Health: Where is the cure?
While allocating more funds to biomedical research and development will help, the problem also calls for a more serious course correction at several levels
Shalini Sharma Delhi
In April, the Parliamentary Standing Committee on Health and Family Welfare in its 100th Report on Demands for Grants 2017-18 of the Department of Health Research expressed concern over the poor research output from the Indian Council of Medical Research (ICMR). It noted, “The committee observes that in two years (2015 and 2016), only 1,685 research papers (965 in 2015 and 720 in 2016) have been published by the Indian Council of Medical Research (ICMR) scientists and three patents have been granted against 45 patents filed. This clearly indicates that its health research output... does not commensurate with the magnitude and disease burden in India.”
India is a reputed producer of affordable, generic drugs across the world. However, we are yet to climb the ladders of the value chain and claim ownership over a seminal piece of health research work that helped cure a disease or that made the diagnosis easier. The fact that we are unable to list important interventions made by us in the field of drug development, vaccines and health sciences, despite having a number of institutes under the Council of Scientific and Industrial Research and the ICMR, dedicated towards medical research is disappointing. The health sector, which is already riddled with a number of basic problems pertaining to the infrastructure and human resource, is chronically underfunded and when that little money is distributed into numerous departments and institutions, there is little left that goes into research and development.
According to award winning scientist Dr VS Chauhan, who is known for his contributions to the development of experimental recombinant vaccines for malaria, “Scientists will always complain that there is not enough funding for their research. Scientific research and in particular biomedical research is expensive, for example, a complete high quality vaccine clinical trial would not cost less than 150-200 crore rupees. Also, there are chances that the experimental vaccine may not finally work. One can argue therefore that such money is not easily available. My view is that India has to invest much more in bio-medical and life science research. Given the limited funding, agencies need to get their heads together to find a way to channelize funds efficiently, focussing on key health issues particularly when one talks about the development of new drugs and vaccines.”
A study published in Current Medicine Research and Practice in 2016 stated that 332 out of 579 medical colleges did not publish a single research paper between 2005 and 2014. To ascertain the seriousness of the situation, one can also juxtapose the number of students pursuing biomedical research in colleges and the output. Also, it is important to note that producing “original research work” is a prerequisite for students who want to earn these degrees. There is also a lack of focus on imparting knowledge of research methodology in undergraduate and postgraduate courses in our universities. In a story published in the Lancet last year, Dr Soumya Swaminathan, director-general of ICMR, had said, “Research is not prioritised in our medical colleges and most faculty members have no prior exposure to research methods.” Obviously, the system does not place a lot of emphasis on research work.
In another interview to a national daily, Dr Swaminathan had stated, “There is just so much need to build up bio-medical research capacity in this country. You find most medical colleges don’t do any significant research. For our population, our output in medical R&D is low. We have 400 medical colleges. We should be doing a lot more research. But there is no interest, capacity or infrastructure. Even out of the 400 colleges, if we support the top 100, we would see much more research.” While the number of medical colleges have increased exponentially over the last few years in our country, there is hardly any increase in the research output.
Apart from a lack of funding and a lack of adequate focus on research work, there are a host of other systemic issues that are responsible for the country’s poor performance in the field of medical research and development. As far as medical colleges are concerned, scholars work under extremely difficult conditions that include long, continuous “duty hours.” Although the teaching load on each faculty in these colleges is not as high as the ones in basic science departments of universities, but teaching often goes on in wards, OPDs and around operation tables. Amidst juggling between attending to patients and teaching scholars, the faculty has little enthusiasm or time for serious research work. A lot of private medical colleges do not even have the minimum number of teaching faculty as mandated by the Medical Council of India (MCI).
Dr Chauhan points to the ivy-league universities in the United States and says that all of them have medical colleges within their campus. In India, however, things are different. Except for Banaras Hindu University (BHU) and Aligarh Muslim University (AMU), there’s hardly any medical college within a university campus. “Research institutes like ICMR and CSIR or the Department of Biotechnology (DBT) are typically small with an average strength of 30-40 principal investigators. And even those 30-40 scientists work on many different challenging areas. That needs clear thinking. If we continue, we are likely to not get much out of it. I don’t think these small institutes are geared to attack bigger problems,” the scientist remarks.
An inability to maintain continuity of research also affects the output. New scholars opt for new topics of research instead of taking forward a lead found by someone else. As a result, despite the large human resource involved in the task of making a pathbreaking discovery, the net result remains disappointing, so much so that we have to rely, for both diagnosis and prognosis, on data generated in other countries whose genetic background is very different from ours.
Dr Chauhan thinks our hesitation to conduct clinical drug trials is one of the factors that impedes drug and vaccine development in India. He notes, “Indian laboratories are good enough to find possible leads but thereafter, it becomes a complicated process. Also regulatory mechanisms in India can certainly be more user friendly and pro-active. If you have to test a drug or vaccine in humans, this translational research becomes tedious and very expensive.” According to him, the country needs to prepare itself for conducting clinical trials because it could be our strength. “There is this whole argument about Indians being treated as guinea pigs, but that logic does not seem to be valid to me because all the drugs that are being used in this country have been tried on humans somewhere else. We never say that they were guinea pigs in other countries. I think the mindset needs to change. But that doesn’t mean we should lower our standards of safety and security. If India doesn’t do trials on diseases like TB, malaria and dengue, who else will? These are our problems,” Dr Chauhan says.
