ISN VIDEO LEGACY PROJECT

DR. K.S. CHUGH
INTERVIEWED BY DR. VIJAY KHER


VK:

Dr KS Chugh is an Emeritus Professor and former Chairman, Department of Medicine and Professor and Head, Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Professor Chugh has been a Past President of the Asian Pacific Society of Nephrology, Past President of the Association of Physicians of India, President of the Indian College of Physicians, President of the Indian Society of Nephrology, President of the Indian Society of Organ Transplantation, and a former member of the Nominating Committee of the International Society of Nephrology and a member taskforce ISN Commission on Acute Renal Failure. He is currently the president of the Indian Society of Hemodialysis, a member of the Council of International Society of Nephrology, and a member of ISN Commission on Global Advancement of Nephrology. Dr Chugh has chaired 26 scientific sessions and delivered 50 plenary and invited lectures in international congresses all over the world. Dr Chugh has been a member of WHO Advisory Committee on Classification of Tropical Renal Diseases and a member of the WHO SEARO Guidelines Committee for the clinical management of snakebites in South East Asian region. He was the Vice President, Organizing Committee of the International Congress of Nephrology held in Sydney, Australia May 1997.

Considered as Father of Nephrology in India, Dr Chugh is a world-renowned physician and a nephrologist, and a recipient of Padma Shree Award, Honorary Fellowship of the Royal College of Physicians of London (FRCP) and has the singular distinction of being the only Indian physician to be the recipient of the Honorary Fellowship of the American College of Physicians. He is also the recipient of Gifted Medical Teacher Award of the Association of Physicians of India, Dhanvantri National Award and Doctor BC Roy National Award as the Eminent Medical Man of the Year 1992. Dr Chugh was the first Asian nephrologist who was honored by the National Kidney Foundation of USA with Distinguished International Award, and Nephrology Forum Award by the Kidney International. Besides these he is the recipient of 24 more national and international awards including Nishane Khalsa Award and Bharat Guarav Award. Born on 12th December 1932 at Patti, a place thirty miles away from Amritsar, the city of Golden Temple, one can see the determination and dedication of Dr Chugh even as a young medical graduate and post-graduate. A never-say-die attitude helped him push faster through the slow tracks of the country and achieve what others had given up. Well reputed for his steadfast devotion to scholarship in nephrology, he is also an embodiment of bonhomie and camaraderie. With these qualities of head and heart, Dr Chugh is a favorite of most. Let me take this opportunity now to talk to Professor Chugh.

Dr Chugh, when did you decide to become a nephrologist?

KSC:

Five decades ago, nephrology as an organized discipline did not exist anywhere in the world. I was a fourth year medical student in 1954 and at that time no treatment of renal failure was available except the Bull’s diet which was totally ineffective in managing these patients. The clinicians, as well as the students, realized the futility of this treatment. At this time the reports were pouring from the rest of the world that a dialysis machine had been devised by Dr Willem Kolff. And also while going through the literature at that time, I came across a report in the Lancet that a new diagnostic approach to the diagnosis of kidney disease had been published and that was on renal biopsies. Simultaneously another report appeared about the first successful transplantation in the world, which was carried out in Boston by Joseph Murray, David Humes, and JP Merril. This was between identical twins and the transplant was successful. This gave me a hope that in future we may be able to do something for these patients, and I decided to take up renal medicine as my career in the future.

I passed my MBBS from the Medical School in Amritsar, in 1955 and I started preparing for submitting a thesis plan, as was the practise at that time, for pursuing MD in Medicine. I selected “Evaluation of renal biopsy as a diagnostic procedure” for my MD thesis and at the same time I applied that I may be given permission to do MD (Medicine) with Renal Diseases as my special subject.

At that time only cardiology, gastroenterology, and neurology were the recognized disciplines. So when my plan went to the Punjab University and it was discussed in the Faculty of Medical Sciences, my plan was approved, but they objected to my special subject of Kidney Diseases because they said it did not exist anywhere in the world and I could not be permitted to do MD Medicine with Kidney Diseases as my special subject. This took three months and the plan came back to me, and the suggestion was that whereas I could pursue the thesis project but my special subject would be MD Medicine with Gastroenterology. This was not acceptable to me; I wanted to do MD Medicine with Renal Diseases. I talked to my mentor at that time. In fact, he was also not very keen that I should do MD Medicine with renal diseases because he was a gastroenterologist himself. In any case, I did not accept this proposal and I applied to the Punjab University again that I wanted to do MD Medicine with Renal Diseases. They discussed the plan again and this time a suggestion came back to me that if I do not want to do Gastroenterology, I could take Cardiology as my special subject. When this came back to me again I didn’t want to accept this either. Perhaps it was my obstinacy at that time. I wanted to pursue kidney as my career, so therefore I represented for the third time, giving instances from the world literature as to how much could be done for patients with kidney diseases. When the plan went to the Faculty of Medical Sciences of the Punjab University, third time, I learnt later that the Dean of the Faculty of Medical Sciences commented that “this person seems to be a madman”. Let him do MD Medicine with Kidney Diseases if he’s insistent on doing so.” And therefore after about nine or ten months of struggle I was accepted by the Punjab University to do MD Medicine with Renal Diseases as my subject. This is how I started my career in the field of nephrology and became the first qualified nephrologist of the country.

