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Eminent Indians in Medicine

Dr V. Ramalin aswamiMD, DSc (Oxon), FRCP, FRS

Vulimiri Ramalingaswami (b. 8 August 1921) has been at the centre-stage of the Indian medical scene for more than two decades. He hasmade major contributions to research in protein calorie malnutrition,Himalayan goitre, endemic goitre in Southeast Asia and liver diseasesin India.

He began his career as pathologist for the Indian Council of MedicalResearch (ICMR) at the Nutrition Research Laboratories, Coonoor,South India (1947-54), and later became Assistant Secretary andDeputy Director, ICMR (1954-57). He was professor and head ofthe Department of Pathology at the All India Institute of MedicalSciences (AIIMS) from 1957 to 1969, and then became Director ofthe Institute. In 1979he returned to the ICMR as Director-General,and retired in 1986.

During his celebrated career he has held many important positionsand has been the recipient of many national and internationalawards including the Padma Bhushan; Leon Bernard FoundationAward, WHO; J.e. Bose Medal, Indian National Science Academy;Basanti Amirchand Prize, ICMR; Shanti Swaroop Bhatnagar Award;Watumull Award and Edward Chapman Research Prize, MagdalenCollege, Oxford.

A man of varied interests including music, literature and sports,Dr Ramalingaswami is currently adviser to the UNICEF.

NMJI: Dr Ramalingaswami, would you tell us aboutyour early life, your parents, school days and universityeducation?Dr Ramalingaswami: I was born in a place calledSrikakulam, which is today the headquarters of the north-ernmost district in Andhra Pradesh. I was born into a familyof teachers well known in that area. My grandfather hadbeen a contemporary of Sir C. V. Raman's father whenthey taught at the A.V.M. College in Vishakhapatnam. Helater moved to Bobbili near Srikakulam and established ahigh school of which he was also the headmaster. I spent apleasant childhood in that school. It was a beautifulschool, set in a mango grove, with spacious airy rooms anda big playground.

My father was a minor official in the local Raja's court.He was deeply committed to puja and meditation and wasnever interested in a professional career. My mother alsocame from Srikakulam. Although she had very littleschooling she could read and write. Her father was anartist. Of all my relatives the person who influenced memost was my grandfather. He was a scholar in Sanskrit

and English, and was among the first graduates in Englishof Madras University. He was also a contemporary ofDr S. Radhakrishnan, the late President of India. Whenmy grandfather became blind, I had the morning task ofreading out to him the Hindu newspaper. It containedclassical pieces of writings by Dr Radhakrishnan.

In school I was very keen on sports and used to playhockey and football, Academically, I was always amongthe brightest. I never wanted to go into medicine. You willbe surprised to know that in those days seats in medicalcolleges were not completely filled. Medicine held littleattraction for the best students, who were more interestedin mathematics, physics, chemistry and engineering. I,too, took mathematics, chemistry and physics in my two-year preparatory career in college. I was about to join theengine.ering college, when a family friend happened tomeet Dr J. F. Shephard, the principal of the AndhraMedical College, and asked about admission. The collegehad 30 seats but only 29 students. Though there was a wait-ing list, the grades of those candidates were unimpressive.The principal looked at my grades and thought they were

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good. Though I had no background in biology, he got asanction from the Surgeon-General and I got intomedicine without having studied biology in the two-yearpreparatory course.

NMJI: How did you fare at medical school?

Dr Ramalingaswami: Very well, extremely well. Again, Inot only excelled in academics as before but also in sports,debates, and in dramatics. I must say that at the AndhraMedical College my stay of five and a half years was verypleasant.

NMJI: And what did you do after medical school?

Dr Ramalingaswami: I decided to specialize in internalmedicine, called general medicine at that time. AnEnglishman from the Royal Army Medical Corps,Samuel Shone-a product of Guy's Hospital-was theProfessor of Medicine at the college. He encouraged meto study internal medicine. Another person from whom Ibenefited a lot was Kutumbiah, an Indian Christian whopreached on Sundays. He was a man of high principlesand was extremely well read. We were like father and son.

NMJ/: How did you get into pathology?

