Gagandeep Kang interview: Lessons from researching an ‘unglamourous’ disease

Diarrhoea, as Dr Gagandeep Kang often says, tends to be considered a “solved problem”. Modern science knows why it happens, knows how to fix it, and has ways of preventing it from becoming a genuine medical threat. And yet it continues to be a major cause of death or serious illness for hundreds of thousands of children around the world, every year.

Kang has spent decades attempting to tackle this troubling dichotomy. Her work at Christian Medical College, Vellore, as well as many other levels of India’s health-research ecosystem, led to the development and widespread use of two Indian rotavirus vaccines, pioneering research on infectious diseases and cost-effective ways of monitoring disease burden across the Indian population.

In 2024, Kang was awarded the prestigious Gairdner Global Health Award for building “an internationally recognised and competitive research programme centered in India that prioritises Indian needs while providing valuable and translatable insights to other regions affected by enteric infections” as well as being an “exemplary leader” in the field.

In her current role as Director for Global Health at the Gates Foundation, Kang has been building on her work on enteric and other infectious diseases in India, while also using insights developed there to help build programmes in other countries around the world.

In September, Kang delivered the CASI Nand & Jeet Khemka Distinguished Lecture, “Building Global Health Research from India for the World”, which can be watched here. CASI Managing Editor Rohan Venkat spoke to Kang about the impact of the Gairdner Award, what it was like to focus on an “unglamourous” problem like diarrhoea, and what examples the medical research ecosystem in India might have for other developing countries.

I wanted to start off by congratulating you also on the Gairdner Global Health award. There have been no shortage of accolades over your long career, but what does it mean to get an acknowledgment like this?

More than the acknowledgement of a person, it is the acknowledgement of the importance of a field and the fact that things have changed because of the efforts of a number of people. The area that I work in is enteric infections, which can also impact adults, for whom it’s uncomfortable. But in children it can be devastating and can result in death if it is a severe acute event. Repeated events, even those that are not severe, can lead to chronic effects that can be extremely difficult to recover from. Most of these effects are on growth and development, and, as you can imagine, it results in lifelong impact in terms of people not performing as well in school and that affects all of their subsequent employment, careers, etc.

So, it is important to have this field recognised, especially for people who frequently feel like they are working in an area that is under-recognised. If you think about where awards usually go, they go for groundbreaking new discoveries that help people with cancer, or with neurological disease. They don’t often go for something that people view, at least in the western world, as a solved problem. Diarrhoea and enteric infections are not issues in the news very often. If you hear anything about the gut, it’s about precision nutrition, it’s about the microbiome, not about making sure that you have basic things attended to in a section of the world’s population that tends to be really, really neglected.

I’ve seen and read on a number of occasions you saying that you ended up working on diarrhoea, working on rotavirus in part because it was not glamorous and not somebody else’s turf. I wanted to hear a little bit more about that, how you started off.

The foundational elements were what really are the problems that bother the community the most? And then in the community, selecting children, as damage to children has consequences for a lifetime. And then in children, what do you work on? The most common things are pneumonia and diarrhoea, and pneumonia was a well-covered field. It just made sense to head in this direction because it was aligned with everything I wanted to do.

Which specific pathogen I wound up working on was a combination of circumstances, both the issues that you frequently have of turf, but also that I had the opportunity to train in the US with someone who was an outstanding rotavirus researcher at the Baylor College of Medicine and wound up collaborating with her and with colleagues in the UK. This meant that instead of doing my research at a level that was, “oh, I’m going to be the best in India”, it was really about, “what can we do in India that will be relevant to the rest of the world?” The framing 25 years ago of trying to solve a problem that was bigger than my own location was what determined where I ended up.

Was it difficult to make that choice? It seems to me a rather brave choice given the circumstances. Was it something you felt as difficult at the time?

It was very, very hard for the first five years, before I built my own group and felt a little more confident about continuing. There were always questions of, why am I putting myself through this? It would have been so much easier, since I passed my UK exams, to have gone and practiced there. I could easily have had a job in the US because my mentor was happy to take me back, but I didn’t let that be an option ultimately.