 

VK:

Dr. Chugh did you think of going to USA or UK for special training?

KSC:

After I got selected as a Lecturer in the Postgraduate Institute of Medical Education and Research, Chandigarh in 1963 I became actively involved in dialyzing patients of renal failure. I was also doing a lot of work on kidney biopsies and had started investigating patients with renal diseases at Chandigarh, I thought at that time my main aim was to set up a new department. Although it did come to my mind that I should go for training outside, yet I thought I was doing fairly well. With the help of Fellows in Medicine who were working with me at that time, we had started some projects on renal failure and had started publishing on various kidney diseases. Since we had actively started doing dialysis work ourselves, at that time I did not go to UK or USA for further training. However I did go to Hammersmith Hospital, London in 1967 when our unit had become fully established. During my stay in Hammersmith Hospital I worked with Doctor Oliver Wrong. The renal unit of Hammersmith did not run the dialysis center and the dialysis program was under the care of urologists. Renal transplantations were also actively going on in the Urology unit. Since Dr Oliver Wrong was largely involved in research in acid-base and electrolyte problems, I worked on a project which involved making cation exchange resins in aluminum phase. Soon after we published this work in the Lancet in 1968, we received a number of critical comments on our work highlighting that aluminium could be toxic. Therefore the work on aluminium resins was not pursued any further.

During my stay in London, I met several of the important renal physicians in the United Kingdom and more importantly Dr Stewart Cameron in Guys Hospital. I was very impressed with the kind of nephrology that was being pursued by Dr Stewart Cameron. Later I also went to Newcastle Upon Tyne where Dr David Kerr had improvised a chronic dialysis system using Kiil Dialysers without monitors. I picked up lots of ideas from David Kerr’s unit. We used to make our own Teflon tips for AV shunts by using Teflon material at that time. I returned to Chandigarh in 1968 and then we started a Chronic Dialysis Program with our own improvised setup.

VK:

Doctor Chugh, when did you start the training program in nephrology at the Postgraduate Institute. Later Postgraduate Institute became the Mecca of Nephrology education in the country. So, how did it all happen?

KSC:

The training program in nephrology at the Postgraduate Institute, Chandigarh was started in 1969. We recruited two MDs, one from Madras and the other one was from the Armed Forces Medical Services, and we started an organized course in nephrology in 1969. This was a two-year course. The candidates were supposed to work on a project and at the same time involved themselves in all the clinical and research work in the Department of Nephrology. The first batch of two candidates passed in the year 1971, and it might surprise many that this examination in DM nephrology at Chandigarh took place one year before the American Board of Nephrology Examination which took place in 1972. So therefore I can claim we were one year ahead of the Board of Examination in Nephrology in the United States.

VK:

Dr. Chugh, PGI achieved eminence as the best department of the country. Had you ever conceived it in the beginning this is how it would develop and how did it happen? Was there contribution by others for the development of this department?

KSC:

I can say it is never a single man’s effort. I think when we started doing some good work at the PGI Chandigarh, everyone appreciated that the department was coming up very well. Our training program was well organized. The fellows took part in the various research projects and at the same time they started learning the techniques of various forms of dialysis. Also in the Institute, clinical meetings and Clinico-pathological Conferences were being held regularly in which all the fellows actively participated. We also organized a regular bedside teaching programs and the result was that during this two-year period spent by these candidates for their nephrology training, they picked up almost everything. We encouraged them to participate in group discussions and seminars. We also organized Journal clubs. Whatever was appearing in the literature from anywhere in the world, we used to discuss these regularly and therefore we were all, actually I would include myself, learning what was happening in the rest of the world and in that way the candidates were updated with various developments taking place in the world. When the candidates went back to their institutions after doing their DM in Nephrology, they started developing similar programs and organized various diagnostics facilities in their own institutions. Some of them also went abroad.

I’m very happy to say that any fellow who went abroad and had the opportunity of working in an advanced centre, he/she created a tremendous impression because of the training he/she had received at Chandigarh. Their performance was so good that everybody was very happy with the training they had received at Chandigarh. In that way I think they created a tremendous impression outside as well as inside the country. The standard of training has improved over the years. I’m proud to say that some of the fellows whom you know very well, they have done so well in countries like United States, that they are regarded as world leaders today.

Let me give you the example of Dr Brian Pereira. He went to the United States in 1989 and within a period of about 12 or 13 years he became one of the renowned nephrologist of that country. He was often invited to deliver Plenary lectures to the American Society of Nephrology, became the President of the National Kidney Foundation of the United States and at this moment he is the President of the New England Medical Center where he had joined as a fellow in 1980.

Similarly another fellow who was trained in Chandigarh, Dr Ravi Mehta, today he is an accepted authority on the Continuous Renal Replacement Therapy. Both of them have written books which are of international standards and are comparable to any textbook published form anywhere. In the country most of the fellows who had their training in Chandigarh, went back to lead their respective departments. I can say that the work done by them during the last two or three decades, has often found a place in the national and international journals and the facilities which they have established in their institutions are well-known to all. I can proudly say they have done extremely well and that is how Chandigarh had gained a good reputation.

