Statistical Trends, along with Clinical Data, are reliable indicators of a potential outbreak of a disease in a population at local/state/national level.
Rifa Khan, our next pathbreaker, Clinical Epidemiologist at the Y R Gaitonde Center for AIDS Research and Education, investigates the trends in prevalence and incidence of diseases to identify gaps in service delivery and improve patient care.
Rifa talks to Shyam Krishnamurthy from The Interview Portal about having several questions around universal health care and health governance mechanisms that prodded her to shift focus to epidemiology and evidence based interventions for control of infectious diseases.
For students,ask yourself, “Why does India, a country with some of the best doctors in the world, have poor access to healthcare? “.
Rifa, can you tell us about Your background?
I grew up in Bengaluru and moved to Chennai to study Medicine. I always wanted to be a doctor. There are no doctors in my family, but my parents were extremely supportive. My late father served in the Indian Navy and later transitioned to civilian life as a founder-director of a leading courier company. My mother is a designer and loves the finer things in life. I always loved reading, so my parents made peace that books would be my first friends. Every book left me a different person from when I began. My father always encouraged me to stay up to date with national and global current affairs, have an informed point of view and be unafraid to speak my mind. This helped me foray into debates, writing plays and starting school and university newsletters. I was being honed for a career in public health and research – both of which require critical thinking and an ability to maneuver dynamic workspaces.
What did you do for graduation/post-graduation?
I completed my MBBS from Sri Ramachandra Medical College in Chennai. I spent my Pongal holidays shadowing scientists at the International Center of Genetic Engineering and Biotechnology, New Delhi. As a first-year medical student, I had learnt how to synthesize a hormone in the lab. In second year, I went back to learn about diagnostic tests in Malaria. In third year, I had joined a student group that had adopted a registered slum. That was my first brush with the politics of healthcare in India.
Medical school couldn’t answer a fundamental question for me: Why does India, a country with some of the best doctors in the world, have poor access to healthcare?
To understand this, I did my post-graduation in Public Health for Development at the London School of Hygiene and Tropical Medicine. I learnt about health economics, epidemiology, statistics for epidemiology and interventions for control of infectious diseases. I never imagined that the practical sessions on investigating and managing an epidemic would come to life on the scale that COVID-19 presented to us.
What made you choose such an offbeat, unconventional and uncommon career?
My parents never pressured me to join the rat race but always encouraged me to think for myself, ask questions and read better – if I had to read more.
My friends in school were exceptionally brilliant and just did well at the fields they chose – none of them opted for Medicine. My mentors in medical college encouraged thinking about out-of-the box solutions and they continue to be my advisors even today.
I lost my father just when I completed medical college. This was an extremely grounding moment that changed the way I approached life. I learnt to respect life processes that keep humans alive and while death is inevitable, every human deserves a fighting chance to live in dignity.
My work at St. John’s Medical College and Hospital shaped many of my choices in academics and practice.
Professor V S Chauhan was crucial to my evolution as a researcher.
How did you plan the steps to get into the career you wanted? Or how did you make a transition to a new career? Tell us about your career path
In a nutshell, I was always curious beyond what was taught in class and required reading beyond our syllabi. Sometimes my questions led me to a lab, and sometimes to a community that needed care. I was drawn to public health governance issues and the thought process even now is: Is there a practical, sustainable solution? Is it worth it? If the answer to both is yes, then I follow through with my plans.
Though I was never keen on athletics in school, research in medicine and public health introduced me to the joy of endurance sports. Training and running marathons helps me keep fit, be aware of my limitations and connect with my strengths.
After final year, I was accepted as a medical intern at St. John’s Medical College and Hospital, Bengaluru. My rotations through medical specialties at SJMC shaped my approach towards patient care and continue to do so. Ethics, evidence-based practice, and empathy formed the bedrock of patient care at this institute. Immediately after internship I was offered a position at the St. John’s Research Institute as a clinical research associate for infectious diseases. I was expected to be stationed at a TB sanitorium in Madanapalle (Andhra Pradesh). Unfortunately, I had to return earlier than expected due to civil unrest leading up to the birth of the state of Telangana. I was offered a new post as a Research Medical Officer in Endocrinology. This involved attending to patients enrolled in clinical trials. I was a sub-investigator for over 10 clinical trials. This experience led me to opt my post-graduation specialty. I had given the Indian entrance exams for PG and was offered a seat in ENT in a reputed college in Mangalore. I was working up to be a surgeon, but I realized that it was changing me as a person. I was driven by pathology rather than the idea of health. I saw numerous patients who benefited from the clinical trials and was aware that they wouldn’t be able to afford these medications once the trials were over. I had questions about universal health care and health financing mechanisms that were answered in my post-graduation at the London School of Hygiene and Tropical Medicine.
