Dr. Salim Yusuf

Dr. Salim Yusuf Editor-in-Chief (EiC) Where were you born and tell us about your early life? Salim Yusuf: I was born in a small town called Kottarakara in Kerala into a family with modest means. My parents were the first in their families to receive a college education. Editor-in-Chief: What about your schooling and how did you manage to go to St. John’s, Bangalore? Salim Yusuf: I went to different schools around India because my father had a job that was transferable. So, for some time I was in Bombay, in Calcutta, and my last 4 years were at the Kendriya Vidyalaya in Cochin. Editor-in-Chief: And then you finished school and your goal was to go into medicine. I suppose like today in those days getting into medical school was not eaSalim Yusuf:. Salim Yusuf: I applied to four places. Only St. John’s invited me for an interview and where I was admitted. Editor-in-Chief: So, you obviously did well in medical school. Why do you think you were chosen for a Rhodes scholarship? Salim Yusuf: There were a few factors. One was in addition to having done well in medical school, I used to play a fair amount of sports, in particular hockey, and I played for my university. There were also two other things. One was that in my internship days, I had to work in the rural areas, as probably most of us did. When I finished my clinics in the morning I noted that a lot of the patients had waterborne diseases. So along with a fellow intern, we did a survey of the 12 wells in surrounding villages (in Malur in rural Karnataka). And then, we collected water from all the wells and got them tested in the public health laboratory. The coliform counts were high in everyone except one well. Then, we did a survey of the wells to see, where the cow sheds and the latrines were. They were all close by, unfortunately. We could not do anything about that. So, we chlorinated the wells with the help of high school students. And a couple of weeks later, we retested the water and the water improved in almost all wells. My Professor of Community Medicine suggested I present it at a national conference. I received a small recognition. And then, I had to work in the tea estates of Munnar for part of my internship. And there we did two simple surveys but seemed to be relevant. The first was to look for goitre in children. Goitre had never been reported from South India at that time. So, we did a survey of a couple of hundred children in a few schools in the tea estates. And there was a very high prevalence of goitre, even at the age of 10 or 12. And then, we also did another survey, to understand why women were having tubal ligation many times the rate that men were having vasectomies. You know, one is simple, the other is more complicated. And we could not work out the reason from formal surveys until one of the workers told us – ‘so what would you do if you had had a vasectomy, and your wife became pregnant?’. That’s when we realised there were a lot of extramarital interactions between the tea bushes. So, it was a sociocultural driver of why vasectomies were less frequent than tubal ligation. I described these in my essay for the Rhodes scholarship, and this may have played a role because at the interview, they questioned me about all three. And I suppose surmised that, here is a person who identifies problems and then tries to find solutions. Editor-in-Chief: Was Oxford a life changer for you? Salim Yusuf: Oxford was transformative. When you go to Oxford for the first few months you are lost. All the other graduates are so confident and ambitious in their thinking. They felt that their generation could solve the problems of the world. And whenever you walked around various places, there were plaques to famous scientists. And at the hospital, there were one or two Nobel Prize winners who were working there every day. And there is so much history there. Thus it was inspirational. There were no formal courses or lectures. You just had to pick up things. And I felt very insecure. And so, I would make appointments to see my supervisor about once a month. He was a famous Professor called Sleight who passed away 4 years back at the age of 94. And he was very kind. He would always give me an appointment for half an hour, and we would review my project and he would give feedback, but it was up to me to carry things out. He was very supportive. But the person who really influenced my scientific thinking was Richard Peto, from whom I learnt epidemiology and clinical trials. The Oxford DPhil is one largely based on thesis. And so, you had a lot of flexible time. This meant in the afternoons on certain days, I’d be playing hockey or cricket on the college fields and then work till quite late. The experience was also tremendous because people from all over the world were there, and famous professors were visiting, giving lectures, so you rub shoulders with them. It was a place where young people believed they could do important things. But so, Oxford was a remarkable place. Editor-in-Chief: So, what prompted you to go to the National Institutes of Health (NIH), rather than come back to India? Salim Yusuf: I tried to come back to India and it was impossible. I actually visited AIIMS, Vellore and the Sri Chitra Institute in Trivandrum. I had, by then not only had my D-Phil, but I also had a membership (magnetic resonance cholangiopancreatography) and I had about 30 publications, two in the Lancet, BMJ, a few in specialist journals such as Circulation. All three institutions did not recognise my training and degrees from Oxford. You have to come here and start MD all over again. So, it was as if, 5 or 6 years of my life did not exist. That was too hard to go back. The other thing is also, I soon recognised that even these big places such as AIIMS or Vellore or St. John’s or wherever had done very minimal serious research. Unfortunately, that is still the case today. Editor-in-Chief: Why do you think this is? Salim Yusuf: It is a cultural issue. The first is the culture of moving up the ladder is based on years of service, rather than excelling in the profession, and certainly research in those days was not considered important. Second is the culture of discovery, was minimal. Many of these institutions are adequately funded, have huge patient volumes, and incredibly bright talented