Former Director SKIMS, Dr M Sultan Khuroo is just not a successful gastroenterologist only. During the last four decades, he discovered Hepatitis-E in Kashmir, did a basic research about Budd Chiari Syndrome, and helped create a protocol for managing Percutaneous Drainage for Hepatic Hydatid Cyst and discovered Portal Biliopathy. In a detailed interview, he tells Khalid Bashir Gura about his life and his scientific pursuits
KASHMIR LIFE (KL): You have achieved phenomenal success in your profession as a gastroenterologist and discovered many new diseases. How will you explain the long learning curve?
Dr M SULTAN KHUROO (MSK): I was born in the 1940s and its preceding decades were difficult times for Kashmir. Many unusual events happened. I came from an educated family. My grandfather was a Persian scholar. My father and uncle were well-read and Persian literate. In 1957 floods in Sopore almost destroyed it. It was followed by a drought and most of my classmates had to drop out of school due to hunger. The natural calamity also tested my determination to stay in school. Soon I saw myself earning by giving tuition to my classmates and doing a small business to support my finances. I studied at Jabri School where we had good teachers. After passing class twelfth, I got enrolled in Medical College, Srinagar where we had highly devoted non-local teachers. Thereafter, I completed my MD. I soon went to the Postgraduate Institute of Medical Education and Research Chandigarh, (PGI) to specialize in gastroenterology and after that, I came back and joined Sheri Kashmir Institute of Medical Science, SKIMS for the next 14 years. In between, however, there was a forced exile and during turbulence, I went to King Faisal Hospital and Research Centre (KFSCH), Riyadh, Saudi Arabia for ten years. I also went to New York to get trained specifically in Hepatitis.
KL: Did your research experience precede your Hepatitis discovery?
MSK: The most important work, I did in the 1970s was the publication of a research paper in which 105 patients of Budd Chiari Syndrome following pregnancy were documented. It was a new syndrome. At that time I was pursuing DM at PGI.
KL: What is Budd Chiari Syndrome?
MSK: Due to Budd Chiari Syndrome the vein of the liver gets blocked. It is not a common disease. I studied files of such patients at PGI since the beginning of the PGI. I personally studied 40 such patients and reviewed all 105 cases. Besides, I also discovered 16 such patients that had developed diseases following pregnancy. I also explained and gave a critical analysis of how this disease leads to the blocking of veins in the liver during pregnancy. That paper is still being referred to.
KL: You worked extensively on Hepatitis E. What is Hepatitis and please shed light on your contribution?
MSK: A long ago, someone from Sopore rang me up on a landline at SMHS Ward 3. The worried caller said that the whole village has jaundice but the pregnant ladies are dying. Soon I moved out of clinical duties to study the epidemic and spent the next six months. However, many of my colleagues did not join me in the mission and everybody was fearful of contracting the infection. But I involved and trained 500 health care workers for a survey. We surveyed an area of two hundred thousand people and in six weeks we found that 53,000 people contracted the disease and 1700 died and most of the deaths were recorded in pregnant ladies. There were only two viruses then: Hepatitis A and B. It was a new disease, so we categorized it as non-A, non-B Hepatitis. It killed pregnant ladies and after rigorous research, we found that it was a water-borne disease.
KL: How did you find it is water borne disease?
MSK: The people who consumed water from Ningle Nallah were diseased. People who consumed water from springs, and tubewells, were immune to it. The Nallah was surrounded by lavatories. So we described a new disease which kills a pregnant woman and over the years it came to be known as Hepatitis E. The area is still under our surveillance and the last survey was carried out in 1992. The research was taking place at various levels. We were planning to transmit the virus to rhesus monkeys when a Russian doctor, Mikhail S Balayan ingested a faecal extract from a patient in Afghanistan and got the virus and disease in himself. Now the Russian government awards yearly medals in his name after his death and I was the first recipient of that medal.
When I came from Chandigarh after DM, I was always curious to know why the pregnant woman died of jaundice. In Kashmir, it is water-borne. However, in Europe and US or other developed countries where people do not consume contaminated water, it is caused by sausages. It is made of pork liver and it like all animals is infected with Hepatitis E. And it is very common in Europe and they were oblivious of its prevalence.
KL: How did the scientific community respond to your discovery?
