumariji was invited by the Rockefeller Foundation to USA and
see the working of some of the Institutions in the country. The Foundation
extended to me also the invitation to accompany her. It so happened that I
was invited by Sir Harold Hamsworth to attend a conference on Medical Research
in London to which representatives from an organization in France were also
invited. It was then decided to time our visit to USA accordingly.
The journey to London was not entirely uneventful. After we left Cairo, within
a few minutes, the pilot noticed sparks flying from one of the engines. We had to
return to Cairo and board another plane, twenty-four hours later, to London. I was
thus just in time to attend the conference. Sir Harold Hamsworth had presided
over it. His summary of the problems we discussed and conclusions arrived at
were indeed marvellous. That summary was published in a book form later.
From London we went to Boston. The American Public Health Association was
meeting there at the time. We attended a few scientific sessions but spent most
of our time in sight-seeing and then we went to Denver by train. The purpose of
our visit was to meet Dr Washburn who was engaged for many years on the study
of problems connected with growth and development of children. Huge amount
of data was collected over the years and files relating to them were stacked all
along the walls on racks. Dr Washburn was rather pessimistic about analysing the
data. The enormity of the problem worried him. He wished he could have done
something about it periodically as data were being collected. I was reminded of a
similar situation I had to deal with in India. The ICMR was giving grants, year after
year, to Dr Frimodt Muller for his work on Tuberculosis at Madanpalli. No reports
were submitted, year after year, for many years in spite of frequent reminders
to that effect even though statistical aid had also been provided. Obviously, the
magnitude of the problem had also frightened him!
I have every reason to remember that visit to Denver. One evening Rajkumariji
had invited couple of scientists to dinner. Just before dinner I developed acute pain
in my abdomen. I knew it was gall bladder trouble. The condition was diagnosed
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by Dr Ashar, Professor of Paediatrics in Madras Medical College. We were on a visit
to Conoor to attend a meeting in the Nutrition Research Laboratories there. I felt
very uneasy after a breakfast of Idli and Dosha at Mettapalam en route to Conoor.
Dr Ashar was attending the meeting. He examined me and said that I was suffering
from gall stones! On return to Delhi, Dr Gadekar took the X-rays and confirmed the
diagnosis. Since then the condition was gradually getting worse and by the time
I undertook this visit, I was getting frequent attacks of pain. Indeed during the
stopover at Cairo, I had quite a severe attack of pain. However, I had not informed
Rajkumariji of the trouble I was having.
So when Rajkumariji received the message that I would not be able to attend
the dinner, she came immediately to my ward to enquire about my health. I told
her the whole story. Next day at lunch she informed me that she had discussion
with Dr Grant and both of them felt that since we were scheduled to go to
Boston en route to India, it would be desirable if I were to get operated there for
the removal of the gall stones. I thanked her for the suggestion but told her that
it would be rather inconvenient for me to get operated just then, since I had to
attend the ICMR meetings in Baroda immediately on our return to India. Then the
conversation was somewhat as follows:
“That is no problem”, she said, “I could send a cable immediately to say
that the meeting is postponed”.
“I would not like to postpone the meeting, Rajkumariji, for the
arrangements must have been completed already. Besides I would get myself
operated immediately after the meeting.”
“Pandit, you know that Boston is widely known, internationally, as the
centre for gall bladder surgery. You do know that Sir Anthony Eden had to come
to Boston for being treated. And as it happens you would be in Boston and the
Rockefeller Foundation would make all the arrangements. Why do you want to
miss this opportunity?”
“I am sorry, Rajkumariji, but I would prefer to be amongst my own kith
and kin for this, and I have full confidence in the surgeon, Dr Baliga, who is going
to operate”.
“All right, if you prefer that way. But when we go to Boston, I would like
you being examined by the surgeons there. I would like to be assured that there is
no immediate need for the operation and that it can be postponed till you reach
India”.
I readily agreed.
From Denver we went to San Francisco by train. There we met the officers
of the Public Health Department and had discussion on the organization of
the department and the problems they had to tackle. We, of course, visited the
Berkeley University and did the usual sight seeing.
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From San Francisco, our next “stop” was Puerto Rico! We left San Francisco
by plane in the morning, arrived New York early in the night and left immediately
by plane to Puerto Rico. It was indeed a tiresome journey. Fortunately we had a
sleeper on the plane!
