A Clear Roadmap for Collaboration – Interview with Dr. K. Srinath Reddy


How many McAloo Tikki burgers is too many?

By Zoe McLaren

I had the opportunity to meet with a group of teenaged girls to talk to them about public health is.  The topic of healthy eating seemed to resonate most.  So how much information do well-educated teenagers from good, but modest, backgrounds know about healthy eating?

These young women face similar challenges as in the United States.  They knew that healthy eating means a “balanced diet”, eating vegetables and avoiding sugar.  Eating dairy products like yogurt was considered healthy.  With a little prompting they suggested that limiting salt and oil would be a good idea.  They taught me the Hindi word for refined flour — maida – and knew to avoid it when possible.

india_cookies600From their perspective, the main unhealthy eating problem in India is junk food (“packaged foods”).  They know it’s bad for your health but not exactly why.

Many good questions came up during our discussion.  If salt is bad, does that mean all spices are bad? How can they tell if a food is “processed”?  How much salt and oil is too much?  If the McDonald’s India burger is made from potato (the McAloo Tikki Burger) and not beef then isn’t it okay to eat it five times a week?  Is it possible for women to get heart attacks?

india_veggiestand600The young women I spoke to have a lot of the information they need to make healthy food choices, but they admitted that it wasn’t always easy to make the right choices.  They suggested that having public health messages that were relevant to them specifically would help.  What important information would you want to tell them about how to maintain healthy eating habits?


India Trip 2013: Final Thoughts, and What’s Next

Dealing with missing data in India

Biostatistics is a field of public health that is just getting started in India. The country has many excellent statisticians, but they’re mostly focused on highly mathematical, theoretical problems. This is something Trivellore Raghunathan hopes to change.

Photo of Dr. Raghunathan,  professor and chair of the U-M SPH department of biostatistics

Dr. Raghunathan, professor and chair of the U-M SPH department of biostatistics

Although biostatistics is complex, Raghunathan has a simple way of explaining what it is. It’s all about the design and analysis of data, he says.

“It’s not just about the analysis,” he added. “A lot of people come to you with the data they’ve collected, and they want to analyze it. But if the data is not collected in a good manner, no amount of analysis is going to be useful. So therefore I emphasize the design and the analysis.”

Raghunathan was part of the delegation from the School of Public Health at the University of Michigan. He left Ann Arbor early so that he could teach a one-day workshop about biostatistics at Indian Institute of Public Health in the southern city of Hyderabad.

The timing of the workshop was unfortunate because it was on a major holiday. But that didn’t affect attendance much, and 25 students showed up for the six-hour workshop. Many were clinicians from medical schools in Hyderabad, while others specialized in health informatics. Several traveled all the way from Kolkata in the east and Bangalore farther south.

Photo of Dr. Trivellore Raghunathan and participants in his workshop

Dr. Trivellore Raghunathan (front row-center, blue shirt) and workshop participants

“There were at least four or five people who said they cut short their holiday to come to this workshop,” Raghunathan said. “This is amazing. I was very pleased.”

One of the topics he covered in the workshop was what to do with missing data, a common problem in India. Often people decline to participate in a vaccination program because they fear the vaccine will make them ill or cause other problems. So data collection can be spotty.

“When you create a study, some people don’t show up and that can create a bias in the results,” Raghunathan said. “You are making conclusions about people who gave you the data, not those who should have given you the data. My research is on what kind of additional data can you collect from those people who don’t show up so that you can make an adjustment for your inferences.”

He added, “A great study design is important to find out what is the truth. That’s what I emphasized.”

Trivellore Raghunathan is a professor and chair of the department of biostatistics at U-M School of Public Health. He was part of SPH’s delegation that visited India on Oct. 11-19, 2013. 


Childhood Malnutrition: The Indian Engima

India’s ‘dual burden’ – obesity and malnourishment

Photo of Andrew Jones, assistant professor in environmental health sciences, at Qutab Minar in Delhi

Andrew Jones, assistant professor in environmental health sciences, at Qutab Minar in Delhi

By Andrew Jones

When I first traveled to India ten years ago for a winter break from my service as a U.S. Peace Corps volunteer in Kazakhstan, I was overwhelmed by the sensory contrasts – the smell of aromatic spices fused with the stench of open sewers; ancient temples poised against the backdrop of soaring high rises; and soft-spoken greetings amidst the frenzied din of city traffic. As I would come to learn, the societal contrasts in India are no less stark.

Nutrition is just one example of these contrasts, but a revealing one especially for those of us interested in public health. Between 1998 and 2005, the Indian economy grew by leaps and bounds, expanding by 40 percent in just seven years. Yet, malnutrition among preschool-aged children, one of our best indicators of the extent to which development efforts are reaching the most vulnerable, declined only marginally in that same time period.

Analysts posit that inequitable growth biased away from the poor explains this enigma. Others suggest that low coverage of proper sanitation and adequate health services is the culprit. Whatever the cause, the prevalence of overweight in India increased by 20 percent in that same seven-year period. Currently, one in five individuals are overweight, and the prevalence may be double that in some urban areas.

This so-called “dual burden” of malnutrition, wherein undernourishment and overweight co-exist, presents a serious challenge to developing coherent nutrition policy. Cultivating a more nutrition-sensitive food system is almost certainly a big part of the solution. This means providing not only sufficient calories for all, but ensuring equitable access to balanced, diverse diets that do not rely on processed foods. Coordinated efforts from many different sectors are required to reach this goal.  With the highest number of malnourished children in the world and rapidly westernizing diets, India cannot afford to linger in moving this agenda forward.

Jones is an assistant professor in environmental health sciences at the University of Michigan’s School of Public Health. He was part of SPH’s delegation that visited India on Oct. 11-19, 2013. 

A goddess of many hopes or beast of many burdens?

By Sonia Hegde and Zoe McLaren

Photo of young volunteers who work in an urban health center in Hyderabad as ASHAs - Accredited Social Health Activists

Young volunteers who work in an urban health center in Hyderabad as ASHAs – Accredited Social Health Activists

Traditionally, community health workers have been chosen members of a community to provide basic but essential health care with limited training, support and supplies. In India, however, the model of the ASHA – Accredited Social Health Activist – was instituted by the Ministry of Health and Family Welfare  in 2005  to create awareness of health and its social determinants and to increase the rates of institutional delivery (rather than at-home births) and immunization.

As the majority of India resides in peri-urban or rural lower economic status communities, ASHAs play a significant role in distributing health information through their trust, intricate knowledge of the families and repeated observations of behavior. Our delegation from the University of Michigan’s School of Public Health debated whether or not the responsibilities of an ASHA should be expanded, and if so, into which realms. Should ASHAs be encouraged to become social entrepreneurs or should the current model of “incentivized volunteer work” remain?

Is it possible to give the ASHAs more training and more responsibilities without reducing their effectiveness at their current tasks? Could they learn how to identify cases of diarrhea, pneumonia or tuberculosis? Could they identify a child who has been coughing with fever or blood and urge a visit to a hospital? Remind a mother that oral rehydration salts are the best treatment for diarrhea? Could ASHAs serve as front-line surveillance systems to identify infectious disease outbreaks?

ASHAs could improve public health and increase the empowerment of the young women themselves. A greater investment in ASHA could yield a big impact.