VK:

Dr Chugh you played a stellar role in establishing the Indian Society of Nephrology. There must have been very few nephrologists when the first meeting started. How did it all happen and can you tell us as to when was the first meeting held and how did the Indian Society of Nephrology grow?

KSC:

The Indian Society of Nephrology was founded by me and Dr P. Koshy of Vellore in 1970. We had our first meeting along with the Association of Physicians of India in Mangalore in January 1971. At that time I invited Dr Emillio Rotellar, the then President of the EDTA to inaugurate the 1st Scientific meeting of the Indian Society of Nephrology. Frankly speaking, apart from myself, who was a qualified nephrologist at that time, we were only fifteen or sixteen in 1970 who were involved in the specialty of nephrology in one way or the other. Gradually the Indian Society of Nephrology has become an established society. Today we are over 800 in this country. If one goes back to the Annual Congresses of the Indian Society of Nephrology the standard of research work being presented in these meetings has improved tremendously. This is because, after Chandigarh, several other centers also became established in the country and had started DM Nephrology training programs. The result was that more and more trained nephrologists started joining the Society and the standard of the conferences improved significantly. The impact of this Society was felt even outside when for the first time in 1974 Dr Khoo EnTeik organized the First Colloquium of Nephrology in Singapore. I presented my work, which was being done at that time at Chandigarh and Dr K V Johny and Dr Mohan Rao who also attended this meeting presented their work being done at Vellore. Everybody in that Colloquium appreciated the efforts which we had made in India. In our surrounding countries in the South East Asia, not much renal work had been done by that time. Therefore the Indian Society of Nephrology gained an enormous reputation.

Later, in 1979, I was invited to New York by Dr John Merril and Dr Eli Freedman to participate in the First Conference of the International Society of Artificial Internal Organs. I presented a paper on the therapeutic facilities available in India and the state of Indian nephrology at that time. By that time we had done 365 transplants in India and about 30 dialysis centers had been established. I had collected statistics from all over the country and I presented these there. So this is how over the years, Indian Society of Nephrology started getting recognized in the outside world. Another thing, which I did, that every year at the time of the annual congresses of the Indian Society of Nephrology we invited some of the very distinguished nephrologists from UK, United States, Europe or Austalia. These visits gave a tremendous exposure to our Consultants as well as Fellows in Nephrology. I think that their visits helped us in updating our knowledge at the time of our annual meetings. In 1972, I started corresponding with Dr Oshima in Japan and Dr Priscilla Kincaid-Smith in Australia, that we should form an Asian Society of Nephrology. Dr Oshima in 1973 wrote to me and asked me how many members we were in our society. I informed him that we were about 120 by that time. He wrote back to me that there were 2300 members in the Japanese Society and therefore, he thought, that at that time it was not possible to make an Asian Society until a sufficient number of countries from the region came up with a larger numbers of nephrologists. So we couldn’t make a society at that time. When we met in Singapore in another meeting, I again talked to Dr Priscilla Kincaid-Smith that we should work towards forming an Asian society of nephrology.

In 1979 the first meeting of the Asian Congress of Nephrology took place in Tokyo along with the Asian Colloquium in Nephrology. The second meeting of the Asian Pacific Congress took place in Melbourne in 1983 under the joint leadership of Dr Prsicilla Kincaid Smith and Dr Oshima. This was followed by the 3rd Asian Pacific Congress in Singapore in 1986. At the time of the Singapore meeting, we made a Council of elected representatives of the Asian Pacific Society of Nephrology. Dr Prsicilla Kincaid-Smith was elected as the first President. The fourth conference was held in Beijing where Dr Hatano was elected as the next President and I was elected as the President-Elect unanimously. Dr Hatano presided over the Fifth Asian Pacific Conference of Nephrology held in Delhi in 1992. I presided over the Sixth Conference in Hong Kong in 1995. So when other societies in the Asian region had become active, we had formed the Asian Pacific Society of Nephrology, which today has become a very important society in the world.

VK:

Dr Chugh, over the years you became a leading authority in nephrology not only in India and the Asian pacific region but also in the international community. How did it come about?

KSC:

First of all I’d like to say that the work which we were doing at Chandigarh largely dealt with tropical problems. I regularly presented our work in the various national and international scientific meetings. I attended almost all the international congresses and made it a point to present our work in every meeting. In the Asian region, we actively participated in the Asian Pacific congresses as well as the Asian Colloquium of Nephrology. The result was that nephrologists realized that most of the tropical work which was coming out was from two or three centers only. Our centre was one of the leading centers which established the pattern of acute renal failure in India and the tropical world. Thus the major factor, which gave recognition to our centre, was that I presented our work in the national as well as in the Asian and international meetings. We also published a lot on the pattern of acute renal failure in the tropical countries, the pattern of Glomerular Disease in the Tropics, and some of the problems which the rest of the world did not see, for example, renal disease in leprosy, tuberculosis and conditions like snake venom induced renal disease. When I presented our work in the international forums, it gave me tremendous recognition in the rest of the world. The result was that I was frequently invited to various meetings. Our institute did not have funds for supporting these meetings, I attended these only on invitations. Gradually from the Asian society we moved to the International Society.