Dr Grant was working at the time in Puerto Rico, in the field of medical
education. He had considerable experience in this sphere as the Head of the
Peking Medical Institute in China, to which I have already made a reference and
later as the Director of the All India Institute of Hygiene and Public Health in
India. In Puerto Rico, there was a big municipal hospital attached to the medical
school. Dr Grant established another hospital in the campus, to which patients
considered suitable for teaching were transferred. In this manner, a large turnover
of patients was ensured and the students could be instructed on a variety of
diseases and ailments during their sojourn in the medical school. I regret I did not
see the final report of Dr Grant if he had submitted one. I had always felt that the
idea was worth trying in India especially when we are compelled to admit a large
number of students in our medical teaching institutions, with limited staff and
hospital beds available for teaching purposes.
In Puerto Rico we had discussions with the local health authorities on their
medical and public health problems, as well as on the problems associated with
the migration of Puertoricans to USA. However, I was not particularly interested in
them. We left Puerto Rico and arrived in Boston en route to India.
In Boston, Rajkumariji had given me two assignments. One was to go to the
Boston Clinic and get myself examined for my gall bladder trouble. The other was
to see Dr Sujay Roy who had specialised in Cardiology and who would be suitable,
we were told, for an appointment, in due course, in the All India Institute of Medical
Sciences in New Delhi.
Regarding the first, I went to the Clinic in the morning. The surgeon examined
me and assured me that an immediate operation was not indicated and that I
could safely travel to India and get operated there. I told Rajkumariji about this at
lunch and the gall bladder episode ended.
It was arranged that I should meet Dr Sujay Roy at breakfast the next day.
We had a long chat about his work in Boston. He was no doubt very well qualified.
However, the prospect of his being immediately appointed in the Institute was very
dim and I told him so. To his enquiry I also told him that I could not offer him any
post in the ICMR suitable to his qualification and that anyway, I did not have the
power to offer him a post beyond that, at best, of a Research Officer. I advised him
strongly to remain in Boston for the time till the recruitment for the Department
of Cardiology in the Institute was made. I was so happy when he eventually joined
the Institute as Professor of Cardiology—an assignment he fulfilled with credit to
himself and to the Institute, till his death due to a heart attack!
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CHAPTER XIV
NEW LOOK AT LEPROSY
I
Creating interest among Indian scientists in the problem of
leprosy
Iwas a member of the Leprosy Advisory Committee,of the Indian Research
Fund Association. At its meeting in New Delhi in 1946, I expressed the view
that generally speaking, leprosy as a disease, had not attracted the attention
of scientists in India, apart from the very commendable work done at the School of
Tropical Medicine in Calcutta, by Drs Muir, Dharmendra and others, and that some
positive steps should be taken to generate interest in them to deal with the several
facets of the problem. After some discussion, it was agreed that as a first step, a
critical review should be prepared summarising the present state of knowledge in
respect of some aspects of the disease which could then be circulated to research
institutes for their information. The task was entrusted to a committee of three,
viz. Lt. Col. Hugh Mulligan, the then Director of the Central Research Institute,
Kasauli, who was to deal with the epidemiology of the disease, Dr V.R. Khanolkar,
the Director of the Indian Cancer Research Centre in Bombay, who was to deal
with pathology and myself, to deal with bacteriology of the disease.
Unfortunately, though we did our respective reading, the document did not
see the light of the day. Owing to political changes, Col. Mulligan left the Institute
to take an appointment in London. However, Dr Khanolkar after studying the
literature got very fascinated, as he himself told me, with the pathology of the
disease and initiated work at Cancer Research Centre in Bombay.
How this was accomplished will be evident from an extract from the report
of the Committee appointed by the Ministry of Health to provide a blueprint for
the establishment of a Leprosy Research Institute, of which Dr Khanolkar was the
Chairman and I was the Member-Secretary. I quote the relevant paragraph below:
“The need for initiating researches on the fundamental problems of leprosy
has been stressed in the report.