Dr Ramalingaswami: Drs Samuel Shone, Kutumbiah andPinnamaneni Venkateshwara Rao (a surgeon who is stillin private practice), all advised me to pursue a researchcareer. My dissertation was on anaemia. It was consideredthat an MD postgraduate in Internal Medicine, whoentered state service and joined a medical college, wouldsoon become a millionaire and wield a great deal of localinfluence. But I did not enter government service. I sawan advertisement for the post of a research officer at theNational Nutrition Research Laboratory at Coonoor inthe Blue Mountains (Nilgiris). I knew of the institutewhen its director, Dr Aykroyd, had paid a visit to Vizag inconnection with his research into beri-beri. When Iapplied for the post, an Indian called Patwardhan, anextraordinary man, had become the director of thelaboratory. At that time they had no physician and somebeds in a local government hospital. I went there as a clinicalresearch officer. It was then that I described the syndromeof kwashiorkor. In the same year, 1947, I also describedthe diarrhoea in children which, I thought, could be attri-buted to vitamin A deficiency. I published those papers inour local medical journals and am still very proud of havingdone that. People ignored these articles until much later.I was the first to see the skin lesion in kwashiorkor which isits most arresting feature. These patients have a dermatosis,which the Gillman brothers in South Africa called theInfantile Pellagra syndrome. I was in touch with both thebrothers. I used to push in nicotinic acid and the skin lesiondried and the crazy pavement dermatosis of kwashiorkorbegan to heal. I was filled with hope that things werebeginning to move and yet, within a few days, the patientswould die. Obviously, I had not reached the core of theproblem; rather, I was addressing an epiphenomenon. Iwanted to know why these children died. In the smallgovernment hospital, I used to do autopsies and wasstruck by the intensely fatty livers. That started my journey

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into Pathology and I decided to devote myself to Pathology.My interest in the liver also started with nutrition. I triedto produce a similar fatty liver in animals while I was inCoonoor. During that period, I told Dr Patwardhan of mydesire to receive some training in Pathology and that, withmy background in Internal Medicine, this would be useful.I had spent a year as a clinical research officer from 1947to 1948.

The government of independent India announced thatthey would provide scholarships for Indian scientists to betrained in Britain. I was one of the first selected, butbefore I left India in February 1949, I had a six month stintwith a man in Pune, Leo Krainer, who was a very goodneuropathologist from the Vienna School of Medicine. Atthat time I was feeding monkeys with Lathyrus sativus inan effort to produce lathyrism. The monkeys came downwith dragging feet. I saw from the autopsies that I hadproduced scurvy instead of lathyrism, and this reinforcedmy desire to go into pathology. I went to Hugh Sinclair inOxford who had a Well come Research Laboratory onhuman nutrition. He also had close connections with theDunn School of Pathology and with the Pathology depart-ment of Radcliffe Infirmary. He was happy to accept meas a scholar. I received a handsome stipend of £38.

NMJI: Could you tell us about your career since then?

Dr Ramalingaswami: Oxford was again a period ofgrowth and learning for me. I earned my D.Phil. there,fully participating in sports as well as in the Oxford Unionbesides doing my own work. I would have been a contenderfor an Oxford Blue in hockey but pulled a hamstring duringthe final selections. The Oxford period was characterizedmostly by experimental studies. I came to know AlistairRob-Smith at the Department of Pathology of theRadcliffe Infirmary and Sir Howard Florey at the DunnSchool of Pathology with whom I had a lot of interaction.

Another contact at Oxford was Sir Robert McCarrisonwho was the first director of the Nutrition ResearchLaboratory. He is well known for his work on Himalayangoitre and was the first to elucidate the concept of goitro-gens. His study of cretinism in the Gilgit area of Kashmir,way back in 1920, is considered a classic. This associationsparked off my interest in goitre.

I returned to India after two years and went back to theNutrition Research Laboratory as a senior researchofficer. I was made the pathologist-in-charge, and Ienjoyed it greatly. The Ph.D. students were bringingbiochemistry and pathology together and this gave me alittle insight into biochemistry. However, I did not stay inCoonoor for long. In 1954, Rajkumari Amrit Kaur (thenMinister of Health) and C. G. Pandit (then secretary ofthe Indian Council of Medical Research) asked me tocome to Delhi and work with the Rockefeller Foundationwhich had a strong interest in Indian medical colleges andresearch. At that time only a few medical colleges in Indiawere doing any research. I and P. K. Anderson, a represent-ative of the Rockefeller Foundation, were to visit Indianmedical colleges and develop a scheme for encouragingand stimulating medical research in the medical schools. Ijumped at the idea, because I wished that the kind of

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research being done in the Nutrition Laboratory shouldalso be done in medical colleges. I was supposed to comeonly for three months, but I stayed on.

A good medical school in India was needed to trainIndian scientists entirely within the country, and sendthem back to their colleges. A draft constitution of theAll India Institute of Medical Sciences (AIIMS) was passed,and the first students were taken in 1956. Some time in1956 I applied for the position of Professor of Pathologyand I was selected though I had no teaching experience.The enlightened selection committee under the chairman-ship of Sir Lakshmanaswami Mudaliar looked into what aperson had achieved and what potential he had ratherthan his experience.

