DR VIKRAM PATEL, the Pershing Square Professor of Global Health in the Blavatnik Institute at Harvard Medical School and a well-known expert in public health, will take charge as the new chair of Global Health and Social Medicine at the prestigious Harvard Medical School on September 1. Patel has served on several World Health Organization advisory committees and has served on multiple Lancet commissions on global mental health. He currently co-leads the Lancet commission on reimagining India’s health care system. In an exclusive interview with THE WEEK, Patel spoke about a range of issues from the barriers in achieving health equity to the problems with our medical curriculum. Excerpts:
Q/ Harvard has partnered with historically black educational institutions to promote equity, social justice, and human rights. How do you envision fostering similar partnerships with institutions in the global south?
A/ First and foremost, it's important to acknowledge that health inequities stem from distinct historical factors in various countries. In the United States, a significant portion of these disparities can be traced back to a history marked by violence, beginning with the mistreatment of indigenous and native American peoples, followed by the atrocities inflicted upon enslaved African populations.
India grapples with a distinct form of structural violence perpetuated through its caste system. Interestingly, both nations share a form of violence that transcends borders, namely the impact of neoliberal systems that have exacerbated wealth disparities on a global scale.
Within these neoliberal economies, there's a pronounced fragmentation of health care, manifesting as a privatised and profit-driven medical system catering to the affluent, while the less privileged are left with an inadequately funded and resource-deprived public health care system. This dynamic isn't confined to India; it's equally applicable to the United States. There's a peculiar similarity between these two countries in terms of the sorts of injustices and inequities.
What Harvard is seeking to do is to participate in a national process of reparation to correct this violent past of America by forming partnerships with historically black universities. Also, in my department, we have a strong commitment to decolonising global health. What does that mean? It's a movement. The global health component of a much larger conversation that's happening in India as well when we talk about decolonising education. When we say decolonising the way we think about the world around us.
This, I think, is an important process. Because colonisation was a brutal experience for three-fourths of the world's people, including everyone in India. It only ended recently for some parts of the world. And I do believe that, in my department, we need to directly address how the practice of global health has been influenced by those colonial inequities.
A prime example is the setting of health research agendas, which has frequently been dominated by entities in the global north―akin to institutions like my own. This bias also becomes evident in the allocation of health research budgets, with an unjust proportion flowing toward institutions like mine. Moreover, historically, research credit has predominantly been attributed to universities in the global north.
My colleagues and I are, however, committed to partnerships with the global south. I co-founded Sangath, an Indian NGO that remains one of my university's leading health research partners in India. Our goal is to ensure, for example, that when we work with Sangath, our colleagues in Sangath set the research agenda. They do this in partnership with local ministries of health and communities that they're trying to serve. And importantly, when we publish our findings, Sangath researchers are given the opportunity to be the lead or senior authors.
Q/ Research universities, like Harvard Medical School, have the potential to effectively address health care delivery issues, especially for vulnerable populations such as the poor. In your opinion, how can research universities contribute to achieving global health equity?
A/ Harvard is an incredibly privileged institution. And I think what our role has to be is to use and deploy our privilege and also, honestly, our authority to actually do public good. And that public good must include explicitly addressing historic injustices in how health care resources are distributed. I think one example is our investment―direct investment through research capacity building in institutions in Africa, South America and, of course, in India.
I'll give you one concrete example. In Rwanda, a significant feat was accomplished through the establishment of the University of Global Health Equity (UGHE), an endeavour spearheaded by my predecessor, the late Paul Farmer, whose legacy I now follow. This university is one of the first medical schools in the world where the entire focus of medical education is addressing health inequities.
This approach is potent and transformative. Contrasting this with the scenario in India, medical education continues to carry vestiges of colonial influence. Scrutinising the curriculum and its historical context, one can discern that it closely resembles its state in 1947. Its foundations were heavily shaped by the notion that we were preparing doctors as if they were bound for England, destined for city hospitals. What was required, however, was a comprehensive curriculum overhaul that mirrored the health inequities prevailing in India during that era. Regrettably, traces of these inequities endure to this day, albeit, hopefully, to a lesser degree.
A pertinent example lies in our failure to emphasise primary health care, equipping doctors to serve both urban and rural underprivileged populations. Our curriculum should have gravitated toward ailments that disproportionately affect our populace, such as infectious and tropical diseases. Instead, we find ourselves entrenched in a medical education paradigm that readies doctors for careers in the NHS or the corporate hospitals in India, or even those in prominent medical centres like Boston, rather than centring on addressing India's public health demands. What UGHE is doing in Rwanda is completely turning that around. It is training doctors primarily in the skills that they need to work with the average person in Africa and indeed in any part of the world, you know, depending on where the students come from.
Q/ What are the elements from different medical education models that Indians must take note of?
A/ Various aspects of different medical education curricula warrant examination. Take the United Kingdom, for instance. Following the completion of MBBS training, individuals are not automatically eligible to practise in any setting, including primary care. Instead, they proceed to undertake speciality training, which includes primary care or family medicine specialisation. This model merits consideration on a global scale, with the aim of elevating primary care and family medicine to specialised status and thus rendering it more appealing. The challenge at hand is to strategise how to entice the brightest medical graduates toward primary care. Rather than overhauling the entire medical curriculum, one approach could involve establishing a specialised MD track in primary care and family medicine.
Another innovative approach is exemplified by certain medical schools, mostly situated in the global south. For instance, in Granada, Zimbabwe, there's a medical school where students engage with families in the community from the onset of their MBBS training. Over the span of four-and-a-half to six years, students establish ongoing relationships with these families, frequently visiting and interacting. This immersive experience fosters a comprehensive understanding of health and health care within its social context, effectively expanding medical education's focus from being hospital-centric to embracing community-centric principles.
Numerous such innovations are evolving within medical education. However, it's paramount that we address a shared concern in both India and the United States: the privatisation of medical education. This matter warrants deep consideration due to its potential repercussions. Graduates burdened by substantial financial debt incurred during their medical education are inevitably compelled to prioritise debt repayment. As fresh medical graduates are not typically high earners, there's a subconscious temptation to gravitate towards lucrative commercial practices rather than patient-oriented care, largely driven by the need to settle the debt. This phenomenon underscores that the commercialisation of medicine poses a significant threat to global health equity. This trajectory is initiated from the very moment a student enrols in a private medical school. So I do believe that the commercialisation of medicine is the single biggest threat to health equity in the world today. And we really do need to, therefore, re-examine the cost of medical education.
Q/ India is considered a global pharmaceutical major. But do you think that we still lack original research? And what can we do to improve the situation?
A/ I think India’s research infrastructure in the health field is extremely weak. We have to take [into consideration] what scientific publications we have and products and patents that have transformed health care. There are only a few, for a country of our size. In large part, it has to do with our health research infrastructure and the funding mechanisms.
Another big challenge is the fact that most health research should be taking place in medical schools. However, medical schools in India do not do any research. Barring a few exceptions, medical schools are largely educational and service centres. This is in contrast to Harvard Medical School, for example, which is one of the world's top medical schools, not only for the medical care that the hospitals deliver, but actually because of the outstanding research that is conducted there. So I do think that the lack of adequate investment in medical schools for research is a big barrier.
Our biotechnology sector is very strong. We have 1.4 billion people. We have diseases of all kinds in the country. We have this enormous network of hospitals. India should be at the forefront of medical research, but we're not. And I think this is a very important challenge that can be fixed.