Work on these lines cannot be started immediately in the Central Institute
at Chingleput since the necessary laboratory facilities do not exist at present
and would not be available for at least two years or more The Committee
have given considerable thought to the question as to how such work could be
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Dr. Vasant Ramji Khanolkar, Eminent oncologist, made
contribution in understanding Leprosy pathology
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initiated by utilizing the facilities and trained personnel already available. The
Committee noted in this connection that the Indian Research Fund Association
had constituted a clinical research unit at the Tata Memorial Hospital for cancer
research in Bombay. The Committee believes that it was the intention of the
Associtation to make the services of such units available, not necessarily for
researches on the problem of cancer but for other clinical researches as well,
wherever the need for the same would arise. The Committee, therefore, suggests
that order to make an immediate beginning in this respect, the IRFA may be
requested to consider the possibility of entrusting this work to the clinical research
unit already located in the Tata Memorial Hospital, Bombay. In making this
suggestion, the Committee have taken into account the facilities readily available
at the Acworth Leprosy Home in Bombay which is situated not far away from the
Tata Memorial Hospital...”
I am referring to this episode here, for many had asked me how it was that
Dr Khanolkar with his primary interest in cancer, got involved in the problem of
leprosy. Dr Khanolkar’s contributions are well known. The isolation of the so-called
‘ICRC’ bacillus’, initially by nerve tissue culture method by him and Dr (Mrs) Ranadive
from a leprosy tissue, was, in my opinion, a finding of great importance. What had
impressed me most was that apparently no attempts had been made elsewhere to
confirm or refute his findings. Yet the Ciba Foundation had held a symposium in his
honour where the findings were fully reported by Dr (Mrs) Ranadive!
II
Working out a basis for National Leprosy Control
Programme
In 1949 I submitted to the Leprosy Advisory Committee of the Indian Research
Fund Association of which I was the Chairman, a memorandum on the ‘Treatment
of leprosy patients in their homes —An approach to the problem of control of
leprosy in endemic areas’. It is, indeed, very interesting to note the evolution of
our ideas in the control of leprosy. The isolation of cases of leprosy as an effective
means in limiting the spread of the disease had been recognised throughout the
ages. In India, even today, there are many who would like to adopt this measure. In
practice, however, insurmountable difficulties had been encountered in instituting
this measure. The Bhore Committee in their report published in 1945 had stated
thus:
“The special committee had pointed out that in the past, the isolation of
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leprosy patients in their homes was widely practised by the people in India, but
that the tradition has gradually weakened in the country as a whole, and that
it survives, as an effective measure in one or two isolated parts of India, e.g. in
the Kangra valley in the Punjab. The Committee considers that the results have
been disappointing, and from the experience gained so far, it cannot be said that
isolation holds out much prospect of being widely and properly practised”. (Vol. II,
para 24, page 194)
Even so, the Health Survey and Development Committee had advocated
group isolation of cases of leprosy in certain selected areas in two specialised
institutions to be established for the purpose, one for the isolation of infective
cases and the other for the treatment of non-infectious ones!
With the discovery of Hydrocarpus (Chuulmoogra) oil derivatives fresh hopes
arose in the minds of leprologists for controlling the infection through effective
chemotherapy. The drug was particularly useful in the treatment of children
suffering from leprosy and it was believed that if childhood leprosy is controlled,
the affliction in adults would be controlled automatically after a lapse of a few
years! However, these expectations did not materialize.
With the introduction of sulphones and the results obtained initially, fresh
hopes arose in the minds of leprologists and public health workers, on the
possibility of control of the disease through chemotherapy. The patients not only
became bacteriologically negative in due course, but the clinical improvement was
also more marked. However, it was considered necessary that instead of giving
treatment at random, a deliberate attempt should be made to study all aspects
of the question at one selected centre including the optimum dosage needed to
affect a cure. Accordingly, I suggested the following scheme for the consideration
of the Leprosy Advisory Committee:
• The scheme should be regarded as a research project in the first instance.
• The scheme should be worked in association with an existing and well
established leprosy clinic or a sanatorium in a suitable endemic area in
the country.
• A small number of villages, not less than six, situated in close proximity to
the clinic or sanatorium should be chosen for study.
• It would be necessary to survey these villages in great detail to determine
the exact incidence of leprosy. The contacts of infective cases should also
be examined both clinically and bacteriologically.
• Half the number of villages should be chosen for sulphone therapy and
the rest treated as controls.
• Choice of the drug, the dosage and the mode of administration should be
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worked out in consultation with experts who have had some experience
with this form of therapy.
• Examination of patients at regular intervals should be conducted to
assess the effect of treatment on the progress of the disease.
• Provision should be made in the sanatorium to isolate for short periods
such patients as show any toxic or unorthodox reactions. Facilities should
be provided for routine biochemical investigations necessary in such
cases. On subsidence of such reactions the patients should be discharged
from the hospital and brought back to their own homes.
