Welcome to another section of DocScopy, MedBound Times was fortunate enough to have an enlightening conversation with one of the most humble and respected personalities in the Healthcare field, Dr. Ravindra Dewan.

Let's see what Dr. Dewan has to say about his Journey from being a thoracic Surgeon to being a Director of the National Institute of Tuberculosis and Respiratory Diseases [NITRD] through the conversation between Dr. Dewan and MedBoundTimes [Dr. Aarti Nehra and Parul soni].

Parul: Sir, kindly tell us something about your professional Journey

Dr. Dewan: I was born and brought up in Delhi. After completing my graduation [MBBS] from Maulana Azad Medical College, I did MS and later post-doctoral MCh in Cardiothoracic Surgery from the same college in Delhi. Later, I joined this institute (National Institute of Tuberculosis and Respiratory Diseases) as Thoracic Surgeon after my residency in 1992. Since then, I have been serving as Thoracic Surgeon and with regular promotions on my way, I became the Director of NITRD on December 2020.

Parul: Sir, please tell us more about NITRD

Dr. Dewan: Let me start with a brief history of this institute. In the post-independence period, there was something called the Colombo Plan in which the countries that had recently become independent, were being supported by the western countries. Under that plan, the land adjacent to this institute was given to the government of India by a philanthropist, Lala Ram Swaroop. Then, the government decided to give this to the TB Association of India, which was a government-sponsored body, an NGO back then which ran this TB hospital from 1956 onwards. It was inaugurated by Countess Mountbatten under the Colombo plan.

In the year 1991, it was formally taken over by the Government of India as an autonomous institute under the Ministry of Health and Family Welfare. The objectives were threefold:

1. To act as an apex institute for the treatment of TB and other respiratory diseases.

2. To support the National TB control program

3. Teaching and training the personnel related to this work.

So, many departments were opened, the biggest being TB and Chest Department which caters to patients with various respiratory ailments; The Department of Thoracic Surgery is there as the institute has been providing surgeries as and when required since the 1960s.Then other departments include Intensive Care Unit, Anaesthesia, Pathology, Microbiology,etc. Microbiology is a big department as it is very important in TB control nowadays. The unique thing about this institute is that it is the only institute dedicated to Respiratory diseases with extensive clinical facilities [500 bedded hospital (always fully occupied…)] wherein services are availed by people of Delhi and neighboring states as well as from adjoining countries [Nepal, and Bangladesh]

Parul: What inspired you to take up this career path?

Dr. Dewan: After completion of MCH in cardiothoracic surgery, there was much glamour for cardiac surgery and most of my fellow doctors were going ahead with cardiac surgery. At that time when I was doing training at G.B.Pant hospital, we use to get many patients who had thoracic problems, and somehow they were not being attended, and I got to learn from the patients, about the institute in Mehrauli where thoracic surgery is done.

I was more drawn towards thoracic surgery than cardiac surgeries as thoracic surgery procedure is more challenging…It’s more like a dissection. On the other hand, I found that cardiac surgery operations are very repetitive. Moreover, I was more inclined toward a government service, and this place was offering me a good government job at such a young age and that too a specialist position. This alone was not the prime reason, another main reason to join NITRD was Dr. R.C.Jain, my mentor and the 1^st director of the institute, also a thoracic surgeon. He groomed and trained me in such a manner that I became a confident thoracic surgeon in 5 to 6 months. I started getting referrals from across the country and getting positive feedback from patients was a satisfying and meaningful experience that inspired me further. That’s why I stuck with the job to develop it further. I have continuously enjoyed my surgeries and the kind of satisfaction that we are giving to the patients is very immense and rewarding...

Parul: How passionate you are about this profession and serving people with TB?

Dr.Dewan: I don't see myself as only a thoracic surgeon, but now I see myself as a TB manager because of the National Institute, and I'm in an administrative position, I'm the director... As far as thoracic surgery is concerned, I have realized over the years that I am amongst the very few surgeons in the country who are doing these types of surgeries. 

• We decided to form a separate ‘The Indian Society of Thoracic Surgeons & Trust’ which is slowly growing. In 2015, we started another course Diplomat National course dedicated to General Thoracic Surgery. About 10-12 people have already completed that course and they are settling in different parts of the country to meet the growing need for Thoracic surgeons.

• We have also started a course of ‘Fellowship in Thoracic surgery’ for three months, especially for Assistant/Associate professors working in the government sector sponsored by the ‘International Union Against Tuberculosis and Lung Disease’. We provide residential accommodations and scholarships are also available, so that interested people can come and gain exposure to this specialization.

I have observed over the years that Patients with chest ailments suffer from needless morbidity which can be addressed very well. It's not that surgeons aren't interested, many want to, but it's just that cardiothoracic surgeons are busy doing cardiac surgery and general surgeons are afraid to treat chest diseases. So, I'm focused on training all surgeons to make a bigger pool of thoracic surgeons. I have had an opportunity to train foreign surgeons from Hungary, Armenia, South Africa, the Philippines, Nigeria, Bangladesh, Afghanistan, and Iraq, who came on their own, spent 3 months with us, and went back very satisfied. Once a Kenyan doctor also came for training and took chest bags to treat his patients back in Kenya. It gives me immense satisfaction to train all willing surgeons.