I joined AIIMS in 1957. During my stay at AIIMSfrom 1957 to 1979 I developed an intense interest inmedical education. I introduced the case method of teach-ing in pathology and the clinico-pathological conferenceas practised at the Massachusetts General Hospital. Iintroduced student evaluation of teaching methods, as acorrective tool, at the end of every teaching session.Medical education was given a community orientation withBallabhgarh (a small town near Delhi) being developedas a field practice area. During the early part of thisperiod, three men-Benjamin Castleman, Hans Popperand Hans Smetana-were great influences on my life andI learnt a lot from each one of them.

In research, the main features were the experimentalstudy of the pathophysiology of protein energy malnutritionusing the Rhesus monkey as a model and, of course, thediscovery of NCPF (non-cirrhotic portal fibrosis). At thattime nothing was being done about Himalayan goitredespite its extensiveness, on the ground that we knewnothing of its aetiology. Thus a massive problem laycovered under a Himalayan blanket. I had developed aninterest in this area while at Oxford and the work onendemic goitre came to a peak at this time with theavailability of radio-iodine from Trombay and the use ofGeiger counters. I set up field areas where one could doreasonably sophisticated work and established a connectionbetween a large teaching hospital and a field situation.M. G. Deo, of course, was the key figure in all theseoperations, aided by M. G. Karmarkar who provided thebiochemical support. A. D. Pochin from UniversityCollege, London was involved with me in these studies.We found high uptakes of iodine, no goitrogens, no con-genital or genetic problem which may have a role in thebiosynthesis of thyroid hormones and a clear evidence ofsevere environmental iodine deficiency. The conclusionwas obvious: we had to get on with iodization. It was nota great discovery in itself but it had, in those days, (thelate fifties) a tremendous public health potential. How-ever, having established the aetiology and published thefindings I felt compelled to pursue the matter further bydemonstrating an effective intervention at the communitylevel, measuring its impact and then passing the results onto the government.

I then carried out the Kangra Valley experiment involv-ing 300000 people-giving one group salt fortified withiodide, another group salt which was iodated and a third

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group, no fortified salt. This might be criticized today asbeing unethical. I think at a time when our knowledge waslimited such a demonstration was necessary. After 18 to20 years of follow up we confirmed that a very small doseof iodide or iodate could prevent endemic goitre, cretinismand deaf mutism. This information formed the basis oftheNational Goitre Control Programme. Unfortunately, theprogramme did not really work well, but that's anotherstory.

Pathology in India suffered for many years by not havinga good autopsy service and utilizing autopsies as teachingand research tools -.But Lazaro, Sujoy Roy and others atthe AIIMS were committed to change this. Autopsy yieldswere very good and each case was well studied and providedmaterial for an excellent CPC (clinico-pathological con-ference). CPCs flourished at that time. Sujoy Roy and Iworked together on juvenile mitral stenosis and I wasgreatly influenced by him during this period.

In 1979, I was offered the post of Director-GeneralICMR, which I accepted because I had already spent tenyears as director of the AIIMS. At the ICMR I managedto get a four to five-fold increase in resources for medicalresearch. I believe that resources are essential. Gone arethe days when you could just borrow an electron microscopefrom somebody.

My major task was to relate research at the ICMR tothe dominant national health problems which desperatelyneeded new or additional knowledge to improve healthprogrammes. However, I ensured that 15% to 20% ofresearch funds were allocated to open-ended research, forcreative ideas from people not necessarily related to thesehigh priority areas. I also had a role to play in acceleratinga systematic approach to the study of indigenous systemsof medicine-particularly health problems for which themodern system of medicine does not have effective tools.

NMJI: From the ICMR, you went to the United Nations.

Dr Ramalingaswami: I retired from the ICMR in August1986. I went to the National Institutes of Health as aFogarty Scholar in residence. I was able to utilize sixmonths of scholarship left over from an earlier period. Iworked with Bob Purcell, who is a leader in non-A non-Bhepatitis, and I did some laboratory work. I then went toHarvard for the whole of 1987 as a Visiting Professor ofInternational Health Policy. During that exciting period,I did some teaching and a course in tropical diseases withJohn David besides getting involved with the InternationalCommission on Health Research and Development. In1988, UNICEF asked me to advise on the Child Survivaland Development Revolution, which aims to improve theChildhood Immunization Programme, control of diarrhoealdiseases and improvement of nutrition-all of whichpromote primary health care. I have now moved to NewYork, and immensely enjoy my work at the UNICEF.