• Periodic surveys should be undertaken to determine the effect of such
measures on the incidence of the disease in control and experimental
areas.
The advantages of instituting such a programme were emphasised. If
the treatment is begun with the most infectious cases in the first instance, the
improvement that would be noted in their appearance during the course of
treatment, apart from any other clinical improvement, would be a sufficient
incentive for other less advanced cases to volunteer for treatment. There will not
be the same tendency for the concealment of the disease as hithertofore.
The scheme did not materialise. Because of the very reasons mentioned
above, the Ministry of Health decided to launch mass treatment of leprosy cases by
creating SET (Survey, education and training) centres in the endemic areas in the
country. The programme was carried out, it would appear, with varying degrees of
efficiency in different regions. The results. however, could not be assessed, I was
told, for want of adequate records. This deficiency, however, was remedied to a
certain extent by the work done under the aegis of the Gandhi Memorial Leprosy
Foundation with which I was associated since its inception.
III
Concept of an Institute for research in leprosy
As a step towards the implementation of the recommendations of the Health
Survey and Development Committee, the Ministry of Health decided to establish
an institute for leprosy research and appointed a Committee in 1948 to advise them
on the location of the institute and other cognate matters. Dr V. R. Khanolkar was
the Chairman of the Committee, Dr B. B. Dikshit and Shri T. N. Jagadesan were
278 My World of Preventive Medicine
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members and I was the Member-Secretary. Some of the terms of reference to the
Committee were as follows:
• The location of the proposed institute. In taking its decision on this matter
the Committee should take into consideration the existing institutions
which can be expanded in their activities in order to establish the
proposed Leprosy Institute as quickly as possible. The proximity of other
medical institutions, such as a medical college and a science or research
department under the control of the Government or of a university,
existing leprosy activities and the availability of laboratory and library
facilities should all be considered.
• The structure and functions of the proposed institute.
• The technical and administrative control of the institute.
• The successive stages through which the institute should be brought
into being”.
The Committee held its first meeting in Calcutta and discussed generally the
scope and functions of the proposed institute. The following recommendation of
the Health Survey and Development Committee formed the basis of discussion,
viz.:
“Its functions will include the training of leprosy workers, the active promotion
of research in this subject and the development of an information service providing
the latest information regarding the treatment of the disease and anti-leprosy
work in general for the benefits of Governments and organizations interested
in leprosy in India. It should assist Provincial Governments in the development
of their campaign against the disease, if so desired. The development of clinical
research and field investigations, as distinct from laboratory studies should be an
essential part of its duties.”
In order to acquaint themselves with several schemes of Leprosy Control
and Relief in several States, the Committee had discussions with Ministers and
Administrative Medical Officers in them. In addition, the Committee was fortunate
in receiving memoranda from several leprosy workers in India and particularly
from Dr Earnest Muir, Dr Dharmendra, Shri M. B. Diwan and Dr R. G. Cochrane. The
Committee also visited several institutions in the country, most of them functioning
as leprosy asylums. In one institution established 50 years ago, two patients were
still its inmates though admitted there in the first year of its existence!
Based on the study of the problem of leprosy, and the views expressed by
experts in the field, the Committee formulated its views on the scope and functions
of the proposed institute as follows:
• It should undertake research into the basic problems relating to the
inception and spread of leprosy.
My World of Preventive Medicine 279
Planning for the Future (1948-1965)
• It should promote field studies for the application of the results of basic
researches to the problem of controlling leprosy in the community. In
close collaboration with the local health authorities the institute should,
therefore, have access to a sufficiently large population among whom
epidemiological and other studies, as well as the application of curative
and preventive measures, can be carried out.
• It should produce leprosy workers of various types in sufficient numbers
and of the requisite quality.
• It should become the centre from which technical advice and guidance
emanate for the promotion of anti-leprosy work on sound lines.
• It should participate actively in the organisation and development of
provincial leprosy institutes when such are established and its services
should be available for the investigation of special problems in all parts
of the country.
While recommending the setting up of some traditional departments such
as for clinical research, laboratory research and epidemiology, the Committee laid
special emphasis on the development of the department of Orthopaedics and
Rehabilitation. The Committee noted as follows:
“The problem of physiotherapy and orthopedic treatment and rehabilitation
of leprosy patients is important and would continue to be so for very many years to
come even after a specific cure for leprosy is discovered.
