Renowned cardiothoracic surgeon Dr Jose Chacko Periappuram has many firsts to his credit. He performed Kerala’s first heart transplant, India’s first heart re-transplant, and the first heart-lungs transplant in Kerala, besides performing over 20,000 open heart surgeries.
Dr Periappuram, also the founder and chairman of Heart Care Foundation, was recently awarded the Padma Bhushan for distinguished service in healthcare. Excerpts from an interaction with TNIE:
You went to the UK in the 1980s after completing MBBS and specialised in cardiothoracic surgery. What was the inspiration?
All of us have someone who influences us in our professional lives. I did my house surgency at the Kottayam medical college and worked with cardiothoracic surgeon Dr Chandra Mohan. I saw and touched a heart for the first time then. That has influenced me. In cardiac surgery, we can generate 90% to 100% results if patients come to us on time. So, it was more satisfying to become a cardiothoracic surgeon.
Students who do PG do not choose this field these days...
Yes. The mindset of the young generation is different. They want work-life balance. They are not keen on a field that requires 24-hour attention. Also, most of the procedures that cardiothoracic surgeons did once are now done by cardiologists. Even valve replacements can be done by cardiologists. So, the new generation thinks that the relevance of cardiothoracic surgeons has reduced.
Has radiology become the number one choice for medical students?
We hear about attacks against doctors who directly deal with patients. That might have motivated more doctors to choose radiology. The work is defined and you don’t interact much with patients or their families.
Is there such a fear among doctors?
The patient-doctor relationship is not as transparent as it used to be. Young doctors sometimes look at the patient and family with suspicion.
How did the first heart transplant happen?
I told Chandra Mohan sir that I wanted to do cardiothoracic surgery. Back then, there was no training in this in India. So, I decided to go to the UK. He also asked if I was planning to come back. I said I want to do the first heart transplant surgery in India. That was in 1986. When I returned, the first heart transplant surgery had already been performed at the AIIMS in Delhi. Then my dream was to perform it in Kerala.
First, I wanted to create awareness about organ donation. Though healthcare had improved, there were no systems for organ donation. Initially, I had to establish myself as a cardiac surgeon doing the basic work. Dr Varghese Pulickan (founder of Medical Trust Hospital) supported me when I told him about heart transplant surgery. He said we would do it for free for the first patient. That motivated me. The surgery happened in 2003.
Do you think there’s still a lack of culture of organ donation in Kerala?
Organ donation is indeed a heroic act. We hear stories of organ donation, particularly eyes and kidneys. However, cadaveric organ donation, especially in cases of brainstem death, is still relatively rare. The true heroes are not the individuals who have suffered brainstem death but their families who make the selfless decision to donate their loved ones’ organs. Unfortunately, after a surge in donations until 2012, the numbers have plateaued.
What’s the reason?
Over the past five-six years, misinformation has spread, fuelled by vested interests. False claims that doctors are certifying brain death and harvesting organs for commercial gain have done considerable damage. The media and films, such as ‘Joseph’, have perpetuated these misconceptions, showing accidents being staged to harvest organs. As a result, heart donation and transplantation have become extremely rare in Kerala. I recently had to send four patients to neighbouring states for heart transplants.
Is there a perception among patients that states like Tamil Nadu are better equipped for heart transplants?
Yes, that’s true. Tamil Nadu performs around 100 heart transplants annually, with 80% of the donations coming from within the state. They have dedicated hospitals and facilities, including helicopters for transporting harvested hearts.
How do you convince a family that a patient is brain dead?
There are strict and internationally accepted norms to declare brainstem death. There are around five tests to confirm this. Multiple panels of doctors conduct repeated tests to confirm the death. These doctors are not from the same hospital. The death has to be certified by neurologists, neurosurgeons, and physicians from government and private hospitals, who are empanelled to do that.
The procedure will become transparent only if the family is convinced that the state is facilitating the transplant, not the hospital. If I try to convince the mother or wife of a donor, they will always think that this doctor has got a patient who needs a heart and is trying to get the heart out of my son or husband. To avoid such a situation, we should have a transparent mechanism where the staff of a state government organisation communicates with the family.
The Kerala State Organ and Tissue Transplant Organisation (K-SOTTO) says the problem is with the doctors who are not ready to follow the procedure for confirming brainstem death...
