From pioneering World Hepatitis Day to raising alarms on the surge of NAFLD and other liver diseases, abuse of diagnostic tests, and a collapse of public health systems, renowned gastroenterologist, former head of the gastroenterology department at SCB Medical College and Hospital, and current president of the South Asian Association for Study of the Liver, Prof. SP Singh, gives a blunt account of India’s health practice.
Taking part in the Express Dialogues, Odisha, he urges accountability and a return to patient-centred care, with awareness and prevention as the prime focus of the medical fraternity and public health systems.
You started observing Hepatitis B Day in Cuttack on July 28, marking the birthday of Prof. Baruch Blumberg, who discovered the virus and developed the vaccine for the disease. The WHO later adopted this date as World Hepatitis Day. Prof. Blumberg has also mentioned your efforts in his Nobel biographical essay. How do you look back on this journey from a local observance in Cuttack to a globally recognised public health movement?
I look back at it with a lot of satisfaction. I got introduced to the name Blumberg for the first time during my MD days. I wanted to be a cardiologist, but my teacher in the medicine department literally brainwashed me into becoming a gastroenterologist. When I joined gastroenterology, I realised that Hepatitis B was something that was completely preventable through awareness and vaccination.
In 1995, we organised a full-day symposium on Hepatitis B in Bhubaneswar. It was a first-of-its-kind programme, and by that time I was convinced that we needed to do something about it. A doctor's job is not just to treat patients; it is also to treat society. We must address different maladies not only through medical treatment but also through awareness and prevention.
Then in 2001, I thought that a dedicated day was required to focus on Hepatitis B for its eradication. I decided to start it on July 28, the birthday of Dr. Blumberg, and began organising different programmes for creating awareness in society. We created some impact, and the Indian Society of Gastroenterology and the Indian National Association for Study of the Liver adopted Hepatitis B as their society programme in 2005. One day, out of the blue, I got an invitation from the World Hepatitis Alliance, and it was Dr. Blumberg who was responsible for me being called there. The meeting, attended by UNICEF and WHO representatives, had a huge impact. Subsequently, the proposal was put up in the World Health Assembly. July 28 was accepted, and that is how the world adopted the day.
India still struggles with a high burden of Hepatitis B and C. What are the gaps in screening, prevention, and vaccination that must be addressed?
Ignorance remains one of the biggest challenges, with the government failing to create public awareness about the severity and risks of the disease. Unlike successful campaigns for polio, the government has hardly focused on hepatitis. For instance, roadside barbers, who are at high risk of transmission, are completely unaware of Hepatitis B and C. Due to lack of awareness, many people do not understand the importance of vaccination, which affects both children and adults. While there has been progress in Hepatitis B vaccination among children, a significant portion of the population, especially adults, remains at risk.
I would also say Hepatitis C is emerging as a big public health problem. In Punjab, it is more severe because of drugs. But you will be surprised to know that Hepatitis C cases are also increasing in Odisha, particularly among the youth. Widespread education, particularly for healthcare workers and high-risk groups, and better public health infrastructure can ensure that both preventive measures and treatment for hepatitis are easily accessible to all.
Liver disease cases are rising alarmingly across the country. You have done pioneering work in non-alcoholic fatty liver disease (NAFLD), which is emerging as a silent epidemic. What do you see as the biggest drivers of the rise?
Lifestyle and food. With progress and modernity, our food patterns and living habits have changed. We are eating much more than we did as children. Again, the type of food we are having is obesogenic. Correspondingly, our physical activity level has gone down to the minimum, thanks to TV and mobile screens.
Now, this can be corrected if people are aware of what is good and bad for them. We conducted a study on patients with fatty liver disease and normal people and were surprised to find that at least two-thirds of those who were overweight or obese thought their weight was normal. This is very much linked to our culture. People don't give much importance to their weight. In many cases, even doctors and health professionals are not aware of the problem.
However, there is a simple formula to overcome fatty liver disease. In most cases, one does not need any medication. The most potent cure is food and exercise. Exercise, walking, and a physically active lifestyle with a healthy diet will automatically bring down weight and resolve NAFLD.
We are also working on a formula for weight and its correlation with NAFLD for Indians. We are going to publish it soon. Your waist circumference should be half of your height. If it exceeds that, you are definitely at risk of having fatty liver. You have to keep it below that level. All the tests currently being done are also not validated in Indians. The fatty liver we have is different from that of the West. I have been saying this from the beginning.
Alcohol and smoking are other major causes of fatty liver. The biggest killer in liver disease today is not Hepatitis B; it is alcohol. All the wards are chock-a-block with alcoholic liver disease patients.
Are Indians predisposed to NAFLD?
Definitely, Indians are predisposed. We have more insulin resistance and other factors. In many cases, insulin doesn’t work, leading to complications including heart problems. It is also known as syndrome X or metabolic syndrome. However, our research has shown that there is something more to it, beyond plain insulin resistance.