This is particularly so in view of the fact that about 75 per cent of persons
suffering from leprosy in India belong to the neutral type who present problems
not of specific treatment but management of limbs and prevention and correction
of deformities… It will be the function of the Department of Orthopedics and
Rehabilitation to make notable advances in this subject”.
The Committee gave considerable thought to the question of locaation of the
Institute. Ultimately, it came to the conclusion that there were only two institutions
which could be considered for the proposed development of the Institute, viz.
the Leprosy Department of the School of Tropical Medicine in Calcutta and the
Government Lady Willingdon Leprosy Sanatorium at Chingleput, Madras. Both
were actively engaged in one or other aspects of research in leprosy. Ultimately,
the Committee decided in favour of the latter. The sanatorium had extensive
grounds for expansion. The hospital was well equipped including a good operation
theatre. There were also excellent library facilities in Madras. The facilities of the
Silver Jubilee Clinic for Child Leprosy would be at the disposal of the Institute when
established. Some work had also been started on orthopaedic problems with
the help of a visiting team from Vellore. The Committee, therefore, came to the
conclusion that work in leprosy, as envisaged by it, could be started immediately
with the existing set up at Chingleput.
280 My World of Preventive Medicine
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When I was in Madras, finalising some details with the Administrative Medical
Officers of the State, I got a telegram from the Ministry of Health in New Delhi,
asking me to send my biodata “urgently”. I did not know the reason for the urgency.
Anyway, I was to leave for New Delhi the next day. I contacted Rajkumari Amrit
Kaur immediately on arrival and asked her why the Ministry wanted my biodata.
She told me that the Prime Minister was finalising the list of a medical delegation
to China and that my name was included in the Delegation. I thanked her for the
honour. However, I told her that if I were to go to China, the final report on the
proposed Leprosy Institute would be delayed considerably and hence I was rather
hesitant to go. She looked at me and said that she was glad to find someone more
interested in work in India than a ‘jaunt’ abroad.
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CHAPTER XV
MY ASSOCIATION WITH THE GANDHI
MEMORIAL LEPROSY FOUNDATION
Ihave been fortunate enough to have been associated with the above
organisation since its inception. Initially the work was started under the
auspices of the Gandhi Smarak Nidhi and Dr Sushila Nayar was its first
Secretary. She worked as the Secretary of the Organisation for the first two years
or so at the end of which she submitted a report of its activities. I have drawn
heavily on that report to describe any contribution in the development of work in
the initial stages of the organisation.
The work envisaged for the organisation was, indeed, ambitious. The following
extract from the letter of Shri Devdas Gandhi to Dr Rajendra Prasad is worth noting:
“The Gandhi Smarak Nidhi undertakes country-wide campaign for leprosy
relief and its prevention by modern scientific methods with the ultimate aim of
eliminating it altogether. To this end all work carried on by Government and
private agencies will be coordinated under a central authority to be created
for the purpose. While work in villages will necessarily be aimed at relief and
prevention and must be a special feature of the undertaking, research institutes
will be established wherever convenient and necessary and adequate steps will
be taken to derive the fullest benefit from the experience of other countries”.
It was suggested that a sum of Rs. One crore should be set aside for this
purpose.
To give effect to the above general recommendations, a subcommittee under
the chairmanship of Shri Devdas Gandhi was appointed. Dr K. C. K. E. Raja and
myself were asked to attend the meeting of the Committee. When endorsing
the views expressed above, the subcommittee recommended the setting up of
a body to be known as “Mahatma Gandhi Leprosy Council” which would act as
a central organisation `charged’ with the duty of coordinating all leprosy work
carried out in the country by official and non-official agencies. The Committee also
recommended earmarking of Rs. Fifty lakhs for this purpose.
In November 1950, the Executive Committee of the Trust, with Sardar
Vallabhbhai Patel in the chair appointed a Board consisting of sixteen members
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to work out the policy and programme of anti-leprosy work under the Trust and
to supervise and guide its implementation. I was made a member of the Board
along with Dr Khanolkar, Dr Dharmendra and others. Unfortunately, before the
meeting of the Board could be held, Sardar Vallabhbhai Patel died in December
1950. The meeting was then held in February 1951, under the Chairmanship of Shri
Dadasaheb Maolankar. At this meeting the policy to be followed by the Board was
again discussed. It was emphasised by the Chairman that the policy of the Board
is to ‘put forth the maximum possible effort not only for the relief, but also for
the eradication of the disease’. He further added: “While the value of research was
recognised by the trustees it was not their idea to have it carried out within the
four corners of the laboratory room. The principal field of work in research would
be the human element, the patient’s actual suffering and an investigation into
their social, physical and psychological condition. For obvious reasons, the Trust
could not think of spending large capital amounts in buildings and equipment.