The doctors are afraid because cases have been filed against some of them. For example, a neurosurgeon at Sri Chitra Institute called me once and said one particular doctor has been calling all the empanelled doctors and threatening them with cases if they certify brainstem deaths. He is the person who has done the maximum damage. He has written letters to me too, saying that I’m not a trained transplant surgeon. Why has the government not taken action? This doctor has even gone to the families of organ donors and told them that the doctors created brainstem death and took away the organs. One can imagine how traumatising it must be for the families. So, doctors are scared. The government should come forward to protect them.
Why is there such a vicious campaign against organ donations and transplants?
Certain sections are behind it. In the affidavit and the PIL (public interest litigation) this particular doctor filed before the high court, he said Dr Jose Chacko has done 30 heart transplants and only one person was alive. A completely false statement. We have around 18 patients living. They are all healthy. Some people have been alive for 10, 11, and 12 years since the transplant. The first heart re-transplant in India was done by us. The patient, Gireesh, has been alive and healthy for 11 years now.
How good is Kerala’s healthcare system compared to other states?
Excellent. It is on a par with the West. The maternal mortality rate is low. The infant mortality rate is low, lower than the rate in many European countries. Immunisation is very good. It can be seen that in the past 20 years, the superspecialty scene has become not only better but also affordable.
Organ transplant surgeries too have become cheaper. The last transplant I did saw the patient going home with a bill of just Rs 8.5 lakh, including a one-month hospital stay, food, and medicine. In the neighbouring state, hospitals charge around Rs 40 lakh to 42 lakh for the same procedure. If we take into consideration the mortality rates during surgeries, we are doing great. In the case of cardiac surgeries, the mortality rate in my department is just 0.49%. The average mortality rate in the world is 1.3%.
At the same time, it is said that most people in Kerala have lifestyle diseases…
That’s because we have always maintained excellent data in our healthcare system. This was evident during the Covid period. Our state was the only one that had a system in place to collect the data of all patients, complications, and mortality.
What’s your take on the correlation between heart diseases and Malayalis’ food habits?
It is difficult to comment on food habits because we know there are many diseases, not only of the heart. It may not be because diseases are spreading all around but can also be due to the good number of detections happening. In the past, when a person had a heart attack, the only treatment available was rest, medicines, and morphine. There was no angiogram. When I returned from the UK in 1996, we had just three centres doing angiograms. In the past 15 years, the number of cath labs in Kerala has risen to 180.
Every small town has a cath lab. So we are detecting more, doing more angioplasties, and doing more heart surgeries. The same is happening in the case of other diseases. This is one of the reasons why we think the state is showing a higher prevalence of lifestyle diseases. Having said that, we must modify our food habits. We have to cut down on fast food, meat, and junk food.
What’s your advice on food portions?
I think around 80% of the people above middle age eat a balanced diet. But eating outside has become a part of our lives. When we talk about heart diseases, another risk factor that needs to be taken into consideration is ageing. We can’t prevent ageing.
Studies show obesity and heart-related issues are increasing significantly in society. What’s the reason for that?
It is because we have access to more food. We should motivate people to maintain balanced nutrition. Also, we advise patients and their family members to restrict ‘white poisons’—sugar, salt, and white rice. Some claim eating porotta and beef repeatedly can cause cancer. I don’t know the scientific validation of this claim but if you continually abuse one type of food, it will cause problems. You can eat beef, chicken, and mutton, but everything should be within limits. I advise patients to consume food in moderation.
Is genetics a cause of cardiovascular diseases?
There are many factors. One of the chief causes is diabetes, which is rampant in our society. Around 20% of people above 40 have diabetes. About 80% of my patients have diabetes. Hypertension is also very rampant and another major cause. Similarly, obesity is a concern although it isn’t as prevalent here as it is abroad. Smoking is also a reason for cardiac diseases.
Family history is another crucial factor. If there’s a history of cardiac issues in the family, people should be cautious from a young age. Even after making all lifestyle modifications, people with such a history have a 10% higher chance of developing a heart disease. I’m not talking about a case where a grandfather died of heart disease at the age of 90. It is about first or second-degree relatives being diagnosed with heart diseases before the age of 50. But if the disease was diagnosed at 60, it is possible the condition might have developed at the age of 45.
There could be more than a decade’s difference between the actual beginning of the heart disease and the onset of symptoms. It’s like the rusting of a pipe—only when the pipe gets blocked do we realise there’s a problem. By making lifestyle changes, we may be able to postpone the disease by five or 10 years. But I think everybody will get a heart disease if they live long enough.
