"I am a doctor for populations"

In celebration of World Health Day on April 7, the IAI Interview Series welcomes Dr. Jaime Miranda.

Dr. Jaime Miranda a physician-researcher, is a research professor at the School of Medicine and director of the CRONICAS Center of Excellence in Chronic Diseases, both at Universidad Peruana Cayetano Heredia (UPCH) in Lima, Peru. His research includes a wide spectrum of health issues including obesity, hypertension, diabetes, and depression. Dr. Miranda is a researcher in the IAI project “Land use, climate and infections in Western Amazonia” (CRN 3036). In 2014, he was recognized by Qué Pasa megazine and LatinAmericanScience. org as one of the 30 scientists under 40 who are redefining the future of Latin American science. Last year, Dr. Miranda made a bold decision to take a year off to travel with his family through Latin America. He talked to us about his experience in research, the obesity epidemic and healthcare issues in Latin America.


With global change, both natural and human-induced changes have triggered climate-related "accidents". We've seen an increase in a number of health-related diseases and problems. Based on what you've seen and studied, what are some of the main problems that countries in the Americas will face over the next 10 years?

I think climate change brings so many challenges, but also an opportunity to refocus on the interaction between the individuals and the environment. From a Latin American perspective, climate change can bring a unique opportunity to put all the knowledge and expertise into action based on experience that can lead to something better for the humanity.

Coming from the health side, one of the biggest agendas in Latin America for the last 20-30 years has been fighting undernutrition in children and infants. It was important, and it still remains important, to protect our human capital. Today's changes in the environment, in our changing environment, will make it much more difficult for individuals to transition to better lives during their lifetime. Whether they are small changes, big changes, in small places or large cities, whether it is the migration, infection, floods, etc., changes are going to arise and those changes are endured by humans, our human capital. If we describe how the environment is going to be different, that's one part of the story. But who are the ones that are going to endure it? That's the other part of the equation.

It's like preparing for the Olympics. If you are well trained and ready, you are going to do well. However, if your starting point is that you are not trained and just showed up on the Olympics, you are not going to perform that well. Latin America has been at the bottom of this game of fighting against chronic undernutrition. I come from a generation where there was a 50% prevalence of chronic undernutrition in childhood. Which means that 1 in 2 of our generation was chronically undernourished during childhood, and this certainly adds a penalty for the future. Ironically, the challenge for today’s generation is obesity. One in every 2 adults in Peru and in the Latin American region in general are overweight or obese. This epidemic is also observed in today’s children. Before we fought chronic undernutrition. Today our children’s threats are still chronic undernutrition plus overweight and obesity. How are we protecting our human capital? Is this capital ready for the next Olympics?

The reality today is that our human capital is not in the best shape, they are going to the Olympics not necessarily trained, developed or well adapted. Changes brought by climate change are going to be much more challenging for them, for our children as well as for our current and future adults. Hence the need to align population’s health with climate change, so we can demonstrate much better resilience towards the environmental changes.


Can you remember the moment you decided to become an epidemiologist?

I was trained in medicine in Peru, then I worked in the Peruvian Andes, and afterwards I ended up in the UK. I was trained in an institution where research is highly appreciated. I was happy with the interaction and engagement with the patients, but I left the hospital early on. I wished to contribute as a doctor for a “bigger” patient —my patients are populations.

I asked myself: what is it that I need to learn? Two things came to my mind. One was to learn the technical jargons in research, to understand scientific papers and the terminology they used. In science we value knowledge, yet, in addition to the language and professional barriers, there were the technicalities that we use when communicating through scientific manuscripts. The second thing was to know more about the ways of doing research, to learn about research methodologies, the how to do and conduct research. Taken together, understanding the communication of science and its methods allowed me to live up to what epidemiology is about, which fundamentally is to study “the causes of the causes”. For any given problem, studying the causes of the causes means that you need to sit back and try to understand what’s going on and link properly problem and solutions.

When it was my chance to go back to Peru, knowing that there were not that many people trained in the field, I was ready to return with a better understanding of the science, its communication style and its methods. The epidemiological approach, framing challenges as research questions and experimenting with alternatives to address such challenges by using different study designs is very unique and has been very useful to me.


This year's World Health Day's campaign is about "universal health coverage". What is the biggest obstacle to achieving health care for all in Latin America?

Currently, we are living in a transitional period calling upon scrutiny and reflection on how health care services are organized. In the past, health care system was about reacting to acute conditions. That’s pretty much how medical professionals were trained as well. Very reactive, and it became very sophisticated as well. However, with the increasing demand for chronic care, people do not need reactive care but repeated interactions and sustained conversations with the health system. Right now, we have been very good at developing and delivering reactive care, but we are not good in terms of sustaining engagement and a continuous conversation with the health care system. In addition, adult people suffer from more than one health problem and this is known as multimorbidity.

Multimorbidity is very common, and the practice of highly specialized medicine has prioritized the clinical specialization, which largely focuses on organs rather than people. Prevention and primary care are therefore extremely important because we need to move away from the hyper-specialized care. Healthcare is not only about specialized care, healthcare of today and healthcare of the future requires a sustained conversation between individuals, their caregivers, their multiple conditions and the healthcare providers. That’s why primary health care and universal health coverage are much needed. Linking this to global environmental changes and the analogy of the Olympics, remember, each Olympic team have very few doctors, not specialists for every single part of the body, but one who knows what is happening with the athletes. Similarly, primary care doctors will be in high demand, understanding their athletes, their patients.


What needs to be done to ensure quality primary health care in Latin America?

I come from Peru, where the primary health care is very weak and almost non-existent compared to other countries like Argentina or Brazil, or Chile. How do we shape this transaction between society and its population? Health is important, period. Having strong primary care is fundamental for society’s well-being. High quality primary health care is very much needed, and it doesn’t mean reactive health care.