I’ve also seen you say on occasion that you feel like you spent many years of your life as a primary data collector. What did you mean by that?

There are two ways of looking at it. When you do research in a lab, you gather data, you design experiments, but then you analyse your data and come up with the interpretation of that data. If you do research with an international collaboration, for example, and especially if it is data that is collected on a long timescale, like cohorts, what tends to happen is that researchers in developing countries are the ones that are responsible for the data collection, but very infrequently responsible for analysis of all of the data that has been collected from multiple sites.

That’s usually the privilege of the high-income country collaborator. And so that’s how you wind up with papers being published where the first and last authors – the first author is a PhD student or trainee of the last author – are all from international institutions. And in the middle, by way of acknowledgement, you have all the people that slogged it out, got the study set up, collected data day after day, who were not actually accorded the privilege of saying, “Now you interpret the data that you have collected”. That is a problem.

The second part of being a primary data collector for me, because I set up a lot of surveillance systems in order to build burden-of-disease estimates, is that strictly speaking, understanding the burden of disease should be the role of the government. If you are a researcher, that burden data should be the baseline from which you operate. I might design a better surveillance system, but routine surveillance should not be something that an academic is supposed to be doing. Unfortunately, in most low- and many middle-income countries, it does wind up being researchers collecting data instead of being a public health function of the ministry of health.

I wanted to dig into both of those elements. On the first, just for readers who are not as familiar with your world, I wanted to draw out the fact that it’s not just a question of citation or an individual career. It’s also that if the analysis is not being done in the developing world, it might mean some things are being missed or the analysis ends up being Euro- or West-centric?

There are a couple of things related to that. One is obviously interpretation of context where your international analysers might not understand context, or realise context, or pull out those elements that are most relevant to the country.

The second part of it is actually having the methods available. If I never learn the methods to analyse multi-site data, I’m not going to advance in my abilities. And I’ll add a third point to this, which is just take a look at time and how you spend your time. As a researcher in a developing country, if you’re spending all your time on primary data collection, getting the study set up, quality of the study, monitoring, etc., where do you have the time to learn new things or do new things that you haven’t done?

In a high-income country, the researcher who is a collaborator is not responsible for primary data collection. They can do some level of monitoring maybe, but they have all that free time to be able to do the analysis and get outputs. If you go by, strictly speaking, the guidance that is given for medical journals, it is that people who are data collectors are downgraded, people who analyse, interpret and present are upgraded. There is clearly in the division of labour itself an inequity there.

It feeds back into the idea of those early choices being brave because in choosing not to end up working in the West, it also meant you were taking on a lot of that more mundane work.

Would I have published more papers if I sat at a Western institution? Yes, it’s very likely. Would I have published more high-end papers? I’ll tell you that for sure, because for me to get a paper into a top-end journal writing as corresponding author from CMC Vellore, when I’ve had colleagues who in the West who’ve done similar kinds of papers, it takes me twice as long, at least sometimes up to three or four years to get a paper published when other people get responses in six months.

Second, on the question of primary surveillance as a researcher. With your experience in India, and your current role looking over some parts of Global Health at the Gates Foundation, is there a sense of replicating your work in India in other developing countries, reducing the burden on academics to do this?

The hope is that that will happen. What timescale it will happen in is unclear. In India, for example, the responsibility of surveillance was through the integrated disease surveillance programme that was established in the early 2000s, but under-resourced. If you don’t have resources, how do you deliver?

So, then it becomes an academic’s responsibility because they are interested in an area and they want to fill in the gaps, and if they can find the support, they can do that. So, the question becomes, is it the government’s job? The WHO [World Health Organization] sometimes comes into the picture and sets up surveillance for certain areas, then the government begins to rely on WHO to generate the data. In India, we also have the national polio programme, which is winding down polio and taking on other responsibilities. So, when you begin to have these multiple players, again, it becomes really challenging to be able to generate reasonable representative surveillance data for different diseases, because different systems give you different estimates. We hope to see this change.

