The act of replacing affected organs with healthy ones is termed organ transplant, representing a monumental stride in medical progress. India stands at the forefront of this field in Asian subcontinent. The evolution of medical science has significantly transformed the transplantation process, presenting it with a newfound dimension and significance.
Dr. Harsha Jauhari is a renowned name in the field of organ transplantation. Dr. Jauhari is chairman and senior consultant, Department of Renal Transplant Surgery at Sir Gangaram Hospital, New Delhi. He has been the pioneer in starting successful renal transplant surgery programs at government registered centers in three states. He’s advisor organ transplantation to the Ministry of Health and Family Welfare, Government of India since 2014 and is involved in developing the National Organ Transplant Program and national organ and tissue transplant organization. He is also a recipient of Dr. BC Roy National Award. Dr. Jauhari is a man of many talents and wears multiple hats in his professional life. Here are edited excerpts of an interview with Dr Harsha Jauhari:
Question: What motivated you to pursue a career in organ transplantation?
Dr. Jauhari: My teachers thought I was mad because during mid 80s, transplantation was on the frontiers of medicine and it was considered far too experimental for people to actually take it up as a career. But I found it fascinating. Also because of a more personal reason. My own mother developed kidney failure and there was really no treatment around at that time. So I thought I must do something to at least pay my debt to my mother and to others who are suffering from the same problem.
Question: And how has been the journey since then?
Dr. Jauhari: Tumultuous with lots of ups and downs. But ultimately we have achieved far more and we can be proud of what we have achieved than what we had expected when we started. Initially we used to say, can we do the transplant? Will it be successful? Today we don’t talk about can we be successful? Today we talk about success rates as high as 90%, 98%, 99%. And we say, why can’t we do more? Why can’t we take more donations from people living and cadavar? So the whole focus has now shifted to what the government can do, what people can do, what society can do to get involved in transplantation. So it’s a very exciting time for people to be in transplantation.
Question: What is your perspective on the current state of healthcare in India?
Dr. Jauhari: See, if we look across the board, we have got, at any given time, almost estimates. Nobody knows the real figures. About 400,000 people in the country every year having various kinds of organ failure. Heart, lung, liver, kidneys, other intestines. And we are able to transplant only a few thousand. So the rest of them eventually die.
So in my entire life I’ve been able to do little over 6000 transplants. What have I done in that period? Millions have died. It’s a drop in the ocean. So there’s so much more to be done and I would like it to be done. That transplantation should be in every government hospital, in every medical college. It should be as freely and easily available as any other major operation such as Hip replacement or bypass. Why you should not have it in every hospital? It should not be an elite treatment.
Question: Though the medical science behind organ transplant procedure – be it heart, liver or kidney – has improved multifolds, the supply for organs is never equal to the demand. Every year, millions of people die waiting for an organ. What is going wrong? Why can’t we have enough organs?
Dr. Harsha Jauhari: There are multiple reasons, but the main reason is misinformation among the public. And we over centuries have been used to understand that a person has died when his heart and his lungs fail, cardio respiratory failure. So the concept of brain stem death, that the brain has stopped functioning and inevitably the person is going to stop breathing without any ventilatory support, is new to people. It is something which people resist because you see the patient and you say the patient’s heart is beating and he’s having breathing, but that’s because of the ventilator. And they don’t understand that if you stop that, within a short time, everything will come to a halt.
So that, as a concept, requires a lot of public education and awareness. In our country, we have a tradition of donation. If you ask them nicely, people do understand. So the very rich and the not so well off, they are the ones who come forward. The middle class, who are the very intelligent people, always ask questions and it’s very difficult to convince them because there’s always a counter question.
But people are coming around. And we’ll be able to get far more organs for transplantation, especially the ones which are heart, lung, intestines, etc., which you can’t take from living people. So basically liver and kidneys, we can take from living donors. Rest of the organs come from cadaver.
Question: The concept of organ donation is not new. So, what has stopped us from having a wide spread educational campaign pushing for a change of mindset among the population?
Dr. Jauhari: See, the government and various NGOs have been spreading awareness over the past many decades. For example, we started with eye donation. we went right down to schools and colleges to educate youth. I personally believe that talking to the old or the middle aged people is a waste of time. I feel that if you want any program to succeed in this country, you must always go to the youth. They embrace it because they understand and they are open to new ideas.