There are claims the Covid vaccine is causing heart issues. We have had instances where people have collapsed in gyms or on the playground…
There is a tendency to blame the treatment rather than the disease itself. About 99% of the world’s population has had the Covid infection. Some weren’t diagnosed because the infection probably was mild. In such a background, why should we blame the vaccine? The issue is related to Covid rather than the vaccine.
Covid has made structural changes in the human body. It has triggered a lot of inflammatory changes, especially in the blood vessels. Most often, heart disease starts with an infection in blood vessels.
An infection can cause inflammation in the intima (inner wall of the blood vessel), which can gradually lead to small ulcers. This is why it is documented that people who have had Covid are at a higher risk of heart disease. I believe this is one of the reasons for the rise in heart disease among young people. It needs extensive studies.
What’s the solution? Should people avoid strenuous exercises?
Exercise is one of the best lifestyle modifications that humans can make. There is a lot of scientific data showing that exercise saves lives and prevents or prolongs the onset of diseases. However, what is crucial is understanding who should exercise, what type of exercise is suitable, and at what stage of life.
Can people with a low heart rate engage in sports activities, especially football?
Professional players undergo medical checkups regularly. We should all strive to reduce our heart rate. The lower our heart rate is, the longer we live. Exercise helps our body consume less energy for more work. That’s the principle of exercising. When a person exercises for the first time, their heart rate can rise to 200 beats per minute.
With regular exercise, we can train our heart to function efficiently with less effort. A trained athlete who sprints 100 metres may have a heart rate of 100-120 beats per minute, while an untrained individual might reach 200 beats per minute.
Do you recommend annual heart checkups after a certain age, say 40?
We recommend but we don’t insist, except if they have a family history. Generally, if a person has any risk factor such as diabetes, or has a strong family history, then those aged 35 and above should undergo a checkup, especially for the heart, like an echocardiogram and treadmill test. They should also do blood tests like thyroid and cholesterol.
Will there be a stage when Kerala will have no heart attack deaths?
It is difficult to say so. But we’ll have it very much minimised. On an average, a person who is facing a heart attack can reach a cath lab within half an hour anywhere in Kerala.
What’s your take on the modern medicine versus traditional systems of medicine debate? Do you believe a system that combines everything would be better?
That is ideal, but never happens. Modern medicine has a role to play and traditional medicine also has a role to play. We need to define which disease should be treated by modern medicine and which by homeopathy, ayurveda, and unani. Ayurveda cannot replace a procedure for bypass or valve replacement. Ayurveda is a lifestyle.
That might be useful for chronic diseases. But in emergencies, ayurveda cannot do anything. Ayurveda doctors don’t know how to interpret CT scans or liver function tests. Both ayurveda and allopathy have limitations. I feel we need to have a fine balance. Many hospitals now have an ayurveda section.
There is an argument that traditional medicine is pseudoscience. Do you agree with that?
My grandfather was an ayurveda doctor. The ‘thaliola’ (palm-leaf manuscript) was passed on to him by another person. It is still kept at home. He claimed he has even healed mouth cancers. C P Mathew, an oncologist from Kottayam, used to come home to witness his treatment methods. He was not taught scientifically.
But he got benefits and helped many patients. So, we know ayurveda had a role. But there is no scientific proof and data. What complicates matters is when ayurveda practitioners don’t treat a patient the right way... snakebite and jaundice are examples. Their system works on the basis of natural healing, and natural healing would’ve happened even without treatment.
Your life is worth documenting. Any plans for an autobiography?
I have written a book, ‘Hridhayam Thott’. During Covid, I wrote a few articles which were later compiled into a book. It touches upon my life, but it is mainly about patient-related issues. Now I’m planning to publish the same in English. Interestingly, there is a possibility of a movie coming up. One director approached me around three months ago and said they were preparing a script.
You mentioned the need for retiring. When are you retiring?
That’s my dream (chuckles). But whenever I tell someone, they say, ‘No you can’t retire’. No human being is irreplaceable. There were days when I did six surgeries on my own. Now I’m 66 and my body doesn’t allow me to do so. Doctors should reduce workload and delegate work.
TNIE team: Kiran Prakash, Rajesh Abraham, Rajesh Ravi, Unnikrishnan S, Krishna Kumar K E, Anna Jose T P Sooraj (photos), Pranav V P (video)