Commenting on the state of medical research in India, Dr Kamal Mahawar, a Consultant General and Bariatric Surgeon with Sunderland Royal Hospital & an Associate Clinical Lecturer with Newcastle University in the United Kingdom (UK) and the author of The Ethical Doctor, told an English daily, “Research is indeed a key area of deficiency in our society, and not just in medicine. The problem is that research needs top professionals and these professionals are not cheap. We have to start paying wages similar to Western universities, if not more (to compensate for a lower quality of living etc) to attract top academics. There are plenty of top academics of Indian origin in the world, who will relocate for the right freedom and pay.” He rues the fact that academic positions in India are largely given out in “a time-bound fashion irrespective of any real output or any real contribution.” In the West, however, one becomes a professor only after contributing something substantial. If everybody is going to become a professor anyway, what is the incentive in carrying out research?
While talking about biomedical research and development in the Indian context, one cannot overlook traditional medicine sciences, like Unani and Ayurveda, that form an integral part of our tradition. It is a well-acknowledged fact that these forms of treatment are still practised widely in our country, especially in the hinterland. While the setting up of the AYUSH ministry is a welcome move, if it will lead to pathbreaking research in the field to separate myths from reality and to help us understand the principles of these practices remains to be seen. We can also take a leaf out of China’s book where they have smartly integrated Chinese medicine into their formal medicine curriculum.
The DBT was set up in 1986 which was, at the time, among the only government departments in the world that was solely devoted to promoting research and development in the field of biotechnology. DBT has been at the forefront of driving indigenous research and development of vaccines, diagnostics, genomics, and drug discovery among other key areas. A recent achievement was the indigenously-developed Rotavirus vaccine, Rotavac, which was the result of a collaborative partnership between DBT, Bill & Melinda Gates Foundation, and Bharat Biotech among other partners.
In December 2014, DBT launched its National Biotechnology Development Strategy 2015-20 with the aim of creating a biotech sector worth US$100 billion by 2020. The strategy launched four missions in the areas of healthcare, food and nutrition, clean energy and education. The strategy aims to create 5 new clusters, 40 biotech incubators and 150 Technology Transfer Organizations (TTOs). Since onset the DBT has funded about 800 projects in cancer, neuroscience and endocrine-related disorders funded.
The government is steadily shifting its focus to translational research to help take research and innovation to market. In order to create such an ecosystem, it is important to bridge the gap between industry and academia. To this end, the government in 2014 set up the Biotechnology Industry Research and Assistance Council (BIRAC), which is an interface agency to strengthen and empower the emerging biotech enterprise to undertake strategic research and innovation, under the aegis of the Department of Biotechnology. The body is focussed on providing access to risk capital through targeted funding, technology transfer, IP management and handholding schemes and help bring innovation excellence to the biotech firms and make them globally competitive. So far, BIRAC has supported over 300 start ups and entrepreneurs, 40 early stage technologies, and developed 50 new or novel products/technologies. In five years, we have provided funding support to the tune of INR 749 crores to a total of 654 projects. The DBT also signed an umbrella Memorandum of Understanding (MOU) with the Bill & Melinda Gates foundation to collaborate on mission-directed research and build Grand Challenges India to support health research and innovation. As far as research and development is concerned, the move looks promising and could well be a game changer in optimising the output. However, how well it is able to boost innovation is something that will be known in the time to come.
Medical research is not singularly poor in our country but it is a matter of grave concern because it directly affects the health of people and the nation. While sharing one-fifth of the disease burden in the world, we just cannot afford to maintain the status quo. The disparity between the projected fund requirements of our medical research bodies and the amount allocated is huge and definitely impacts the quality and quantum of research work produced in our country. While putting more money into the system will help, the problem also calls for a more serious course correction at several levels. More than rules and regulations, we need commitment and passion towards research. How many students who study medicine are interested in turning their thesis into research? Not many. The incentives of pursuing research are few and when one pits it against the huge amount of money being offered by private medical facilities, it becomes clear why students would prefer to choose a career in a private hospital over one in research and development. However, money cannot be the only motivation to get scholars to invest their time and energy in research work. It has to be coupled with good infrastructure, more freedom, flexible time limits and good mentorship. While placing institutions like BIRAC to ensure funding for good ideas and to bridge the gap between academia and industry will help, one has to begin the course correction from medical colleges and institutions. Good training of medical students in clinical research, especially for those who are inquisitive and research-oriented, has to be ensured.
Recent years have witnessed a huge spread of private healthcare facilities which are well-equipped. They can be used to carry basic science research work but have remained untapped so far. The government can also come up with a plan to engage the private sector in a public-private partnership model and use them as technology incubators for utilising research outputs from both public and private medical institutions.
We need to realise that by improving the quality of research work produced in our country, we would also have a greater say in matters of global health policy. Moreover, diseases like Tuberculosis and AIDS, which are difficult to cure or prevent due to a lack of available options, are our problems. We may lobby for funds and attention but the initiative has to be made from our side. With so much thrust being placed on “Make in India” right now, an attempt should be made to apply the idea to health research as well.