N MJI: How do you manage to know so much about somany different aspects of medicine?

Dr Ramalingaswami: I do not know, it is a part of me. It islike my tendency to pursue a problem and not respect theboundaries between basic and epidemiological research.

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I would think that my background in internal medicine, tostart with, and later experience in pathology (related topathogenesis, aetiology and clinical expression) may havebeen the foundation for this.

Basically, I am committed to the idea, which I read inBertrand Russell's writing, that 'Science has two faces likeJanus. It has the face of creating knowledge, but has theother face of applying that knowledge.' I also believe thatscientific pursuit is not complete unless one attempts toapply this knowledge although one may often feel a senseof inadequacy in trying to do so.

NMJI: How do you view Indian medicine as a whole fromoutside India?Dr Ramalingaswami: Honestly, from what I see of Indiandoctors involved with the teaching and practice ofmedicine in India, I am convinced that they are equal incalibre and talent to those in the USA and the UK-bothcountries in which I have very extensive experience withthe university set up. Indians have great potential forpractising medical science, for research and teaching. Thedifferences, which are strikingly obvious, are that Indianscientists do not exploit the tremendous opportunitiesthat lie just around them to create new knowledge andhelp resolve problems.

NMJI: Why do you think this is so? We all know thatIndian research is not quoted, that Indian journals are notof a high quality and, generally, Indian research andperhaps Indian medical education are declining in quality.Why do you think this sorry situation has come to pass?Dr Ramalingaswami: I think there are two reasons: thefirst is the corrosive influence of private practice andsecondly the work ethic in India. Rewards should begiven to persons whose work is really excellent and not tothose who (the whole profession, students and facultyknow) do not deserve them. There are, of course, somelimitations in resources available to Indian scientists-beit library, equipment or experimental animal facilities.But these are not the primary determinants in the failureof Indian medical science to produce good qualityresearch. They only play an accessory or additional role.

NMJI: What do you think are the major failures in yourcareer?Dr Ramalingaswami: One of my major regrets is to haveleft research and become the Director of AIIMS in 1969.Although I enjoyed performing the duties as I saw them,I feel I may have lost an opportunity to make further con-

, tributions to science. I do not know to this day whether ornot that was a wise thing for me to have done. I even toyedwith the idea of going back to the laboratory after retiringfrom the ICMR. But so many of my friends said, 'Don'tbe silly. You now want to try and learn new techniques.There are hundreds and hundreds who are better suitedfor training than you are. What you have come throughand the experience and insights that you have gained intothe problems of the developing world and the applicationof science are of immense value.' I do not know how far itis true. But this is what I am told and it has pushed me

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further and further away from actually doing sciencewhich I would have loved to do.

NMJI:'you have mentioned some problems related to thedecline of research in India. Do you think political inter-ference has made things more difficult, and has itadversely affected the functioning of medical institutions?Dr Ramalingaswami: Yes. Over the years I see this evenin the AIIMS and it is getting worse now. There is anincrease in politicalization of the Institute. I was connectedwith the concept and spirit which moved Rajkumari AmritKaur when the Institute was conceived. C. G. Pandit hadbeen sent along with the then Surgeon-General to Britainand the USA at the height of World War II to study theirmost progressive institutions. They went to UniversityCollege, London, Oxford, Edinburgh, Johns Hopkins,Harvard and Vanderbilt. They came back with a beautifulreport which you should see-a blueprint of what thisInstitute should be. It is on the basis of those ideas-free-dom in faculty selections, encouragement of talent,creativity in research and autonomy-that the Institutewas founded. Pandit Nehru was tremendously committedto the idea of autonomy and yet supported by govern-ment resources. The entire CSIR (Council of Scientificand Industrial Research) and our scientific researchapparatus in this country was built on the basis ofautonomy. I still remember the debate in Parliamentwhen the All India Institute of Medical Sciences Act wasbeing discussed. A member of parliament said, 'On thegoverning body you want to have all these secretaries andon the Institute body you want to have all these peoplefrom the government. How is this consistent with thefundamental article of the Institute advocating autonomyto a self-generating body of scholars?' Rajkumari AmritKaur gave a categorical assurance that the faculty of theInstitute would be given total freedom to develop its ownethos. Yet I saw, also in my time, political influenceswhich I tried to fight against. By and large, I think, overthe years, no one can deny that there has been undueexternal influence upon the growth and development ofAIIMS. This may be doing damage to the evolution ofthisInstitute into a real centre of excellence: excellence notonly in technique, technology and science, but in ethicsand the application of science for the good of society. Istrongly feel that the sooner we try to remove theseinfluences, the better. But again it imposes a great respon-sibility on the faculty. If the faculty is to be trusted toevolve its own ways of fulfilling the objectives with whichthe Institute was established, it will also have to carry asense of responsibility and behave with dignity in the truespirit of science. I think on both sides we need to havedevelopment.