Our people are much leaner compared to Westerners and yet face this problem. Dr. Yajnik, in his research published in Lancet, found that despite having the same BMI, an American is lean and has no fat, while Indians have a lot of fat. We have to set our BMI limits accordingly. We have set our BMI at 25, though 23 is the lower limit according to ICMR. In fact, I have seen among Odias that once BMI exceeds 22, fatty liver deposition starts. This is the cut-off where we need to be cautious. Gut microbiota also plays a huge role in the pathogenesis of fatty liver disease in Indians. That is why it is advised to eat curd.
But ultimately, the treatment doesn’t go beyond these two things – diet and exercise. Keep weight down. Even losing 1 or 2 kg can bring results.
Ozempic and GLP-1 agonists have generated both excitement and controversy. What is your view on their growing use in India for weight loss?
These are not miracle drugs and may cause more harm than benefits. There are many safe options for obese people to reduce weight before they go for this option. Patients should be educated about its benefits and side effects before taking the medicines. I doubt if patients are properly educated. This class of drugs has many side effects. It slows gastric emptying and produces gastric stress. Patients on such medication also complain about esophagitis. People can have acute pancreatitis and ocular problems. Many are also complaining about Mounjaro rebounds, gaining twice the weight they had before once they stop the medication. It is like a mirage. Studies are also not conducted properly. There is no clear indication of how much weight loss was due to Mounjaro (drugs) and how much reduction was due to lifestyle modification. Real-world data do not corroborate the manufacturers’ claims that these drugs lead to magical weight loss. Doctors are partly responsible for this and must educate patients about the benefits of lifestyle changes and the side effects of weight loss drugs.
You have been very vocal about unnecessary diagnostic tests. What are the major mistakes doctors make and how can it be corrected?
From my years of experience, I am particularly worried about the practice of advising or prescribing tests that are not necessary. Unfortunately, almost all diagnostic tests are being abused. Why would a patient do three to four endoscopies a year? Isn’t one endoscopy enough unless there is a serious doubt about the quality of the test?
Another example is vitamin D. Everyone is now being advised to do a vitamin D test. We do not know the normal level and the dose to prescribe. If the value currently touted as the normal range for vitamin D is considered, then 90 per cent of Indians will be outside the normal range.
CT scans are another racket. They are now available everywhere, and the government has set up units on a PPP mode, which is a loot. Doctors are rampantly advising patients to undergo CT scans. Why? CT scan radiation is oncogenic. With the increasing number of CT scans, the prevalence of cancer will rise further in the community.
How do CT scans lead to cancer?
CT scans increase the risk of cancer due to the use of ionising radiation. I am surprised at the pace and frequency at which doctors are advising patients to go for scans. Interestingly, in many diagnostic centres, people conducting CT scans do not know how to perform them properly or report the outcomes. There are substandard personnel entrusted with reporting. Knowingly or unknowingly, this is leading towards a catastrophe. CT scans must only be used when necessary for clinical decision-making. There should be stringent regulations to prevent abuse of diagnostic tests.
Odisha’s public health infrastructure is undergoing massive expansion, but you have frequently pointed to systemic deterioration, especially at SCB MCH in Cuttack, which is being developed as an AIIMS+ institution.
SCB MCH has gone from bad to worse. A few years back, when the government was discussing the transformation of SCB into an AIIMS+ institution, I used to suggest that they move with caution. An institution cannot be world-class only with infrastructure. You need to have a culture. While many departments are getting shut, half of the doctors and other staff in the remaining departments are contractual employees. The government is opening departments to gain political mileage. A healthcare institution serves its purpose only if it has efficient doctors and service, not flashy buildings.
The issues plaguing the hospital can be resolved if the Health Minister, Secretary, and Dean regularly monitor everything. A task force must be formed involving people who have worked in the hospital to restore the dignity of SCB MCH. That has to be done very carefully. A citizens’ movement is the need of the hour to put things in the right place.
You spent a considerable time in SCB MCH. What concerns you the most?
Many departments and services in SCB MCH are on the verge of closure. Fewer patients are being admitted. There are departments that stop admitting patients if there are no beds. SCB was never like this before. Like ‘Bada Deula’ (as people refer to Srimandir), SCB was ‘Bada Medical’ (premier hospital) for the ‘sarbaharas’ (people living in penury). Those who cannot afford anything go there. They get treated on the floor, and it has been happening for ages. Now they are being denied treatment on the pretext of bed shortage. There is no accountability. You cannot apply certain rules in hospitals that are applicable to industries. In IT companies, you may resort to cost-cutting by using AI, supercomputers, and downsizing human resources, but can you follow the same rules in hospitals? No, you cannot. But bureaucrats have been doing this in hospitals here. They restricted recruitment of regular employees; now outsourced employees are often tasked with handling misbehaving patients and their attendants. Hospitals must have permanent staff who can have a sense of ownership. Hospitals cannot run with contractual employees – from doctors to Class IV employees. Can the government run the Health Department with a contractual secretary and minister?
The state government has planned to set up medical colleges in every district headquarters hospital. Do we need so many medical colleges? If not, why?
No. We do not need many medical colleges. First, we need to strengthen the existing medical colleges and their facilities. Unless they are strengthened, there is no point in establishing so many medical colleges in the state. Governments have been doing this only for vote-bank politics.