Governments are now going into the school level to give lectures. And we would definitely like to do more. There are jingles on the radio. There are these programs every year on National Organ Donation Day honoring donors. Recently, the state government of Tamil Nadu came forward to honor all organ donors, by giving them a state funeral.
And we have been recommending far more that every driving license should have your wish, whether you want to be an organ donor or not. So the scope is wide. In MBBS, for example, we are bringing in chapters so that right from the beginning, medical students begin to understand what transplantation is all about.
So there’s a lot of work going on in this field, and it is bearing fruit. Earlier, when you asked people about organ donation, they looked blank or they looked furious. Now, people are quite understanding because, you know, virtually every family person knows somebody who’s got some degree of organ failure. And you know that there’s a need. Now, whether you come forward or not is a separate question. But nowadays people are aware that there’s something called organ donation and transplantation.
Question: And when there is a shortage of organs, what good does the advancement of medical science for organ transplant do? Does it actually manage to help the needy?
Dr. Jauhari: There are some organs where you have no option, you have transplantation or death. But for some, for example, in chronic cardiomegaly, you can give some temporary support, for liver, you can give a very temporary support, for kidney, you can at least give dialysis.
Now, dialysis is not ideal, but it is a way of keeping alive while you’re waiting for an organ. These are the life-saving ones. Heart, lung, liver, kidney, pancreas, to a point. But for the transplant, you require organs, you can’t make them in factories, unfortunately not yet.
Question: The people living in urban cities may still be lucky but say someone living in rural India – do they have easy access to an organ transplant procedure?
Dr. Jauhari: I would say that it is definitely better than it was earlier. And when people come from rural areas or tier two or three cities they’re fully aware of what is happening in this. Social media has been of great help because they have done their homework before.
So they choose the centers where they feel they’ll get good results. They do the homework regarding the costing, regarding the legal requirements of the family, who the donor is going to be and all. People are more aware now. I think it’s not much difference between the rural and the urban.
Question: We came across a very interesting study which says women donate more organs in India. In your experience, what are the social reasons for this kind of skewed metrics?
Dr. Jauhari: In India, we do not have Social Security and ours is a patriarchal society. And the fact is, one person earns and ten people or 20 people are dependent on that person. So that is a reality. And it was the man, largely, who is the breadwinner. And that is why the entire family rallied around trying to give him the organ, so that at least if he survives, the family will be able to pull through.
Now women are also becoming breadwinners. They’re also getting the organs. And earlier, yes, the mother, the sister, the daughter, the wife, they were coming forward. And not all of it is coercion. Let’s not demean that emotion of generosity and nobility by just saying everything is coercion. No, it is not. They feel very genuinely. Similarly, a son having a kidney failure is a disaster. But if a son in law gets it, this is a bigger disaster, because if he gets a problem, what’s going to happen to your daughter? She’s going to come back with the kids.
So the women do come forward. And yes, earlier the women were more in numbers than the men in donation. The percentage was high. Now it has changed. I remember, my first couple of thousand transplants, I think, what about 300, 400, 500 wives were giving to the husbands? Only about two husbands gave to the wives. Now more and more husbands are coming forward to give to the wives. Maybe not as much as we would like, but I’ve seen mother in law giving to the daughter in law, father in law giving to the daughter in law, Muslim husbands giving to the wives.
With all the conservative thought, they are still coming forward against their family opinion. So things are changing because people are changing. Earlier that fear was there, what’s going to happen if both of us …? Now the results are not so bad as they used to be. People do survive and they do well. I would like to have more men coming forward.
Question: The organ donation rate in Spain has seen an increase due to strong infrastructure, public education, and healthcare-government cooperation. What, in your opinion, are the 3 key changes we need to bring in our system to have a better organ donation ecosystem?
Dr. Jauhari: Everybody keeps talking about Spain. I was there along with the ministry people to study how the system works and they told us that you are spending a lot of money and effort in public education. We did that a few years ago and we found that you don’t need to spend that much, but you need to spend more on organization.
Basically what they were saying is, that those who are willing to give, are willing to give. But the organization, once somebody has committed to giving an organization, how do we reach a logical endpoint of transplantation? That is what everybody is trying to copy.
