Aparna works on making healthcare accessible
Posted On: 07-20-2018
Aparna Rao, a researcher at L.V. Prasad Eye Institute in Bhubaneswar, is looking for new answers to counter the irreversible effects of glaucoma.
WHO? Aparna Rao
WHAT? Eye Specialist and Glaucoma Researcher
WHERE? L.V Prasad Eye Institute, Bhubaneshwar
Reported by Upasana Agarwal
A spectacle for public and private health everywhere, the L.V. Prasad Eye Institute in Bhubaneswar offers state-of-the-art facilities at its free clinics. It is only natural that Aparna Rao, a believer of accessible, community-based health care, should find herself in these halls to find a cure for glaucoma – one of the most mysterious and deadly diseases to affect the human eye. “I want to learn more, to do research that is pertinent to the patient and give back to the community. I want to be able to guide and help my students grow as researchers,” said Aparna in an interview between her lab work and the last of her clinic hours for the day.
In a time when India’s spending on public health presents worrying circumstances for the future, it is reassuring to see what researchers like Aparna are bringing to the table.
Early years as a glaucoma consultant
Aparna started out as an ophthalmologist (eye specialist) fresh out of medical college. She rose to the highest ranks of the profession, soon becoming a super-specialist in glaucoma. However, it didn’t take long before the restrictions of being just a consulting doctor for glaucoma became too much for her. Something was missing. “I was giving the same answers to patients that my professors gave me 15 years ago in medical college. I couldn’t help feel disappointed and frustrated that in all this time, there had been no significant change in the management and treatment of glaucoma. I wanted to give new answers.”
She struggled to find time for research from 2011 until 2014; equipment and manpower were also limited. The hours required of her as a clinician left no time for research. So in 2014, she decided to dedicate herself to lab-based research and learn the fundamentals of science by signing up for a PhD at the Kalinga Institute of Industrial Technology in Bhubaneswar.
Her research topic ‘glaucoma’ is the second biggest cause of irreversible blindness, with over 12 million cases estimated in India, and almost 60 million worldwide. The disease has reached epidemic levels, but the technology for early detection is limited. In most cases, it is diagnosed at a later stage after significant damage has already occurred.
Aparna’s research focuses specifically on ‘pseudoexfoliation glaucoma’, the only type of glaucoma linked to other symptoms in the body, such as cardiac problems and cerebral strokes. On a regular day, Aparna treats around eight to nine patients with pseudoexfoliation glaucoma.
The disease appears as deposits resembling dandruff flakes, in the eyes. The flakes prevent draining of aqueous humour, a watery fluid in the eye, raising the pressure in the eye that ultimately causes blindness. Within the eye research community, these flakes pose a significant mystery. Aparna asks: “Why do only some people develop it and not all? Where do these deposits come from? What genetic and environmental factors are responsible?”
According to her, pseudoexfoliation glaucoma has a very unique geographical distribution – for example, it is concentrated in Orissa, Bengal, Kashmir, Kerala and Tamil Nadu. “There is no obvious connection between these places apart from their climate and diets,” Aparna said.
First viscocanalostomy in east India
In 2015 Aparna was faced with a challenge. A young boy suffering from early onset glaucoma needed treatment but it would have to be a non-penetrating one. Viscocanalostomy is a procedure where a filtering environment is created in the eye through a naturally occurring membrane to drain out the excess solution for maintaining suitable pressure within the eye. This approach, a common method used in the West, seemed like the best option for the young patient. The procedure was used for the first time in east India. She was successful, and she went on to conduct the critical procedure on four more patients.
Despite this working out, Aparna stressed that emulating global western standards is not always the answer. Most procedures require frequent follow-ups, and this is not always possible for patients in India staying far or from rural places.
Studying medicine where healthcare is limited
Aparna’s interest in glaucoma comes from her desire to help and serve patients. From 1993 to 99, still in her teens, Aparna opted to study in a medical college in the town of Ambajogai in Maharashtra. “I wanted to be part of a smaller classroom because I knew it would be more interactive and I would get a better education. Being in Ambajogai, I got to see the real issues that plague the interiors of India where access to healthcare is limited,” she recalled. Such a medical education came at the cost of turning down seats at a well known medical college in Mumbai and Coimbatore Medical College.
In medical college, Aparna had the privilege of being taught by professors who welcomed her aptitude to explore healthcare deeply. “My classmates and I would go to our professor, Dr Baheti, and he would explain the same topic over and over again to us. All he needed was a cup of tea. Another professor, Dr Das at GNEC, was a true teacher, so difficult to find in today’s times. We would go to his office with a bottle of Pepsi or Coke and then he would sit and answer our basic and stupid questions!” she reminisced.