Health care becomes much more important as the population ages. Older population shows higher levels of multimorbidity. When you need treatment for multiple conditions, you need someone who understands how those conditions interact. The conversation becomes much more complex. My friend Victor Montori puts this in a nice way. “Imagine health care as an airline, and an airline carries its own environmental footprint. Right now, the health care footprint on patients is way too high.” The current model is not serving the population in the best way, because it is too burdensome for the patient. We need a health care system that leaves the smallest footprint on us.  


What is one bit of epidemiology and your work with global change that you think everyone should know?

Sometimes we are deeply fond of our earliest work. For my Ph.D., I looked at migrant populations. I was interested in the human and environmental interactions and its impact on cardiovascular health. In the 80s, there was a big flux of people migrating from the rural areas into the urban areas in Lima. This was a perfect natural experiment, where some people were moving from high altitude mountain areas, which are 3,000 meters above the sea level, into the sea-level coastal areas. Are migrants “the same” as non-migrants? How migrants would differ in terms of their cardiovascular risks? We called it the PERU MIGRANT Study. Studying a population in movement is very difficult because migrants have diverse characteristics, but in this case, we had almost a natural experiment.

This is a piece of work that was useful to me because it’s about breaking the myths on migration that migrants adapt to all aspects of city life, focusing on the acquisition of the negative health profiles. Our research found that the effects of migration on health are different depending on the indicator that you look at.

We also tend to focus on describing the negative side, such as bad habits, but it is also important to look at why some migrants are doing much better than their counterparts in the city. Taking a pause to think about the causes of the causes and looking into the human-environmental interaction allowed us to detect early signals and patterns of diseases. A key observation was that 75% of the rural group had none of the five most common cardiovascular risk factors. In other words, they were very healthy! And you wonder, we tend to study populations who are sick, but could we also study populations that are healthy? How are they being protected? Why? Those findings can be used for prevention and planning. Now I see that similar migrant studies are being conducted in China, where a massive number of people are moving onto newly “created” cities. I find it very interesting indeed.


In your LinkedIn profile, it says that you took a year off to travel South America with your family. It sounds incredible! Why did you do that?

I think life is too short. You need to make decisions, be prepared to make the wrong ones, and keep trying. Otherwise, you will end up punishing yourself for the rest of your life. I have a career, and I am very lucky to be able to do the research I like in my home country. As I was watching my research team grow, my kids were also growing up. I was traveling a lot, and there were more and more demands from people wanting to work with our team... which is the most amazing thing for a researcher, more collaborations, more research, more work. Then, I started to think about trying something different.

My wife showed me a book about a family of five traveling through the Americas. They did it with three kids! Why not us? At the time, my youngest child was one-year-old, so we waited for 3 more years. It wasn’t an immediate decision, but it was there, in our brains, getting used to the idea that we were going to do it when it was the right time. There were those concerns such as “you are going to sacrifice what you have built”, “things will fall apart”, and many other negative scenarios. Nevertheless, I said, “look, if everything falls apart, I will build it again. I didn’t have anything 10 years ago.”

We considered two things, education and a place to live. First, we looked at the options for education and we found distance-learning programs, which was great. The next question is where we were going to live, and we got ourselves a tiny house on wheels. This plan later failed, but there was an upside to it. The house was built in Chile and we had to go and pick it up. That’s how the trip started. With three kids and a very demanding job, it was necessary for my family to take that year off and spend more time together. I am really glad I did it. Nobody will take that away from us.


Has the year that you spent with your family inspired you as a researcher in any way? What's have you learned from this experience (that either confirmed what you thought or that surprised you)?

Taking a year off has taught me a lot of things about taking risks. Life is too short to put a break on your decisions. Just do it. 12 months flew by, and now I am happier with the experience that I had. To come to terms with myself, I told myself that I wanted to reward myself and my family. I was working too much, like many of us, and the prospects of retirement didn’t quite accommodate me, I mean the usual equation of work hard, work hard for many years, then you retire, and then, at that point, you enjoy life. I felt it was too late, and I wanted something right now. Spending that time with my family meant a lot to me, and it felt as if I allowed myself to have a little bit of my retirement today, like an advanced payment. I think it was very good for my team, too. This year, they become more self-sufficient, were able to engage in various professional development activities, and they also tasted what is it like to have a larger set of responsibilities. I think it was very beneficial for everyone.


Would you tell me your vision/goal for this year?

I found that I love mentoring young researchers. Not for my own good, but to see young professionals grow and succeed. The goal for this year is to surround myself with young researchers who want to grow, and share what I have with them. I feel like now I have the patience, knowledge and communications skills. I want to focus on people, helping them make decisions to contribute to society from the research side. Last year, my calendar was free of all the meetings and administrative troubles, and I ended up having important conversations guiding people on finding their own ideas and goals.


What do you know now that you wish you knew when you were younger?

That we are all different, we are humans, and that we should learn how to appreciate such differences. Perhaps this is more familiar to the field of psychology, even how to make the most out of different people. If you see how we go through life, it is pretty much that we are all expected to behave in a certain way. Society expects the same from everyone, sort of. Look at our education system, we all follow the same path, from kindergarten to university, we give 20+ years of our lives to do things the same way. But, when do we take risks? When do we experiment, when do we test and fail? At the end of the day, we all have different ways of doing things, potentials, and strengths. I see it everyday, with my three kids, the same parents but the three are all different. I wish I had known that earlier. I had a subtle knowledge, but I wish I was more proactive in exploring the opportunities to live a more exciting life, and not to punish ourselves for taking such risks. Taking a year off taught me that there is nothing wrong with doing things a bit different “than the rest”. Life is too short.