The Trust would like to carry on these activities independently of the Government
organization, though it would always be ready to take from and to give to the
Government such help and cooperation as may be mutually necessary”.
The Chairman, therefore, suggested that the Board should have a small
executive committee which could supervise the schemes finally accepted by
the Trust. Dr Jivraj Mehta was appointed the Chairman of the subcommittee,
Dr Sushila Nayar the Secretary and Dr Khanolkar, Dr Dharmendra, Shri Manohar
Diwan, Shri Jagadesan and myself as members.
The members of the Board had recommended that it would be advisable to
start a “Leprosy Service”, so that the services of medical and non-medical men with
a ‘missionary zeal’ could be utilized for leprosy work. A Committee was appointed
to work out the details. Again, I was made a member of that Committee. It would
be interesting to record what conditions of service the Committee ultimately
recommended. I quote from the report:
“A medical member will draw a salary of Rs. 250/- per month, and non-
medical members Rs. 150/- a month. Both categories of members will be entitled
to an allowance of Rs. 30/- per month for each child up to the age of 21. The
concession was limited to three children. In addition, the same allowance will be
admissible for one or two dependents other than the wife. In addition, they would
be eligible for free quarters or house rent not exceeding 10 per cent of the salary”.
Dr Desikan was enrolled as the first member of the service on 1st January 1952.
There was one recommendation in our report to which I would like to draw
special attention. The maximum salary which any medical person would get,
even when he was eligible to all the concessions stipulated, would be no more
than Rs. 425/- per month. Yet the Committee had stated in the report that “if
any worker chooses to accept lower salary, he should be free to do so”. Was that
recommendation a reflection of the mood of the people soon after independence?
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In 1952, Dr Sushila Nayar, retired as the Secretary of the Organisation and
Dr R.V. Wardekar was appointed to succeed her. More or less at the same time
the Gandhi Smarak Nidhi decided to reorganise the work of the Board. The name
of the organisation was changed to “Gandhi Memorial Leprosy Foundation” and
it was given complete autonomy to develop its programme of work. In 1953, the
Leprosy Advisory Board was also abolished. I continued to be a member of the
Foundation.
The Policy of the Foundation went through a radical change in the ensuing
years. It corroborated with the Government of India in evolving a Survey, Education
and Treatment (SET) pattern for the control of the infection. It was decided to
ascertain whether planned use of DDS in a population could control leprosy as
was indeed suggested by me to which I have referred to earlier. Ten control units
were established for this purpose in different parts of the country. I must pay a
tribute to Dr Wardekar for the manner in which work was organised and records
kept. It was possible to assess the results of this approach in the control of leprosy.
I, along with Dr Wardekar, gave thought to assessment of leprosy control work in
early seventies and a joint article by us was published in Leprosy in India (Vol. XXXIV
No. 2, 1962).
In March 1961, I got a letter from Dr Wardekar. He indicated his desire to retire
from the Foundation, and since I was contemplating retiring from the Indian
Council of Medical Research, I should take his place. He wrote: “It looks rather queer
that at this young age I should leave the Foundation and request you to take over...
at this age of yours”. He further added: “The Foundation is in a very critical State
and needs a person like you at the helm of affairs. If you do not take the post, I am
afraid a promising organisation will crumble.”
Since he could not be persuaded to stay, I agreed to take up the post but
added that the date of retirement has not been fixed. At the meeting of the
Foundation on June 23rd 1961, the following resolution was passed:
“The Committee requested Dr C. G. Pandit to accept the post of Director of
the Foundation as soon as he retired from the ICMR. But Dr Pandit, though willing
to take up the post was not in a , position to commit immediately. .. Dr Wardekar,
therefore, was requested ... to accept the post temporarily”
Since the post of the Secretary was upgraded to that of the Director, it was
decided that Dr Wardekar should evolve, with the help of Dr Pandit, the role
and duties of the Director’s post. It was decided that the Director should not
be burdened with administrative work but chiefly attend to policy matters with
emphasis on:
• Pioneering work of the Foundation.