people, but they are fragmented with. too much political infighting and little collaboration. One has to change several aspects of this culture, to promote research in India. And if people do research in India, it’s on top of everything else they do. It is not that their clinical load goes down. You still have to do the same clinical load or the same teaching. Whereas in the West, your job description could be, well, you’re 50% clinical, with part of your time say 50% protected for research. The other thing is even in day-to-day practice, in most hospitals, there are no standards for quality assurance. Or measures of performance or complications… So, I think the culture of quality assurance could help promote research and the culture that research is valued and supported. Editor-in-Chief: I think it’s a very good answer because I was in AIIMS for a long time. But there’s another problem I feel is of political interference and corruption. And the fact that India does not value meritocracy as much as seniority and contacts. Would you agree with that? Salim Yusuf: You’re absolutely right. Editor-in-Chief: So, you went to the NIH in Bethesda, Maryland, where everyone wants to go, every researcher wants to go. And then you went to McMaster, and you have been in McMaster ever since. What do you think is your major achievement? Is it your international collaboration? Salim Yusuf: I am most proud of the team we’ve created. I always recognise that my success is not the result of my own efforts but that of the whole team. And our team is not only the people at McMaster but also collaborators from all over the world whom we collaborate with. So, I think creation of the global collaboration is what I’m most pleased about. Editor-in-Chief: Why have you succeeded when other people have not succeeded in international collaboration? In India, we can’t even do local collaboration between different states, but you’ve done international collaboration. Why have you succeeded? What is the secret? Salim Yusuf: I do not know, what the magic potion is, but I think it is linking in with the right people. First, you have to make friends before you collaborate. Second is if you’re open and honest with them a lot of them will be open and honest with you. Third is if you have goals that they identify and share that makes it easier. And to be involved in collaboration with many centres, you only need a few people who see things your way. I also believe in sharing funds. Equally, our collaborators take the grants that we write and apply locally to raise money to support their efforts. So, they learn how to raise money. They are involved in major projects that they cannot do without collaboration. And there is a high degree of fun in collaboration. We should not think of collaboration as only sharing. You receive a lot of joy out of it. So, to me, it is not that I started my career saying, I want to collaborate. I’m interested in a certain question. I need to put together a team that can answer the questions. But then, most of these questions take 8–10 to 15 years. There is a study that we are doing now that has been going on since 2004, 20 years. Now, how do you keep something going for 20 years, especially where money is very hard to raise? And that includes being generous, but it also sometimes includes being firm about things. When these big studies finish, we have credit and authorships. The PURE study that we are doing now has already published 250 papers out of which only about half are led by people from McMaster. The other half are led by people from all around the world, including India, Africa, Pakistan and China. And we have a Salim Yusuf:stem of controlling data sharing with the collaboration. So, I think sharing is important to keep the collaboration going. Editor-in-Chief: How are you ensuring that the data that you are being provided is accurate and truthful? Because in India, we have a lot of problems with fudging data, say for instance, in compulsory theses done by residents. Salim Yusuf: First, we keep our studies simple. Second, we look for patterns in the data. You know, you can actually detect problems by running distributions. Like if you find there is a centre with narrow standard deviations, like all the blood pressures are the same, or a large number of patients were seen on the same day and you know the visit takes an hour, then you ask yourself, how can they, and you know how much staff they have, you know it is not physically possible. Then, the other thing is, and we do is random checks. It is not like the way regulators do, but we do a lot of central checks on data by running means and standard deviations. For instance, there ought to be a correlation between body weight and height. If you do not see that correlation, you start to wonder why. As long as people know they are being looked at, not from a punitive point of view, but improving quality, they do it. I mean, poor quality and lack of monitoring of quality is a big problem in India, not only research but also clinically as well. Several people that you meet at conferences from India say, oh, do not believe the data from this centre or that centre, and I do not know what to make of such statements. The thing though is we need to implement a Salim Yusuf:stem where people can trust the data. Editor-in-Chief: How would you do it? How would you go about doing it? Oh, I would ask you to tell me. Salim Yusuf: First keeps a study simple, so it does not take a lot of effort. Second you tell people upfront, which I do at every meeting, everywhere in the world, it is okay to make mistakes. We can correct it, but do not fabricate data. And we say we’re going to check them, you know, by random checks. And you do not do it on every variable, you do it only on the key variables. And it’s not being a policeman, it is trying to get the right answer. Editor-in-Chief: I was telling someone that I’m going to interview the great Dr Salim Yusuf. So, he said, oh, he’s the person who does not believe that high fat and salt intakes are related to heart disease. What do you think of that? Salim Yusuf: I think we have got to take these as two separate issues. With salt, we have to remember diet is a physiological nutrient and an essential part of cell physiology such as the action potential; So too much or too little may be