We talk a lot about sustainability, equity, and capacity building at DHN. That's because we understand that it's not enough to simply send diaspora back to their home countries; what they build has to create deep-seated change that outlasts them. At the same time, we understand just how hard it is to set up that sort of lasting endeavor in a low-income country. That's why it was so exciting to meet Dr. Sudhakar Pesara “P.S.” Reddy, a cardiologist whose passion for India spurred him to found a thriving hospital, medical school, and a large-scale community health project.
Dr. Reddy grew up and attended medical school in Hyderabad, in south-central India, and obtained Membership of Royal College of Physicians (Edinburgh). He wanted even further training afterwards, and with the help of a friend he applied to the University of Pittsburgh, where he was immediately offered a Chief Resident position. He was hesitant to accept that much responsibility immediately (initially declining it) but eventually agreed to complete a year of residency and then become a Chief at Montefiore Hospital in Pittsburgh. He went on to complete a cardiology fellowship at Presbyterian Hospital across the street.
He joined the faculty after completing his fellowship and became the director of the cardiac catherization lab at (what is now known as) UPMC Presbyterian for 24 years. At one point during his tenure he was able to bring a family friend with a congenital heart defect to the hospital for an operation. However, he became increasingly aware of the cardiac need in his home city of Hyderabad, a city of seven million in a country known to have increasing levels of cardiovascular disease, which still did not have an advanced cardiac center.
Not long after he began investigating potential opportunities to address this issue, he also began to tune in to the pressing need for research capacity among India’s medical schools. In our interview, he hearkened back to his first research opportunity here in the United States. He frequently encountered patients with anemia and rheumatoid arthritis, which he had seen treated with an iron infusion in Edinburgh; however, he was unaware of there was any evidence backing that approach. So he went to the library one night, borrowed out a stack of articles on the topics (it was the '60s) and convinced his preceptor to run a small trial to see whether the treatment really improved outcomes.
Things didn't turn out as planned: the first three patients they trialed had their arthritis get worse, and they had to end the study after treating 7 patients. The results still enabled him to produce a paper on it in a major journal, an experience which still affected him deeply.
"Here I come, and the very first week and I become a researcher!" he told us. "Meanwhile some individuals go through their whole life without being exposed to research. I said to myself: one day I'll see that medical education in India has a research component."
He first tried to work with government hospitals in the region, but he was unable to make much progress-- as he explained, "they were so set in their ways; in the host vs graft reaction, host won, graft was rejected." So he decided to start an institution of his own. He contacted alumni of his medical school and raised $250,000 to start the Science Health Allied Research and Education (SHARE). He reached out to both federal and state level government leaders (including the minister of science of technology) to help facilitate the details of incorporation. That's he encountered the first of many challenges in this journey: the huge expense of starting a hospital. He had to up the ante on his networking skills.
"The chief minister of Andhra Pradesh our state came to the US for a kidney transplant. So I met him. He asked me, 'what are you doing?' I said 'I am starting a hospital, I have land and some money but no government help.' He said 'what do you need?' So I took him to Chicago to a meeting of donors. I told him that while I have land I don’t have roads, I don’t have electricity, I don’t have a telephone line. I need permission to run a lottery to raise the money. He said 'I don’t usually do this, but irrespective of the cost, I will give whatever this doctor asked.'"
"I was able to raise 1,000,000, which I used to start building, but the money ran out. I went to financial institutions for loan which refused to consider our application because I was a nonprofit—but I was running like a business! I recruited the recently retired Chairman of Reserve Bank of India to become the chairman of SHARE. Of course, with his credibility, banks gave me a loan for ~10 million Rupees."
Ten years later, the 150-bed Mediciti Hospital was finally built, initially to serve only cardiac patients; this was followed by the construction of another city within Hyderabad--Mediciti City Center. Mediciti Hospital was eventually expanded to a medical school--MediCiti Institute of Medical Sciences--that is now 14 years old and graduates 150 students each year. The hospital now has 800 beds and covers a panel of 500 outpatients daily.
As successful as that was, it soon was evident that even building a hospital and a medical school wasn't enough.
One day, his donors posed a challenge to him: his brand new hospital and medical school were doing relatively little for patients in surrounding villages. They suggested that he take on family planning and immunization, which were both underutilized in the region (the vaccination level at that time was estimated to be about 50%). He decided to accept the challenge, starting with a pilot in a village on Hyderabad's outskirts. He approached a nun heading St. Theresa Hospital in Hyderabad for assistance. Her first piece of advice was telling:
"First thing, you have to have a doctor. And don’t mention family planning--if they have a stomach ache or headache, they should be able to get treated. That’s how you bring confidence."
A doctor and nurse were hired for the village and an assessment survey was conducted to identify all children below 5 years, pregnant women and women with two children or more and to determine need for tubal ligation procedures (the most common method of contraception in India) and vaccinations. Women were invited to have the procedure in a specially designated facility, and were allowed same day discharge to home with home care nursing support (a step up from government facilities which required a five-day post-op stay in the hospital).
There were setbacks: at first local officials were unwilling to partner in Reddy's efforts or provide the subsidy that it traditionally gave to patients in its hospitals. However, more patients were attracted to the shortened stay that Dr. Reddy's operating suite permitted, and as attendance grew, the government eventually came on board. (The vaccination program had it’s own share of challenges related to low staffing and supplies within the existing national infrastructure program, requiring Dr. Reddy to invest in auxiliary staffing, transportation and cold chain storage to enhance delivery.)
Nonetheless, he eventually achieved 100% immunization coverage in the first village, and then went to take on several more villages until the Rural Effective Affordable Comprehensive Project (REACH) covered 40 villages across Andhra Pradesh. A community health volunteer program was set up to surveill marriages and births in each village so that immunizations and family planning could be continually available. As a testament to their work, the 12-23 month immunization rate has risen from 43% to 98% across the village cluster; the total fertility rate dropped to 1.8. (Here are some published results from their efforts.)
Though he is partially retired from practice, he remains involved in capacity building and academic training in India, as well as mentoring the Longitudinal Family Health Study (patterned on the US’s National Children Study) and the Mobility and Independent Living in the Elderly study (MILES), both based in India. (In the middle of all this, he still makes time to spend part of each year to do clinical work and teach at the University of Pittsburgh.) Achieving research capacity in India’s medical colleges remains an important motivation for his work, a process that he feels is iterative, sometimes requiring the repeated instillation of basic skills. Most importantly, it requires strong local leaders as partners:
"Someone locally has to have passion, and even power. Passion without power is useless. In India and China and the Middle East, [the medical establishment] is very hierarchical, and [leaders] can feel threatened if someone junior goes ahead of them. Only the guy in charge of the department can allow the research to be done in the department."
However, was clear to him that any individual in the diaspora wanting to make social change at home, your own passion is paramount for success:
"There are bricks all around you, but there needs to be a cementing force," he told us. "I am just a cementing force, there are bricks who make the building. To lead one has to be prepared to play the role of ‘One’, then many others volunteer as zeros and the organization grows and becomes mightier with addition of each zero [—until you become 1,000,000’s]. A lot of passion and sacrifice is necessary, and even family has to be willing to bear the cost."
At the end of the day, Dr. Reddy is successful because understands the importance of being locally driven. He takes to heart the words of the village nun who helped set him off on his journey to improve public health:
"What you perceive as the need doesn't count--it’s what local people perceive."