As far as TB is concerned, I have learned a lot about TB in my practice over all these years. With 10 million cases every year, and 2.1 billion suffering from the sequelae, TB has become a growing concern. Being the director of the institute gives me an extra edge in supporting other departments such as microbiology and research related to TB.

Dr. Aarti: How has the recent pandemic impacted your institute and work? What was your experience?

Dr. Dewan: All the surgeries were stopped all over the world when the pandemic struck. New admissions were NIL and TB services got affected across the country. Patients could not come to DOT centers and take treatment. In 2021, I opened our hospital for COVID patients during the National Emergency. About 150 patients were admitted, out of which 120 survived as we had oxygen and all the resources.

Then there was a positive fallout after the calamity, We received huge humanitarian aid in terms of ventilators, oxygen cylinders, drugs, hospital beds, oxygen-generating plants, etc. The aid we received from non-government sources amounted to approximately 15 crore rupees, which had never happened before. This year, our capital funding also got enhanced by 1.5 times the original amount we used to get to develop various sections. Now I'm thinking of introducing robotic surgery facilities in our institute. TB diagnostics are an integral part of the treatment plan. We have updated everything to diagnose TB better and are in the process to incorporate new tests [whole genome sequencing, gene expert XDR] along with providing research support to ICMR and TB research.

Parul: What were the challenges you faced before the pandemic as a director of TB institute?

Dr. Dewan: It was always difficult to get extra funding in terms of capital funds as the tuberculosis institute comes after other institutes on the priority list. But we have been getting funds slowly, Funds are better now after COVID.  

The other biggest challenge is that TB is an infectious disease and there is a stigma associated with it; This limitation has been there for a long time, when I joined the TB hospital it was there… and it is still there. Many patients who would have benefitted by taking treatment didn’t come here just because it’s a TB hospital. It’s a general perception. But when people come inside the hospital, they are amazed to see the facilities. So, the stigma has been there, and though it has been reduced, it has not gone completely.

Then along with TB, there is an HIV clinic too. In the beginning, Everybody used to say “why do you want to pose a threat to your own family by doing surgery on an HIV patient? But I insisted that Universal precaution has to be practiced universally; let us go slow and steady and follow those precautions and why deny surgery to needy patients. I started doing surgeries in 2004 on HIV patients if they needed surgical intervention, provided their CD4 count is not very low and they showed a satisfactory response. Making the staff come to the Operation Theatre [OT] for HIV patients was a big challenge.

Similarly operating on a sputum-positive patient in an operation theatre is a challenge for staff. TB may be a disease of the poor, but TB surgery can not be taken in compromised circumstances. We have to have a minimum of basic facilities including a laminar flow, air conditioning, and airflow control unit along with Hepa filters and anesthesia circuits that have to be changed to prevent any transmission to personnel working in operation theatres. We take every precaution possible.

Parul: Sir, Can you tell us more about National TB Control Program?

Dr. Dewan:This program started in 1962, at that time it was based on mass miniature radiography. X-rays were done in the field to diagnose TB. In 1993 sputum smear examination was started when the TB program was revised [Directly Observed Treatment Short-course (DOTS) strategy], earlier the treatment was for a longer duration and then it became for a short duration. In the development of RNTCP, my senior colleague and earlier Director, Dr. Sarin was also involved. This policy is getting refined and sophisticated slowly, In 2018 when the End TB  goal was declared by the Prime minister of India, the focus has been increased again, and now it is called National TB Eradication Program.

The emphasis has changed

• Diagnosing TB has changed from a simple sputum smear to Gene-Xpert. Now the diagnostics are improved, there is a routine drug sensitivity examinations at the beginning itself for all diagnosed patients.

• Individualized patient care has now been included in this program, If there is a communication problem then counseling is done.

• The government provides a direct benefit transfer of 500 rupees to their account for nutrition support.

• If patients develop any post-TB sequelae or any comorbidity, there is a well-defined algorithm to admit these patients. Centralized monitoring is done for these patients under the Nikshay register program.

Nikshay mitra yojana in India is now very good in which there is the involvement of corporates, and NGOs where in they adopt a TB patient and provide a nutrition basket every month, give emotional support while encouraging the patient to continue the treatment to prevent failure, and also provide skills so that they can be re-employed

Parul: How far do you think have you come, or should we say, what is the contribution of your Institute in eradicating TB?

Dr. Dewan: See TB is a long disease, data in 2015 showed us that mortality from 1995 to 2015 decreased by 42%. So, every year there was a decrease in mortality by 3% till Covid came.  We have a better strategy now and the goal is to eradicate it by 2025. we are working diligently towards it. Last world TB Day we found two districts in J&K and Lakshyadeep have achieved total eradication. Many states have achieved 60% eradication from TB. We should keep on strengthening this strategy by making early diagnoses and starting the early intervention.

Parul: How much burden does TB impose on the healthcare system all over India?

Dr. Dewan: In general terms, TB is seen by all the medical specialty departments. It is the commonest disease, seen in the young generation. So, it creates unemployment and creates a vicious cycle of poverty for families who suffer together when a person is affected by TB. This has been creating and putting a big burden on the healthcare system and society. We can reduce the stigma by encouraging some politicians and celebrities by promoting TB treatment. Continuous efforts towards healthcare, lesser overcrowding, and clean breathing air will make a difference in real terms.

Well the story isn't over for us yet. Stay tuned to MedBound Times for Part-2 of this interview series

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