I remember when in 1992 we had the Fifth Asian Pacific Congress of Nephrology in Delhi, Dr Robinson and Dr Schrier were invited to attended this meeting, Dr Robinson was the President of International Society and Dr Schrier was the Vice-President. At this meeting, Dr Robinson mooted an idea that International Society should meet every two years with the various regional societies of the world like the South American Society, the EDTA, the American Society of Nephrology and the Asian Pacific & African Society and every ten years this cycle would be repeated. This idea was later discussed in the International Society of Nephrology and had met its approval. Therefore in 1993 when we met in Jerusalem for the ISN Congress, the Australian representatives along with myself as the President of the Asian Pacific Society of Nephrology presented a joint bid to the International Society of Nephrology for holding a World Conference in Sydney in 1997. After a lot of discussion the International Society of Nephrology accepted that we should start holding joint meetings. So it gave us an opportunity to meet regularly with the International Society of Nephrology. The 1997 Sydney Conference appointed me as the Vice President of the Organizing Committee of the World Congress, along with Dr Ross Bailey.

In 1993, I approached Dr Stewart Cameron who was the President of the ISN at that time, about our plan to hold the Silver Jubilee Conference of the Indian Society of Nephrology at Chandigarh.” Dr Stewart Cameron, I must say, was very, very helpful to us and jointly we arranged a CME on behalf of the International Society of Nephrology during the Silver Jubilee Conference in Chandigarh. Dr Cameron arranged a financial support of about fourty-thousand US dollars with which we were able to invite about fifteen international authorities in renal diseases to Chandigarh for the Silver Jubilee meeting. One significant feature of this meeting was Dr Cameron advised all visiting faculty to visit the important centers in the country in groups of two so that they could evaluate and assess the kind of facilities available in the Indian centers. This was done to enable the International Society to provide assistance wherever it was needed in terms of research facilities or in terms of enhancing library facilities. This is where I played a very pivotal role in organizing the visits of these international authorities to various Indian centers. I think this was of a great help to the members of the Indian Society of Nephrology and enabled them to establish a direct relationship with various leading centers of the world and they could send their fellows or could obtain assistance from them directly.

The next event which happened was that with the initiative of Dr Stewart Cameron and Dr. Schrier, the COMGAN was established. The COMGAN, the Commission of Global Advancement of Nephrology was largely established to provide assistance to various centers in the developing countries. I was taken as a member of the COMGAN in 1995 to represent India. I used this opportunity for our own advancement in this country and the result was that we could, with the assistance of the COMGAN, bring distinguished nephrologists every year at the time of the Indian Society of Nephrology meetings. Not only that, during the previous years, I had visited some of the neighboring countries like Nepal, Bangladesh and Sri Lanka where the facilities in nephrology were inadequate. With the help of the COMGAN, I organized back-to-back meetings of the Indian Society of Nephrology with the surrounding countries of SAARC. I thought the same faculty could travel to Nepal, Bangladesh or Sri Lanka and that we could assist these countries through the CMEs and update sessions and the visit of these distinguished people would help them as well. And therefore we extended our CME programs with the help of COMGAN to the neighboring countries of SAARC every year. I was the one who organized these meetings with the assistance of the COMGAN. Another important event for our country was that in 1988 I was selected by the team of the Editors of the Nephrology Forum of the Kidney International to present a Nephrology Forum. Dr John Harrington, Dr Nick Medias and Dr Cohen came over to India for conducting the nephrology forum at Chandigarh. This was the first time any nephrologist from the Asian countries was selected to present a nephrology forum. Another forum was organized in Thailand at that time, which was presented by Dr Visith Sitprija.

In 2000, we faced another problem in our country and that was about water treatment in various centres. For this, I approached Dr John Dirks, the Chairman of the COMGAN at that time, to assist us in organizing a meeting in India where we could discuss the water treatment problems. Dr John Dirks was very helpful. He talked to Baxter International who, at his suggestion, agreed to provide a financial assistance of US thirty five thousand dollars, for organizing a Consensus Conference on the Quality of Dialysis which included water treatment. This was held at Bombay. We invited various authorities in dialysis and water treatment system and we had a very successful meeting with assistance received from the International Society of Nephrology through the COMGAN. I think COMGAN has played a very major role in advancement of Indian nephrology both in terms of research as well as in enhancing clinical facilities. Lastly, I was picked up by the WHO for the book, edited by Dr Jacob Churg and Dr R Sinniah on Classification of Renal Disease in 1985, I was associated as a member of the editorial team, which edited that book. I contributed some chapters in that book, which is a well-cited book from all points of view for renal diseases in the tropical region. I was also appointed a member of the Advisory Committee of the WHO workshop held in Thailand which was chaired by Prof David Warrell. This was on Snakebite Management Problems in the South East Asian regions.