How did you get your first break?
I was offered a position at the St. John’s Research Institute. This helped me combine clinical work and research.
What were some of the challenges you faced? How did you address them?
Challenge 1: I was the youngest in my team. This can be a huge advantage if one finds good supervisors. I had to read a lot to keep up.
Challenge 2: I was often the only lady in meetings. This can be a challenge to men and women who come from conservative families where often women are not allowed to voice their opinions. While I didn’t have a problem speaking up, I noticed that some men had trouble listening. I think regardless of gender, the least one can do is respect a colleague who has earned a seat at the table. I learnt to speak up because silence can be complicit with inefficiency.
Where do you work now? Tell us about your role as Clinical Epidemiologist
I am a Clinical Epidemiologist at the Y R Gaitonde Center for AIDS Research and Education. This gives me an opportunity to attend to people living with HIV, understanding sustainable service delivery models for key-populations (high-risk behaviour populations who are drivers of the HIV epidemic) and leading community serosurveillance for COVID-19 in Chennai. I can investigate the trends in prevalence and incidence of diseases and advise my colleagues about change in testing strategies. It helps me identify gaps in service delivery and improve patient care.
What problems do you solve as a Public Health Practitioner?
A doctor in India, as in most resource constrained settings, must often consider the economics of the treatment.
Infectious diseases attract considerable stigma – as evident in case of COVID19. This is much worse for people living with HIV. Counselling a patient on the psychosocial aspects of care is equally important and challenging.
I set up databases to document and monitor clinical data. Ensuring data integrity and completeness is crucial to my job.
I am responsible in setting up remote video consultations for satellite clinics.
What skills are needed for your role? How did you acquire the skills?
Apart from being proficient in medicine and epidemiology one must keep reading to stay current.
There are always new statistical packages, but the principles of good research methods remain the same.
What’s a typical day like?
In pre-COVID times I was involved in setting up integrated care clinics in fifteen cities in India. This required a lot of travel to some remote parts of India. It involved teaching and training medical and paramedical staff, meeting peer educators and field workers. Twice a year I’m also assigned MPH candidates to complete their academic course work and mentoring them is extremely rewarding. In community clinics, it’s often a mixed bag of patients who seek care. It’s not a very controlled environment and work gets busy during an epidemic. The key is to be prepared to respond and not react to situations. During the COVID waves it was mostly organizing testing in containment zones, relief, and response. Some Days I’ve been woken up to attend to an emergency, I’ve been called in to call time of death for a patient brought dead on arrival. On good days, I see patients who have recovered and returned to their routine life.
What is it that you love about this job?
I can research better testing pathways and treatment strategies. The data from this research informs evidence-based practice for preventive and curative medicine.
How does your work benefit society?
Epidemiologists are essentially whistleblowers. We investigate data trends and inform public health policy at the local/state/national level.
Tell us an example of a specific memorable work you did that is very close to you!
I was posted in the Communicable Diseases Hospital in Tondiarpet as a house surgeon. During one of the out-patient clinics, I had issued five prescriptions for anti-malarial drugs. I didn’t know then that this was a red flag for an impending outbreak. The head of the institute asked me to justify these prescriptions and then conduct an outbreak investigation with an experienced team of field workers and entomologists. It turned out that the catchment area had mosquito larvae floating in their drinking water and there was indeed an outbreak. I was amazed at the actions taken following the investigations – treatment of the main water supply, mosquito control measures, door-to-dooring awareness campaigns seemed routine. I presented my report to the head of the institute who then insisted that I meet the city health officer in Chennai. It was reassuring to know that conscientious people doing an honest job were quietly keeping a city safe.
Your advice to students based on your experience?
Remain teachable regardless of the number of degrees earned – the best is yet to come!