bad, just like anything, you know, you eat too much, you get obese, you are in trouble, you do not eat enough, you are undernourished. So somehow the scientists involved in nutrition epidemiology have not adapted that thinking in their research. We know of Vitamin A deficiency and hypervitaminosis – both having problems. Indeed, a sodium intake over about 4.5 mmol/L or one below 3.0 appears to be associated with an increase in cardiovascular disease (CVD) events. Other aspects of diet are also complex. Most of the reports on diet have come initially from places such as Finland and the Mediterranean or the US, but not from the majority of the world, such as India or China or Africa where CVD has been increasing. Diets in these countries markedly differ from that in Western countries so we cannot extrapolate from these latter countries. Furthermore, in many of these societies, undernutrition is a problem. The most influential work on fats in the diet was done by Ancel Keys, in the seven countries, he studied. But when you go and look at the publications, the methods do not appear to be robust or meet modern-day scientific standards. There have been several observational studies and a few randomized trials that do not support the dietary fat hypothesis and yet this hypothesis is firmly ingrained in current thinking and needs to be rethought… The field is changing and last month there was an editorial authored by Dari Mozaffarian who used to be the Dean of the Friedman School of Nutrition in Boston where he has more or less endorsed the idea that fats may not be bad. And so, what nutrient is hamful? Refined carbohydrates are the problem and that is true with the Indian diet. The Indian diet’s problem is a lack of fruits and vegetables and very high refined carbohydrates. And you know, when you are challenging establishment dogma, people go after you. So that’s what’s happened with me on both the salt and the fat issue. But, we have now published about 40 or 50 papers on diet in the Lancet, in the New England Journal, BMJ and others after extensive peer review. Editor-in-Chief: I read that you are interested in lowering the mortality from non-communicable diseases by 25%. How long is this going to take and how are you going to do it? It seems that there is too much accent on communicable diseases, but now even in India, non-communicable diseases are important. Salim Yusuf: I am but it’s a huge years back or 15 years back when I those which I would say was a for I was probably and We have very little in CVD in the last My has been CVD And in the last very little change in most countries. has but not The problem is, I mean, the big is we have been to That is The of We have the to it, we have the means to do it, blood is eaSalim but we are not very good at it. And if you look at the of blood in many countries like India, it is not that It can be done by simple means. There have been good trials that. A study in China a big by health You know, they used to be called the So, we need health Salim to implement what we is still not that enough, especially some months after I think we need a health Salim where we Editor-in-Chief: And this me to a key You know, we do not have quality assurance standards in India for people who are in or in Salim Yusuf: And one of your questions were what are the big problems in Indian I would say there are several problems but one is the lack of quality assurance and and because you know even AIIMS does not what it Editor-in-Chief: One now is the idea of having training from and in published a in which that if you for a they do as well as What do you think of that? Salim Yusuf: I think the is I would not the If you people who as I think it’s a good idea to them if they do the right thing and have some There is no that they need to be no they need standards and should be to to standards and have their work For instance, various in India, and in have done studies with health and that the quality of by for those is much than the We also a study called the study where we randomized about 20 in and in and the provided by the health workers was to that provided by the standard Editor-in-Chief: last questions. One is that tell us about yourself, what do you do from What are your And the would be, what is your for young in India about how he or should work out their Salim Yusuf: I my life from my I have few now work and the So, all my time is with the I have a great wife who really after the family the the and So, we have close family and we time them. I have to I I was to have other I used to read a but have not been to read very much for I used to but have not done much of it in the last 4 years. I go for but as I have get in the way. I mean, had to give up all because they with other people, it’s great to do it. I mean, I I go for So, I have a of different but that is an other than the you know, children and Editor-in-Chief: I’m to give you such a to answer. What do you think about Indian in and how could we Salim Yusuf: it’s a as you said, that is to answer. And we have so many but also so many The are the the that people have in of and these are public health efforts and they largely come about by You know, the and in Kerala we have and you know, Health these simple things And which has very good health the reason for health is they have high which the family to Now, the problems in Indian are very little from the in about of our which is And I know there have been various efforts at the Salim but I do not know how much we’ve The other thing is the lack of and the lack of quality, and so we know your Salim Yusuf:stem is or And when you say quality in all that is and and lack of corruption. And the point I’d like to make on that is being a big problem in families in India. You know that lot of are on it. And there’s a called which you may have seen by Dr was a for the the And a who in rural and So, it’s not all and it’s much more working in a rural in a small place in right now So, I think that’s a and it the without very And there’s a lot to learn from it. So, told a number of but the success is all we’ve in and disease mortality actually the of the of the of for it. has been as do many other countries. So, I think things will but be Editor-in-Chief: you very much, Dr Yusuf. It was very It was very very support and of There are no of