By presenting our work done in India in various conferences and also by associating ourselves with various  bodies like WHO, International Society of Nephrology, and the COMGAN, I tried my best to serve the interests of Nephrology in India as well as in the neighboring countries. It was our work, which we had been regularly presenting, as well as through the efforts made both at the national and international level, that I was accepted as a nephrologist from India who had contributed significantly to the world nephrology I became a member of the Nominating Committee of the International Society of Nephrology, my name had been proposed by Professor Hugh deWardner. Finally, I was elected to the Council of the International Society of Nephrology. This was for the first time that anybody from India had been elected to the Council of International Society of Nephrology.

 

 Dr KS Chugh transcript Part 2

VK:

Dr Chugh, you published extensively. Could you specifically mention and highlight some of your key research interests?

KSC:

Yes, I have published about 400 papers. Sometimes I wonder myself, how could one achieve this during one’s life time. I must admit that this achievement is not due to my personal contributions only but is largely because of the efforts of the fellows and colleagues who have worked with me in our department or other departments in the Institute. Because of joint efforts, we could produce lot of work which was accepted not only nationally but also received international attention. The first striking example was when I compiled my work on renal biopsies which I had done for my MD thesis in 1958, twelve out of sixty patients showed renal amyloidosis. This was very surprising and thereafter we started looking at the pattern of glomerular disease as seen in our part of the country. In 1963, when we started doing dialysis, we found a very heavy load of patients with acute renal failure who were totally different from those seen in the western world. For example, the commonest cause of acute renal failure was severe diarrhea, dehydration and volume depletion. Another common cause was renal failure associated with obstetrical practice, both following septic abortions and occurring in late pregnancy. One of the very striking feature when we analyzed the data on renal biopsies in our patients of obstetrical acute renal failure was that 25% of the patients showed acute cortical necrosis which was the highest incidence, recorded anywhere in the world. When we published this work in the Green Journal – Obstetrics and Gynecology – I started receiving invitations for presenting this work from various centers in the United States and UK. Therefore our work on the pattern of tropical acute renal failure was the beginning of a very big project in tropical nephrology. Also, we started seeing patients of renal failure due to snake bites and bee & wasp stings, which are not seen in the advanced world.

Whenever we sent our data on tropical problems for publication, the international journals accepted these readily and our work was quoted frequently. Leprosy and tuberculosis are other common problems in our country, so we started working on renal involvement in these tropical diseases. In another project, we found that young people with hypertension in our country did not suffer from renovascular hypertension of the classical type associated with fibro-muscular dysplasia or renal artery stenosis as seen in the west, we found that these patients were really suffering from Takayasu’s arteritis. Therefore our interest began in the investigation of patients of reno-vascular hypertension. We found that 60% of young hypertensives were due to Takayasu’s disease. We have published extensively on this disease. I also worked on various aspects of dialysis and transplantation, particularly regarding tropical infections, which are common amongst these patients. Some of the fungal infections are commonly seen in tropics but are uncommon in the rest of the world. There is also a high incidence of tuberculosis amongst transplant recipients. We also worked on the economical and ethical aspects of renal disease and in fact we have contributed chapters in various text books on ethical issues involved in live donor renal transplants and other renal diseases. Thus, we largely concentrated on tropical problems or problems of the developing countries.

We didn’t involve ourselves in highly sophisticated research at the genetic or molecular level, but worked on the problems which were facing us in our own country. That is how we could publish a lot. Not only we published a lot in journals, I was invited by several international textbooks to write chapters. I’ve written chapters in Oxford Textbook of Nephrology, Oxford Textbook of Medicine, “Kidney Disease” by Massary & Glassock, and several others. Not only that, our work also attracted attention of the WHO and as I have already said that I became a part of the WHO editorial team, which published a book on “Classification of Tropical Renal Disease.” The Nephrology Forum which I published was on Snake Venom induced renal disease in which we had recorded our clinical observations as well as the effect of venom in experimental animals using monkeys. Therefore my research had largely involved tropical problems and that did attract a lot of international attention.

VK:

Dr Chugh what has been the most touching moment in your professional life?

KSC:

I could cite several of them, but when you say “most” I could cite at least one or two which really touched me. It happened when one of the physicians by the name of Dr Rajinder Chugh, who was the personal physician to one of our late prime minister Lal Bahadur Shashtri and was a well known figure, met with an accident in the country in which he and his wife died and only his daughter had survived. The media flashed the news that Dr Chugh had died in an accident. When it reached some of my friends who knew me well but didn’t realize which Chugh it was, they only knew that Dr Chugh had died, they thought it was me. My wife started receiving lots of phone calls expressing their condolences and she also received lots of letters. Some of the letters were indeed very touching. Several of them wrote how good I was, what a bright professional and academic person had been lost from the world and paid handsome tributes. I still possess some of these letters. Several of my friends expressed that I was such a good host and had all the qualities which one can think of in a great person. I thought I was reading my obituary in my lifetime. I was very touched. These messages were largely from my sincere friends, but when you learn about such things as to how the people think about you, you do become emotional.