Spain is a very small country compared to country like India. Most countries have a three tier medical system. You have the hospital, you have a local authority, and you have a central government. In India, because we are so vast, we have to have at least a fourth tier, a central law, which, unfortunately, health, being a state subject, is not binding on all states. So each state can make its own.
Now we’ve some of the states which have high literacy rate. Karnataka, Tamil Nadu, Kerala, along with Maharashtra and Gujarat coming in very fast. Some other states like J&K, Haryana, Chhattisgarh, Jharkhand, Bihar are lagging behind because of probably less of acceptance of the concept. Northeast people are more aware.
Also, now people are beginning to understand connectivity, how to share the organs across states, creating green corridors. So that is the second part.
So, first point is building organization, second is creating awareness. And the third is the role of government. They are trying, but their role is not clear. Should they be the provider of the health care for transplantation or should they be the payer? The private sector has its own compulsions, not necessarily negative, but they have to spend. If you want first world treatment then you cannot afford it at third world rates. It cannot happen.
So if you promote the government institutions doing this work then you need to pay for it. You want the prime minister’s schemes, the state schemes, all of them coming into the non-government, bringing the prices down. It is not sustainable for the length of time because the cost of the disposables itself, the cost of the nursing, the medical profession, the medicines are so high.
See, either it has to be subsidized by the government and done in government institutions, or it has to be done in the non-government, where you have to make allowances for that. So whether it’s going to be a provider or payer, that has to be clarified. And I think this is where most of the discussions are going on. Let’s hope.
Question: Doctors in India hesitate to broach the subject of organ donation with a deceased family. In a country where ‘violence against doctors’ is an all time problem, How do you tackle an issue like this?
Dr. Jauhari: I will take you back to early 50s when I was a child. Life Insurance Corporation had just come in and the agents used to ring the bell at people’s house to say that, I have come to give you insurance. If somebody dies in your family, we give you insurance. So the ladies used to pick up the slippers and chase them, that you are talking about death in their family. It took almost 20 years for people to appreciate that they are actually insulating you against grief. But it took time because people’s first reaction was, how can you talk about death.
We are that kind of emotional people. And we haven’t changed. We are still emotional. Now, when you talk about somebody talking about organ donation, that means you’re essentially talking about somebody dying. And we don’t like to hear that thought.
So what doctors are talking about is what is called a required request. The doctor on duty is required by law to ask you to donate organs if you want to. If you don’t want to, you don’t do it. But don’t beat him up. He’s only doing a job. He doesn’t want it.
By adding required request, we transfer the actual responsibility to the law so that the doctor at least feels a little more confident. So now a doctor begins the topic of organ donation by showing a poster on the wall. and clarifies that I am asked to do it. These things don’t change overnight.
Question: Why is health literacy important for a lay person?
Dr. Jauhari: We should be proud of our heritage. Every single thing in our country is based on trying to prevent contagion or infection right from the time you are born till the time you die. All of it is to prevent contagion. All your food, all your feeding habits, sleeping habits, cooking habits, everything is based on that. We have got a whole lot of literacy of health. Only question is how do we bring it to the modern concept of organ donation. We have to do it in a way which is acceptable to people. We all are health literate. What we require is updation or modernisation of our health literacy.
Question: What are some activities that you, as a doctor, engage in to maintain your own mental health and well-being?
Dr. Jauhari: You have to maintain your sanity and your calm. You have to compartmentalize your emotions. As a surgeon, if I stick a knife into you, it hurts you. It hurts me as well, but I can’t allow it to hurt me. I have to be cruel to be kind. So these are emotions which have to be kept under check as a person.
I believe that every morning and every night, look at what you have done the whole day and thank the God that he has given you an opportunity to be of meaningful help to people. We should be positive and be happy to that God has been very kind to all of us.
I ask myself: Could we have done better? Sure. Could we have done worse? Definitely. Have we done what we have done honestly, to the best of our ability? I think so. So to that extent, I’m a happy soul.
Question: What are your favorite hobbies that keep you engaged apart from this hospital?
Dr. Jauhari: Reading. Anything and everything. I am a voracious reader. Also tried to write a few things. I manage to find time to read. Five minutes here, ten minutes there. I prefer reading books. You get far more satisfaction by holding a book in your hand than by reading it on a screen.
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