Certainly at the Gates Foundation, what I’ve been pushing for is data collection designed to go as directly as possible to the government. If that can happen, the next step would be governments then becoming responsible for generating their own data instead of relying on external resources. And in many ways, India is much better off because we do have competence, we have some level of surveillance, we have the framework of a programme. But in places like Africa, most surveillance is donor dependent. So, if you want HIV [human immunodeficiency virus] data, you get HIV. If you want TB [tuberculosis and you pay for it, you’ll get TB data. Countries are not putting their own funding toward measuring their own problems. I’d like to see that change.

If there was a young Dr Kang starting out today, whether in India or in another developing country, do you think limitations and complex choices that you were faced with at the start of your career would’ve been broadly the same, or have they shifted substantially?

A lot of things have changed in India. One is the wealth of institutions that we have now, and people that have been trained more in public health. Public health wasn’t a field 30 years ago, even though there were people that were working in that area. In CMC Vellore, we had a department called community health, but it was really about looking after the specific communities that we lived in or were surrounded by. That’s not public health in the way we think about government policies. What might be interventions at a national or a state scale? That’s changed quite a bit. I think in India, we’ve made tremendous progress on how we frame problems and how we seek to address problems as a researcher, just in terms of how quickly we can react to things because of the information systems that are available now. That’s been a sea change. My MD thesis was actually typed on a typewriter, my PhD thesis was the first one on a computer with a dot matrix printer. So yes, things have changed-many processes have become so much easier.

That networked technology has been useful, but potentially also problematic, in terms of a surfeit of information that’s harder to delve through, or of people attempting to game the system and so on…

When you have a sense of what the big picture is like, then the connections are useful because you are reasonably up-to-date with everything that is happening in your field. Of course, it becomes difficult to filter to the most useful, but you have a sense of that because you’ve been in that area for a long time.

What concerns me is young people who haven’t developed the ability to look critically at the credibility of sources of information. You hear about this new and exciting thing, or you have a finding that comes from one particular part of the world, and because of the way information systems are set up, if you express interest in one area, you're going to get a lot more reinforcement about that. I worry that sometimes it sets them up to head down the wrong track because they don't have a bigger picture understanding of a particular field.

It’s been about a year at the Gates Foundation. How has your thinking evolved? What is top of mind now as you’ve moved to this role?

If anything, the foundation has increased the possibilities. My focus has always been on impact, and impact on people for whom finding interventions can be hard, finding the right framing of policies can be hard. What the Gates Foundation allows for is to be able to bring to those problems resources and approaches that I would not have had as an individual researcher.

I still work on enteric infections. One of the things that is top of mind right now is cholera. In the past few years, there have been increased outbreaks of cholera all over Africa, and the supply of vaccines has been limited. It’s not like the western world never had cholera. The foundations of epidemiology are from cholera, but water and sanitation solve those problems.

So vaccines, while they are a stopgap, continue for at least the foreseeable future to be a key tool. And supply of vaccines was very limited because there’s only one company that’s making oral cholera vaccines. In the last few years, we’ve helped that company increase its production to 10 times what was originally planned. But we are also working with other vaccine companies to make sure that there is never again a shortage of cholera vaccines in the world. That kind of thing, I obviously couldn’t have done in my previous role. It’s not a completely solved problem, but we are on the way there.

What are some of the things that your research in India, from surveillance to vaccines to other subjects, suggest have the potential to be replicated elsewhere?

Over the last few decades, first with generic drugs and more recently with vaccines, Indian products have transformed public health or transformed our ability to direct resources toward different aspects of public health because we’ve been able to make products that are at a fraction of the cost than they would be in a high-income country.

Now, obviously, there are sometimes quality issues that are specific to companies, specific to situations, and we need to make sure that the Indian regulatory system is set up to handle that, more for drugs than for vaccines. But over time, our companies that aim at these global markets have gotten better. What they have done is initially make at least the generic versions of drugs and vaccines, but now they’re beginning to become more ambitious. And what’s happened particularly over the last decade is that India’s early investment in science and technology is being reshaped. The Indian Institutes of Science, the IITs, those used to be ivory towers, and now they aren’t ivory towers anymore. They are linking much more to industry. They are incubating startups. They are thinking about what it takes for them to use the science that they have within their institutions to make products or help products that can potentially be transformative.