The second incidence in which I again read my own obituary was in 1998. Dr Martinez Maldonado wrote an editorial on me in the American Journal of Kidney Diseases in a series that he had started editing. He picked me up for one of the issues of the journal, I don’t know who picked me up, but I think I was the sixth or seventh to be picked up from nephrologists worldwide for an editorial. When this editorial was published, on the next page of the same issue was an obituary on Dr Franklin McDonald, also written by Martinez Maldonado. When the Current Contents listed these items, as you know they do, by mistake they mentioned my name under the obituary column instead of Dr Franklin McDonald’s.  When some of my friends read the Current Contents, we again started receiving letters and messages. But the most touching was from my former mentor, Dr Oliver Wrong. Dr Oliver Wrong was sitting in his office in St. Mary’s Hospital London, when he read the current contents, and found that Kirpal, who had been working with him, had died. He thought of writing a letter of condolence to Harjit, my wife, but like a true research scientist, he thought he must first confirm from the American Journal of Kidney Diseases as to what had happened and the facts behind my death. So he went to the library and took out the journal and found that the obituary was on Dr Franklin MacDonald rather than on me. So he wrote a letter, which you can read for yourself.

Dear Kirpal,

It’s not often that one has the chance to write to a deceased colleague, as I am doing now. When I saw the enclosed in Current Contents (Clinical Medicine), I got the impression, as most of your friends must have done, that you were a “goner”, and was trying to decide what condolences to send to Harjit. It’s only when I looked at the Am J Kidney Diseases to get more details that I discovered that the “In memoriam” refers to Dr Franklin McDonald and not to you. You can join Mark Twain in saying that the report of your death has been exaggerated!

Thus I was reading my obituary for the second time and Oliver Wrong mentioning that I can join Mark Twain in saying that, “The report of my death had been exaggerated.”

VK:

Dr Chugh I also saw tears in your eyes in 1994 when your students had arranged a Festschrift for you at the 25th Annual Congress of Indian Society of Nephrology at Chandigarh. Do you remember that?

KSC:

I remember that moment very vividly. I think this was another touching moment for me. When your fellows and colleagues openly express their personal feelings, it is certainly an emotional moment for anybody. When they organized my Festschrift and presented a signed plaque and also a momento, I was very touched. The fact remains that I was considered a strict disciplinarian while at work. I did not encourage anybody coming late to meetings or to work. And I did set an example myself. I would never be late in the meetings unless a crisis had occurred, and therefore I set an example that we must be on time for all activities. I never shirked from taking my bedside rounds which had been scheduled even if I came from overseas after attending an international meeting and had reached Chandigarh two hours earlier. I strongly believe that one can lead but a leader doesn’t have to lead only, he has to set an example. So therefore at that moment, perhaps my fellows must have felt angry with me that I was such a hard taskmaster. If I gave a job to somebody and he didn’t do it at the right time, I was not very happy. If they gave any task to me, for example a manuscript to read, the paper would be back to him next day. As a disciplinarian I was considered very harsh, but at the same time the love and affection, which I received from them, and also what I did for them, they knew it very well. I never spared any opportunity if I could be of any help to any of my fellows or colleagues; I always went out of the way to do that for them. I think they all realized this and therefore this affectionate Festschrift was indeed a very special moment for me.

VK:
Dr Chugh, what has been the contribution of your family to your growth?

KSC:
I must say that your fellows and colleagues are important because they are the ones that make your academic career. But I think the happiness which I had all my life was largely contributed by the support which my family gave to me. My wife in that process suffered a lot because I used to leave home early and sometimes I would even miss the breakfast if I was getting late. I would come back late in the evenings, because I was busy at work, writing papers or doing some projects, but she bore all that. Not only that, I was frequently away from home for meetings, conferences or for lectures, in the country and outside the country so many times and she had to stay back alone. Well, in those days we couldn’t financially support the travel of the family, and most of the time I went alone. She gave me tremendous support and was very understanding. All the social obligations which I couldn’t meet with, were largely done by her and always with a smile. I have two children, Sumeet and Sumant who are also in academics, one of them is a nephrologist  in Northwestern University of Chicago and Sumeet, is a cardiologist, earlier in Mayo clinic and now in University of Oregan Portland. Whenever I was tense, they always helped me and cheered me up. They were also very understanding and I must say the love, affection and the happiness, which we all shared in our family, were a big support for me.

VK:

What do you consider the current status of nephrology in India and how do you foresee the future of nephrology in the country?

KSC:

Over the years, we have come a long way. I can certainly say that standard of Indian nephrology is now nearing the nephrology service being provided by the front line nations of the world. In the last two decades, lots of new centers have come up in the private sector as well. The government institutions have financial limitations in providing adequate service facilities to the common man. We now have hospitals in the country, which can provide service facilities which are equal to the best available anywhere in the world. The standard of nephrology over the years has gone up tremendously. Patients have been coming even from Canada, Europe, or Middle East countries for receiving various treatments including kidney transplants. Admittedly, some of these are for different reasons. But sure enough they have realized that the standard of therapeutic care available in some centers in India was equivalent to that of any other advanced country and therefore they have started coming to India. As I said earlier, of course, this was not the entire reason. The major reason for the transplant patients coming over to India was the easy availability of kidneys from living donor sources. The therapeutic facilities have significantly advanced and we are at a reasonable level of providing good clinical care, to our patients. On the investigative side also, the facilities available in some government hospitals and several private centers for any kind of investigations are similar to what are available outside. The investigative work up of patients is possible even at the genetic, molecular or immunological level. For example, the various experiments on tolerance being done in the country meet with the standards being practiced in the advanced countries.