These informal musings with her teachers were a fertile ground for Aparna’s subsequent research career. “Their teaching taught me to devote and try doing the same for my students. But the student population and their perspectives/priorities have changed as well!” she observed. This is why she feels her current workplace LVP is a special platform that nurtures such open interactions between students and teachers. Nevertheless, it is a struggle to balance time between research, clinic hours and students, she said.
Time as scientist-cum-doctor
After Ambajogai, Aparna moved to New Delhi to join a Diploma course at Guru Nanak Eye Centre at Maulana Azad Medical College. “I was an average student, but with a keen interest in science,” she said. She was mentored by Professor J.C. Das, who is known for introducing and popularising glaucoma valve surgery in India – a procedure where a valve is used to lower eye pressure. This experience helped Aparna gain a lot of exposure to glaucoma. While observing the disease she was intrigued and disturbed by its permanence.
For the next three years, prior to her PhD, Aparna strived to make it as clinician-cum-researcher on her own. She shared the trials faced during this period: “Making breakthroughs was difficult because of the rampant publication rat race. It has led to a surge in predatory journals in India that operate with a pay-to-publish model and lack a peer review process.” Critics of the ‘publish or perish’ trend in the medical research sphere like Aparna argue that not only does this culture produce less researched work, but it also contributes to a trend of plagiarism and other unethical publication practices.
Aparna severely rejects the “recognition quotient” – a long-standing belief that recognised scientists do the best science. “These hyper-competitive spaces are less invested in the long-term efforts required to make significant breakthroughs.”
Feeding patient case studies into your one’s research seems straightforward. However, Aparna did not have an easy time. “Most of the time, the bandwidth with other researchers did not match. Once a researcher notices that there is something novel to be gained out of the work, they’ll use my idea. Later I’ll find out that they’ve taken it up on their own and continued the work. It’s happened to me so many times,” said Aparna. Instead of becoming negative, such occurrences only prompted her to look for the right people and the right time for starting her kind of work.
Researching an organ like the eye serves up further problems. Aparna explained, “Most researchers are working with the same questions but with different diseases. Because the eye is so small, the tissue to be analysed is also really small and most researchers are intimidated by this.”
When Aparna decided to go back to basic science by joining a PhD program, there was resistance from family and colleagues. “I had already established myself as a doctor and so the decision didn’t make sense to everyone,” she said. Nevertheless, she was determined to put in the extra years to set up her research practice formally. “It was what I love… answering the questions that pop in my mind, and so I went ahead and pursued it,” she said. As it turned out, her PhD was only the beginning.
Pushing for change as a glaucoma scientist
Now formally equipped for a research career, Aparna started to apply for research grants and recruit manpower. She knew that there very few institutes where she would be given time for research at the expense of clinic hours. Fortunately, the LVP platform and work culture allowed this to happen without much problems.
Aparna spoke fondly of LV Prasad Institute where she currently heads glaucoma research. It is a space that allows her to prioritise research by giving her incredibly flexible clinic hours. Clinic hours are only half days, and every doctor is given a day off every week for research. “My time at this institute has helped me bridge the gap between clinicians and researchers as well as deliver the more integrated education to my students”, she said contently.
To counter the problem of access and detection, Aparna has been researching easily available methods to spot glaucoma early. Over the last two years, she has developed a detection strip which will work as a tear dipstick assay for easy, cheap glaucoma screening. Simple in form, the strip is based on a principle similar to an over-the-counter pregnancy test. A change in colour of the strip alerts the user about whether or not they are susceptible to the disease. Aparna anticipates that this will stop glaucoma from causing severe damage before detection.
“On its release, it’ll be easily available to patients and can be distributed in bulk to every home in rural areas by, say, ASHA (Accredited Social Health Activists) workers,” Aparna said.
Among her peers and contemporaries, Aparna has seen that doctors are less inclined to opt for research. She holds culpable the lack of spurts in basic research funds around the country and a shift of focus towards popular diseases, which are expected to bring better returns to pharmaceutical companies. “While molecular level research can help towards new medicines and injections, there is little to no significant change in the treatment of the disease. Newer medication produced is more expensive, and treatment isn’t cost-effective,” she added.
Aparna takes her responsibility as a public health scientist very seriously. She feels that more effort should be made to bring ophthalmologists and researchers together on one platform to discuss the major obstacles to pursue research truly beneficial for patients. She concluded, “Today, we need to focus on solving problems faced by a patient rather than focus on the glamour quotient behind every question or research. We need relief from the compelling need to “perform” to the world.”
Making unpopular choices
In her career, Aparna has made unpopular choices, taken a step back to re-evaluate her role in combating a morbid disease. At 42, Aparna has no regrets. Today, she sits in her lab surrounded by confident, young women researchers who spend their time sampling, analysing and documenting data. her students share a laugh about how some boys don’t cooperate and set their own deadlines. “I think we are more patient researchers,” said one of Aparna’s students Priti Sahay.