Now, obviously at an early stage with the startup culture there are challenges, but what I really like about Indian startups is that they are very aware of the context in which they work, which is that we are in a resource-constrained environment. If we build anything for our one billion population, then that is something that needs to be very price-sensitive. And that’s relevant to much of the rest of the world.

In high-income countries when you have a startup, much of it is about, how much profit are we going to make off this? In India, it’s more about how many people will be reached with this, because the expectation is small margins. So that’s, I think, a different framing that we should be thinking about as we promote what India can do for the world.

I wondered if sometimes, as you look at the problems faced by other developing countries in this new role, there’s a bit of deja vu seeing things – like the surveillance systems or the way the government’s operating – that you saw in India?

Yes, and I think India has a lot to learn from its neighbours, and India has a lot to teach the world. So, if you look at what’s happened with really efficiently-managed investments in maternal and child health in Bangladesh, they’ve been able to change their maternal and child indicators much faster than India. Bangladesh is on the level of the best-performing Indian states, and as a country that has historically had many kinds of challenges, I think we should be learning from them and also learn from Sri Lanka about public health and delivering clinical care through government institutions.

If you think about India and what it has to teach the world, the way that our immunisation programmes are managed, the way that we have been able to set up direct benefit transfers for TB patients – not that they are working 100% of the time – but it has made facilitation of care for people, preventive care, curative care, much easier than many other countries. And the ambitions to scale much of that in India, I think, are exactly on the right track. One thing I’m really hopeful for through this digital transformation is that we will have better access to data, more real-time access to data, and be able to handle our own programmes well. Then we’ll have even more lessons to take to the rest of the world.

Is there an equivalent bug that is also unglamorous, or a problem that’s unglamorous that you feel is chronically understudied, that deserves more focus?

It depends on how you define glamour, because in the 19th century, “consumption” was something that was considered glamorous because it made people very pale. And that’s TB, tuberculosis. I think TB is a neglected, underfunded, understudied disease. Somehow, even though the burden of TB is way greater than the burden of HIV, HIV has five times the resources that TB does. So, starting over, I would work on TB.

Are there misconceptions about the work that you do, whether that’s vaccines in diarrhoea or now even broader, the idea of global health, that you find yourself having to correct or combat all the time?

When I was working on rotavirus vaccines, there were very vocal anti-vaxxers in India. Not a large population, but very vocal, and they actually took the Department of Biotechnology, the company that made the vaccine, and CMC Vellore to court. So, I had an experience of going to the Delhi high court and the Supreme Court. And yes, being attacked actually in some ways makes you stronger because you have to make sure that the data that you have cannot be doubted or questioned. It has to be truly solid.

I think there have been times when working in an area has been particularly challenging. The media often looks for bad news, and sees conspiracy theories perhaps more easily than it should. Countering that can be a challenge. But I think I’ve also spent a lot of time making sure that I convey uncertainty where uncertainty does exist, and placing limitations around what I present; to say these are things that we found, but it’s always possible that there might be another finding with another study.

Maybe if I could put a version of the same question, but on a different sort of axis. As you move from global south to global north, do you find yourself also dealing with misconceptions, or an inability to understand some of the challenges that are familiar to you?

When it comes to any kind of global health picture, and particularly one that deals with prevention, it’s just a different scale of people thinking that there is some mal-intent at play. Convincing people that is not the case, I think, can be quite challenging, particularly in settings where they have not had to deal with the kinds of problems as people in other geographies. So yes, it’s the same challenge on a different scale.

Do you have advice for a young scholar or student entering this research world? Not so much in specific areas that you'd send them down, but in ways of looking at this world, or the research world particularly?

I think I was very hesitant to claim my space in the first decade of my career, and that comes from growing up in a pretty hierarchical society where your role is defined by your position. And I hope that the people that I've trained and people going forward don’t feel that they need to wait, or not aim for the full scale of their ambition from an early point in their careers.

Gagandeep Kang is the Director of Enteric & Diarrheal Diseases, Diagnostics, and Genomics, Epidemiology, & Modeling, Global Health at the Bill & Melinda Gates Foundation.

Rohan Venkat is the Managing Editor for India in Transition.