Currently we have about 400 dialysis centers with 13000 to 14000 stations. On an average we have about eight to ten thousand patients on chronic dialysis program. This is a very small fraction of the total number of patients who require care for end stage renal disease. In our country we have about one hundred thousand or more new patients of end stage renal failure every year and yet only ten percent or so can avail of the facility of renal replacement therapy. This is largely because of the financial problems. There is no government support available. Insurance companies do not support chronic dialysis programs. Most of our patients have to meet with the expenses on treatment from their own resources or from charities. Some of the industrial houses do support their workers and provide the financial assistance. Unless such a support comes  from the government, the majority of the patients in our country cannot receive the kind of care that they require. At the moment we are able to do about 3500 transplants in the country every year, but these are largely from living donor sources.

Despite the fact that a legislation was enacted in 1994 in which brain death criteria were recognized, we have yet not been able to do many cadaver transplants. We have done very little so far. Not more than 600 cadaver transplants have been done after 1995. Technical facilities are available, but our problems are financial at the moment. If you compare the per capita income of India, around US$ 500, with the $ 35,000 or 40,000 in the United States you can understand the difference.  You can understand why we have problems in providing the kind of care that one would like to do for all our patients. From the research point of view I think we need to do a little more than we have done so far. We have still not even established a registry in our country to know the extent and  pattern of disease. I think we need to do a little more. As for as the training facilities are concerned, we have now about fifteen or sixteen centres in the country which are running full-time postgraduate courses like DM nephrology, and I can say the majority of these centers have adequate training facilities. The fellows who are trained in these centers have good clinical training. Whenever they go out, they can fit in the programs of the advanced countries very well. The National Board of Examination has also recognized many centres in non-university institutions. Earlier lots of people used to go to United States or UK for training, but I can say that trend has decreased significantly. Most of the postgraduates after finishing their training feel that they are well trained and can pursue their professional careers in the country.

VK:

Dr Chugh, with your achievements and the stature you have achieved I’m sure you are a role model for many young nephrologists. Have there been any role models for you as well?

KSC:

Of course, yes. Three physicians who have been leaders in their own fields, have had a profound influence in shaping my career. The first one was my mentor during my earlier career, Dr PN Chhutani, who was himself a Gastrenterologist. I learnt the qualities of discipline and also how to convey a message through a clear expression which he had, I learnt these from him. The second person who influenced me greatly in my research was Dr. Oliver Wrong of the Hammersmith Hospital, London. He was a thorough investigator, wouldn’t ignore even minor irregularities, which might crop up. Right from the beginning of my career, I learnt from him that there was no replacement for an absolutely thorough investigation whenever you are pursuing a project. The person who influenced me most in my nephrology career, I regard, Dr Stewart Cameron as the one. When I first met him in 1968, I was so much impressed by his way of teaching, his way of writing papers and his way of dealing with the fellows, I think I learnt a lot from Dr Stewart Cameron. There are several others with whom I have been in touch and have been influenced but I consider these three persons as my role models.

VK:

Dr Chugh, who are the other Indian nephrologists who have been recognized in the country or internationally?

KSC:

Yes, there are several Indian nephrologists who have received national and international recognitions. A few names come to my mind at this time. They are Dr Ramesh Khanna, Dr Manikkam Suthenthiran, Dr T K S Rao, Dr Yashpal Kanwar, Dr Kasinath, Dr PC Singhal, Dr Vinod Bansal, Dr Sundaram Hariharan, Dr Ajay Singh, Dr Anupam Aggarwal, and many others who have contributed a lot to nephrology in the world. I have already mentioned earlier the contributions of Dr Brian Periera and Dr Ravi Mehta. Some of the Indian nephrologists who have been honored with the highest civilian awards by the Government of India include Dr MK Mani, Dr RVS Yadav and Dr Ramesh Kumar. Some of the senior nephrologists from India who are well-recognized all over include Dr KK Malhotra and Dr VN Acharya. I think these are some of the names but there are many others who have received national and international recognitions. Also the International Society of Nephrology and the Kidney International have recognized the contributions in the field of nephrology by awarding Nephrology Forums and I cannot help but say you are amongst the only two recipients of Nephrology Forums which have been conducted in India by Kidney International. Your forum on End Stage Renal Failure has been taken as an authentic account of the problem of chronic renal failure in the country.

VK:
Dr Chugh, you spent some time in Nigeria. What was your experience like in Nigeria?