N MJI: You have stressed the need for the scientist to trans-late the products of research into effective public policy. Ifhe finds that public policy is not being generated in thedirections you desire, or not being speedily implemented,should he take on the role of a social crusader?Dr Ramalingaswami: I have no doubt that this is theresponsibility of the scientist. What you do see today is a

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major gap in policy formulation. Policy must be based on'informed judgement'. An informed judgement comesfrom an information base. But one does not have muchevidence of this. Most decisions seem to be taken ad hocor on the basis of what has been allocated in the previousplan or previous year-then we begin to increase a littlebit-but substantive fundamental changes in policy mustbe linked to the knowledge generated by the academiccommunity. This bridging is very necessary. I think theacademic community has a responsibility to inform thepolicy makers.

N MJ I: One of the problems in carrying out research has beenthat of resource constraints. In the West, pharmaceuticalcompanies are funding research to a large extent andcorporate interests are beginning to dominate in decidinghow the fruits of this research will be realized. Do youthink there will be a similar trend in Indian research? Ifso, how can it be avoided?Dr Ramalingaswami: I must pay a tribute to the Indiangovernment for its commitment to promote science. Thisis an example which is quoted everywhere in the developingworld. What the nation received in return for this trust andconfidence that the government placed in the scientificcommunity is a matter for discussion. I understand thattoday it is easier for scientists in India to get large sums ofmoney for research as compared to the tremendous diffi-culty that even first grade scientists are facing abroad,especially in the USA. The secretary of the MedicalResearch Council of UK (MRC) was telling me how firstclass projects had to be turned down because governmentallocations to the MRC have been cut. This constraint isbeing felt, of course, in terms of the absolute amounts ofmoney going into research. There is no comparison withregard to multinationals and industry. There is no doubtthat the potential of industry. in promoting knowledgeand developing new products is enormous. They can, withproper liaison, be made to playa positive role in thedevelopment of products meant for tackling the healthproblems of the Third World. But here, in a developingcountry, it is a double-edged weapon. Modern molecularbiology has brought industry face to face with universitiesand there are excellent tie-ups. I believe that the WHOhas a very important role to playas an honest broker inbringing the enormous potential of industry to address theproblems of the Third World.

NMJI: As the Director-General of the ICMR and also asthe chief of several research funding agencies, you havetried to balance the need for fostering research in priorityareas as well as encouraging the individually talentedresearcher. The question is should we invest in an individual

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or in a subject? You have tried to balance these factors as20% and 80%. Which do you feel is the right approach orcan one- really combine both the approaches?Dr Ramalingaswami: There is no magic formula and Ithink each country will have to work its own way through.This is where I want to refer to the International Commis-sion on Medical Research and what we are coming up withon the basis of our study to introduce the concept of essen-tial national research. This is research that a country, nomatter what its resource position is, has to engage in.What are its health problems? What groups are affectedby these problems? What is the special geographic distribu-tion of these problems? How do you define priorities?What is the current state of knowledge and availabletechnologies? Are they being applied or not? How do weproceed to apply them? This is what we call 'informedjudgement for policy making' in a situation of constrainedresources. Even the poorest country will need to engage inthis essential health research. But as the resource position(not only its economic productivity) rises, it can go higherinto other types of researches leading finally to extremelybasic research. The proportions will vary from one countryto another.

NMJI: Do you believe the quality of research that is beingdone in postgraduate medical colleges in India is ofadequate methodological rigour or does it need to bestrengthened?Dr Ramalingaswami: There are a few exceptions, ofcourse, as you always have, but in general the situation isvery unsatisfactory ..

NMJI: Do you think something should be done to improvethe situation as these postgraduate researchers are goingto be the research leaders of the future?Dr Ramalingaswami: Undoubtedly! You encourage theyounger generation who are going to be the future leadersin research. That's where the importance of undergraduateeducation lies. But even those who have graduated andare today in positions of influencing the current scene inmedical education and research need to do something toupgrade their skills. This is the real purpose ofthe ICMR-Rockefeller Foundation Scheme for which I was broughtto Delhi in 1954.

NMJI: You have made immense contributions in severalareas such as research, medical education, public policyand international health. Which one of these do you thinkhas been the most fulfilling?Dr Ramalingaswami: My own research-whatever I havedone with my own hands or with young colleagues at theInstitute and earlier at the Nutrition Laboratories.