MSK: I went to Pune to apprise my teachers of a new disease. No one believed me. The hall went silent and I had to encounter many sceptics. A relevant question was asked by a senior gastroenterologist, Dr Madan Gopalan, what I found are toxins. I answered that. However, some friends always supported me and Dr Kunio Okuda from Japan believed in my discovery and endorsed it.
KL: Has any category of hepatitis discovery bagged Nobel Prize?
MSK: The discoverers of Hepatitis B and C won the Nobel Prize but not E. Dr Blumberg has won the Nobel Prize in 1976, for the discovery of Hepatitis B. For hepatitis C, Dr Harvey J, Alter got Nobel Prize last year. I called it epidemic non-A, non-B. Alter called it post-transfusion non-A, non-B Hepatitis and that turned out to be hepatitis C. The reason he got Nobel Prize is that the drugs are known and it is a disease which can be cured. I think somebody should get Nobel Prize for Hepatitis E, once the vaccine comes out of China.
Biomedical research is something in which doctors have to raise questions themselves and they should have a way to answer it and then they can take help from basic scientists. Research needs motivation, as so many things get disturbed in life; from your family to economics. You may have to at times ask your subordinates for help in terms of finance and food. Research is not a bed of roses. Also, the research needs ethics and dedication which involves the use of proper research methodology, and techniques and one should have leadership quality and get team along with you like I did when the doctors refused to travel with me and I created and trained another team of health workers. And then, you should be able to communicate, travel and face the sceptics. One should listen to those few who are wise and are with you. You may have done excellent research, and have an excellent idea but if you cannot sell it, your research gets wasted.
KL: What were your new forays of interest after Hepatitis E’s research?
SMK: When I joined the SKIMS, the first thing I got caught up in was working on Ascariasis. Dr Verma, one of our doctors in Medical College, told us that if you have to treat any Kashmiri from cold to cancer give him anti-parasitic treatment for Ascariasis. Ascariasis was common in Kashmir. Every Kashmiri required de-worming. My mother ensured I take two doses annually and because of its bitter aura and taste, I developed an aversion to it.
After some time at Institute, I observed that there was an increased footfall of young ladies with abdominal pain. As their disease was not detected, they were taken to psychiatrists; however, what intrigued me was the acute pain in their upper abdomen lasted for short periods. It was, as I found later, due to this highly motile worm. This worm would get into their gallbladder and cause severe pain but recede back soon and the pain also subside.
The second thing I discovered was Percutaneous Drainage for Hepatic Hydatid Cyst –the so-called PAIR technique. The patients with cysts were put under a knife for hours. The book’s dictum was “never to puncture hydatid cyst because it will kill the person.” I was thinking of this new innovation and it, in future, will prevent patients from surgeries. We set the protocol and decided to treat the hydatid cyst and use hypertonic saline as a colloidal agent to sterilize the cyst. Through this technique, we treated the common epidemic of black motion. Now anyone with a hydatid cyst will go to Institute and they put a needle there and treat it. It is a new innovation as its manual has been published in WHO and a paper has been published in the New England Journal of Medicine that you can treat it Proton Pumping Inhibitors, PPI.
Lastly, we also discovered a disease called Portal Biliopathy completely unknown to the West. We discovered it at SKIMS. In Extrahepatic portal hypertension, the portal would get blocked. I sent two patients to the surgeon and both died. We tried to find our way as patients rarely die in such operations. We found their portal vein was blocked. So somebody who has portal vein block and gets a bile duct disease, we called Portal Biliopathy. Now if someone has gallstones and portal vein block don’t send him for surgery. First, treat the block and then do the surgery. It is a protocol now. We worked for four years to reveal this disease and the data for publication in Hepatology.
What is important in research is data. For any patient I have seen for ages, his images and records are documented. At Dr Khuroo’s Medical Clinic, we have seen 60000 patients and all their documents are digitally recorded. In research one of the very important things is documentation so that one can trace history.
KL: What are your present pursuits?
MSK: I continue staying at Dr Sultan Khuroo’s Clinic and continue having contact with my patients. I help the government agencies during Covid19. I am on governing body and research committee of SKIMS. I also oversee the growth of SKIMS College. I run Dr Khuroo’s Medical Trust. It has done a lot of good work but slowed down due to floods and pandemics. And I continue to write especially about institutions and share my visions.