 

KSC:
Yes I was in Nigeria for about three years between 1982 and 1985. Actually, the new University of Maiduguri in Northern Nigeria had started a medical school at that time and they wanted to establish a dialysis centre. A requisition came through the Government of India and I opted to go there. I thought I will be able to help them in setting up a centre. After joining there we made an assessment and orders were sent by the institution for purchase of four dialysis machines. However, in the next three or four months there was a military coup in Nigeria. Following the coup, they cancelled all the orders for the purchase of equipment, which had been sent to United Kingdom, therefore, we never got the equipment and I couldn’t help them in setting up a dialysis centre. However there was enormous material available on some of the tropical problems which I had never seen in India. For example, schistosomiasis was very prevalent in that place. Similarly sickle cell disease, and renal disease due to malaria and snakebites were also very common. Therefore I thought I’d involve myself in working on these problems.

With that aim in mind, I started working on these projects and I wanted help from my local Nigerian fellows and colleagues. I was used to the PGI culture of reaching the hospital on time at 8 o’clock in the morning, but my Nigerian colleagues wouldn’t accept this timing. In fact they complained to the Vice Chancellor that this Indian Professor calls us early in the morning and we can’t make it. When I started a project on urinary schistosomiasis amongst medical students and we collected the data in about two months time, I sent a small paper to Lancet, which was accepted. In this paper I had put the names of all the fellows who had worked on this project. Once this paper came in the Lancet, they all came and said, “sir, we are ready to come at eight o’clock or at any other time you would wish to call us.” Hence after, we started working on some of these projects, and in three years, we published 19 papers in national and international journals from that centre, which nobody had ever done in that institution by that time. Another striking feature was the absence of some of important academic activities. I wanted to start clinical meetings and journal clubs. In the beginning when I started these, there were only five or six people who would attend these meetings. I tried to coax all the departments, and requested various professors to present interesting cases. At that time our Dean and Professor and Head of the department was Prof Scarborough, many of you might know that he was the editor of the famous physiology book by Bell, Davidson and Scarborough. He was a clinician par excellence and had worked in Harvard in Boston for quite some time. Originally he came from Cardiff in UK. When we started these meetings and the people found these very interesting, within two to three weeks, the attendance increased from eight or ten to about twenty and in the following six weeks the attendance increased to 50 to 60.

After two months there were more than 150 people, more than the hall could accommodate. I was successful in creating a new kind of atmosphere in that medical institution. The meetings started at two o’clock, and by five past two, we had to bolt the door because there was no room inside. Thus, I became a very popular physician amongst the Nigerian staff. To my surprise within 6-8 months of my arrival in Maiduguri, Prof Scarborough wrote to the Vice Chancellor of the university that in view of the outstanding research projects which had been initiated and the way the academic atmosphere had changed after my arrival there, he recommended that I should become the head of the department of Medicine and that he would work under me and indeed he did so. I must say it was very great of Dr Scarborough to have done so. After retirement Dr Scarborough left Nigeria and after sometime he died in Malta. After his death, his obituary appeared in Lancet, which was written by Dr Keith Peters. Surprisingly, I found my name in his obituary mentioning that one of the outstanding persons he had worked with in Nigeria was “myself”.

I had a very pleasant experience of my stay in Nigeria. I could mould my local colleagues in the department in building an academic and research atmosphere in that institution. And finally, when I completed my term, the university organized a farewell dinner in my honor. This had never been done before by the university for any individual staff member of the medical college. So I had a very good experience. Because of the work, which I had published from Nigeria, the Scientific Committee of the International Congress of Nephrology held in London, invited me as the  Chairman of the Scientific Session on Parasitic Renal Disease and the Kidney during the International Congress of Nephrology in London in 1986. My only regret was that during my stay, the kidney machines never arrived and I could not set a dialysis center.

VK:
Dr. Chugh, what will be your advice for the young next generation of nephrologists of India.

KSC:
I would like to give a message not only to the younger colleagues but also to those who are not so young. I feel that the cardinal attribute of a medical doctor, which has given him a distinct status in the Society and has placed him at a higher pedestal than the other professionals is, that the ailing humanity in their suffering regards the doctors as their saviors next to God. It is imperative that the society would also expect the doctors to be different from other professionals. Whereas we must work hard and with honesty, dedication, and devotion to excel in our profession, we should keep in mind two important requirements of our patients. The patients need more sympathetic attitude than what we normally give. And also, they need a hope, because hope may be the only thing they have at that time, let’s not deny them of that hope.

In our endeavor to provide the latest treatment to our patients, we must not fall prey to the unethical practices for minor financial gains, which unfortunately seem to be slowly creeping into our profession. Secondly in the earlier times, the teacher was regarded as a “guru” and a student as his “disciple”. The guru participated not only in the teaching but also in his career and character building. The relationship between the teacher and the student today is becoming more and more mechanical. I have no doubt that the teachers always try their best that their students become excellent scientists, researchers, and clinicians, but they have stopped participating in their character building. Let’s not neglect that important aspect of training so that they also become better human beings in the society. Lastly, the developing world faces newer challenges because of the technological advances, which are occurring in advanced countries. Let us not ape the advanced countries. We must realize the limitations of our patients in the underprivileged world. We need a newer generation of scientists who could use innovative approaches to make the treatment more cost-effective and affordable so that even the poorest in these countries can make use of such treatments. We also need to lay more stress on preventative aspects. I have no doubt that the younger generation is capable of accomplishing these objectives. That’s my hope, I wish them success.