Addressing health disparities: A conversation with Ambrish Mithal, MD, DM
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Founder of India’s first bone density and osteoporosis service, Ambrish Mithal, MD, DM, played a key role in establishing osteoporosis as a serious national health problem.
Along with his contributions to growing the field of endocrinology in India, his work in iodine deficiency and fluoride has gained him recognition worldwide as well as the International Excellence in Endocrinology Award at the ENDO annual meeting.
Mithal, who serves as the chairman and head of the endocrinology and diabetes division of Max Healthcare Hospital, shared his personal mantra, inextricable connection to endocrinology and potential venture as a Delhi tour guide.
Healio: What was the defining moment that led you to your field?
Ambrish Mithal, MD, DM: Soon after qualifying for my MD in internal medicine in 1984, I joined the endocrinology department of the All India Institute of Medical Sciences in Delhi as a research fellow in the National Goiter Control Program. My job required me to travel to some of the less privileged, rural parts of India where goiter and [congenital hypothyroidism] were widespread. As I traveled from village to village, I saw children and adults who were mentally and physically incapacitated, all because of the lack of a few micrograms of iodine. My mentors were pushing for salt iodation at the time, but it took a few years before their recommendations could be implemented. This foray made me realize that in countries like India, simple public health measures could play a critical role in tackling serious human disease and that became my mantra. It also connected me inextricably to endocrinology for the rest of my career.
My second defining moment was in 1989 when I was working as an assistant professor at the Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow. An adolescent with multiple skeletal deformities was referred for an opinion. We found that he was suffering from skeletal fluorosis, a condition caused by consumption of excess fluoride. On tracking and tracing the origin of his condition, we discovered numerous villages in the area where people were crippled due to consumption of drinking water containing toxic levels of fluoride. This was again heartbreaking, but it gave me an opportunity to study the impact of fluoride on bone metabolism. Bone and mineral research, an area that was largely neglected in India at the time, became my companion for life.
Healio: Have you ever been fortunate enough to witness or to have been part of medical history in the making?
Mithal: During 1993 to 1994, I was awarded the NIH Fogarty fellowship to pursue research in the laboratory of Ed Brown, MD, at the Brigham and Women’s Hospital. It was a time of great excitement. In the period intervening between my selection and commencement of the fellowship, Brown and his group cloned the calcium-sensing receptor, a pioneering discovery that changed the way we approach calcium metabolism and parathyroid disease. My stint at the lab was a period of great activity, and a flurry of new findings emerged related to the calcium-sensing receptor. Everything we did during that period was a “first.”
Healio: What area of research in endocrinology most interests you right now and why?
Mithal: My research focuses on the clinical impact of vitamin D deficiency, which is widespread in India. From a stage where no one believed vitamin D deficiency was possible in a sunny country like India, we have reached a stage where vitamin D-fortified milk is increasingly available and may soon become mandatory. What fascinates me, however, is the relationship of vitamin D and parathyroid disease. Hyperparathyroidism is described in textbooks as an asymptomatic condition, whereas in vast sections of the world like India, China and Brazil, a severe form of the condition with bone involvement is dominant. The fact that the disease presentation is changing from symptomatic to asymptomatic even in these countries can be attributed only partially to earlier diagnosis. Vitamin D plays a major — but not sole — role in determining clinical presentation of hyperparathyroidism. So many unanswered questions there.
I also feel that the practice of using circulating 25-hydroxyvitamin D levels as the sole criterion to define vitamin D status is misleading. People with identical 25-(OH)D levels have wide disparities in [parathyroid hormone] level as well as in clinical presentation. Individuals with abysmally low serum 25-(OH)D levels are often clinically normal; those with only moderately low D levels may, at times, show osteomalacia. We need to review this at a fundamental level.
Some course correction is also needed regarding the role of vitamin D in nonskeletal disease. There is scant evidence to prove that vitamin D deficiency can cause major nonskeletal illness. Our latest study (accepted for publication, in press, Scientific Reports) shows that neither baseline 25-(OH)D level nor supplementation with vitamin D correlates with severity of outcomes in patients hospitalized with COVID-19.
Healio: What advice would you offer a student in medical school today?
Mithal: Being a physician, you will be uniquely placed to make an impactful contribution to medical research. In many resource-constrained areas of the world, it is impossible to reduce clinical responsibility; in such situations, physicians tend to focus totally on providing clinical care. However, it may be possible to make a significant contribution by allocating just 10% to 20% of your time to clinical, patient-based research.
The key when working within economic and time constraints is to choose your research areas carefully. The potential to advance patient care or to tackle a larger public health problem are often the primary criteria I use to evaluate prospective research projects. You may have another method of choosing, but make sure you choose wisely.
Healio: What are your hobbies/interests outside of practicing medicine?
Mithal: I love travel and capturing interesting shots on my phone; nature and history fascinate me. During the pandemic I visited many interesting historical sites and gardens in Delhi with just my phone for company and discovered innumerable facts — some important and some trivial — about the 1,000-year history of this city. I am ready to be a weekend guide for Delhi!
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