• Hospital work and research.
• Evolving new techniques.
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• Social education as regards leprosy and its eradication.
• Spread of work in the country.
Fortunately, Dr Wardekar was persuaded to be the Director of the Foundation
and I was spared from assuming responsibility for its work. I, however, continued
to be a member of the Foundation till 1970 when its constitution was amended
and I was elected as its Vice-Chairman which post I held till 1977. In that year, I was
elected Chairman of the Foundation
In the changed constitution of the Foundation (1970) the membership base
of the Foundation was enlarged and some of the veteran members retired and
new members were taken on the management body. I thought that the old
Body should prepare a well-documented evaluation report of the work done by
the Foundation under the old Body and present it to the new Body so that they
know how much has been done and what remains to be done. My suggestion
was approved by the Foundation and a small evaluation sub-committee was
appointed in 1971 with Dr Wardekar, Dr Deodhar, Dr Nilakanta Rao and myself as
members. The Sub-committee brought out its report of evaluation of Foundation’s
work which was appreciated by the new Body. As it was a valuable document, the
Foundation published it in the form of a book entitled “Gandhi Memorial Leprosy
Foundation: Prospect and Retrospect” (1974).
The earlier enthusiasm of leprosy control, evidenced for some years after DDS
was available, has gradually been considerably chastened due to experience in field
and results of small studies. An experiment in the treatment of contacts carried out
by Dr Wardekar from the grant from the ICMR did not give encouraging results
except in young children below 10 years of age (1972). Repeated annual surveys
in areas under leprosy control for over two decades indicated that new cases, in
a steady number, continued to occur in a community and there was a need to
find out some method to bring down this steady incidence. The results of further
assessment of leprosy control work in one control unit of the Foundation indicated
that though the disease process was arrested, treatment with DDS also produced
some kind of deformities amongst patients who had initially no evidence of them
(1978).
I have often wondered whether chemotherapy alone would ever help in
control and eradication of disease. Yaws is, perhaps, the only exception. The areas
of ignorance in leprosy are, indeed, many.
Development of national programmes for the control of
filariasis, smallpox, and cholera
Filariasis
In view of my interest in filariasis, it was but natural that I should give some
thought to the development of a programme for its control. My idea was to use
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the same approach as was contemplated by me for the control of leprosy, viz.
the use of a specific drug for the control of the infection. The introduction of
diethylcarbamazine (Hetrazan) in the treatment of filariasis had made such an
approach feasible. It was known then that the disease was mostly prevalent in
Madras, Andhra and Orissa, West Bengal, Bihar and parts of Uttar Pradesh. After
reviewing the situation in various States, I decided to initiate the experiment in
Orissa, since the Government very readily agreed to cooperate in the endeavour.
The project was launched in association with the then ‘Malaria Institute of India’
which had agreed to provide the staff and necessary supervision in its execution.
The project was initiated in 1949.
The objectives and the plan of work were as follows:
1. To determine the dose schedule that would be suitable for mass
administration of diethylcarbamazine;
2. To evaluate separately the suitability of each of the following methods in
the control of the disease, viz.
• mass administration of the drug on the basis of the selected dose
schedule under (1) above,
• recurrent anti-larval measures,
• recurrent anti-adult measures by indoor residual spray of DDT in
doses of 100 and 200 mg. per sq. foot.
3. To assess the results of the above measures by the following indices
regularly collected at specific intervals:
• vector density;
• infection rate in the vector;
• infectivity rate in the vector;
• the prevalence and the number of attacks of fever, lymphodenitis,
lymphoedenoma, etc. per person at monthly intervals;
• microfilarial rate in the community determined by annual surveys.
After sometime when the research project was under way, I thought I should
visit the project and see the progress of the work. Col. Jaswant Singh, Director,
Malaria Institute of India and I decided to visit Cuttack, the Headquarters of the
project. As stated earlier, the project was really under the control of the Malaria
Institute of India. When we arrived in Cuttack we found to our great surprise that
the Officer-in-Charge was not there. Some of the staff members were on leave and
the records of work had been sent to Delhi! I believe Col. Jaswant Singh was equally
surprised to note this. We had no recourse but to return to Delhi. What surprised
286 My World of Preventive Medicine
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