Current Situation ‘Unsatisfactory’: India’s Top Doc Lays Out New Vision For Health, Research
As many as 332 (57.3%) medical colleges in India did not have a single research publication between 2005 and 2014, according to a 2016 analysis. In comparison, the annual research output of the Massachusetts General Hospital was 4,600 and the Mayo Clinic 3,700, the paper said.
“The current state of affairs is far from satisfactory. There are only a few medical colleges in the country that encourage and promote the culture of research and we need to ensure that in the coming years many more medical colleges and medical college faculty get involved in research,” said Soumya Swaminathan, director of the Indian Council for Medical Research (ICMR), and a Secretary in the Department of Health Research, which is part of India’s Ministry of Health & Family Welfare. The ICMR has 25 major institutes, some smaller field units, and 8000 staff, including 800 scientists.
Swaminathan, who completed MBBS from the Armed Forces Medical College in Pune, MD in paediatrics from the All India Institute for Medical Sciences, and was a fellow at the the Children’s Hospital of Los Angeles, University of Southern California, USA, realized that few Indian institutions provide the opportunity to practice as well as conduct research. She chose to join the ICMR’s TB institute in Chennai, while striking a deal with the children’s hospital to work in the outpatient department in the evening.
“Clinical researchers need to see patients. They cannot do research in isolation, when you are not involved with patients and their problems,” said Swaminathan, who hopes to encourage more such opportunities during her time at the ICMR.
In her free time, which she said she had little of these days, she likes listening to both Hindustani and western classical music. “I love the outdoors. Whenever I get a break or chance to get a weekend off, I like to go in nature and take long walks,” she said, adding that one of her favourite places to go are the Himalayas.
IndiaSpend spoke to Swaminathan, previously the director of the National Institute for Research in Tuberculosis in Chennai, about how more research could be encouraged in India, the changing burden of disease, the quality of health data in the country, and more.
Edited excerpts from the interview.
Q: A 2016 analysis of medical papers published between 2005 and 2014 revealed that even though only 25 (4.3%) medical institutions produced more than 100 papers a year, their contribution was 40.3% of the country's total research output. As many as 332 (57.3%) of medical colleges did not have a single publication during this period. In comparison, the annual research output of the Massachusetts General Hospital was 4,600 and the Mayo Clinic 3,700. Could you comment on the state of medical research in India?
This is an area of real concern for us because one of the mandates of the department of health research and the ICMR is to build health research capacity in the country. This analysis tells us that the current state of affairs is far from satisfactory. There are only a few medical colleges in the country that encourage and promote the culture of research, and we need to ensure that, in the coming years, many more medical colleges and medical college faculty get involved in research.
The first of five pillars of our new strategy, vision 2030, is strengthening biomedical and health research capacity in the country through a number of different schemes. Providing opportunities, encouraging people, training and getting people excited for research. I think that the challenge is to get more medical students in their undergraduate and postgraduate courses to get interested in research, to get excited about research. Still, we do have some brilliant medical researchers, and about 10 of our top institutions like AIIMS, St John's, Christian Medical College in Vellore--are doing very high quality work.
Q: How can research be encouraged and improved in the country?
I think it's the whole eco-system that we need to look at. It would be foolish to think that by training alone or by sensitisation alone one could get more people involved in research. I think about 10 years ago the ICMR started a scheme called the Short Term Studentship (STS). This scheme is basically for medical students who can submit project proposals and they have a mentor either in their own institution or in another institution. During their holidays they take up a research project and get Rs 10,000. Over the years we have seen a huge and increasing demand for the scheme. Currently we get 7,000-8,000 applications every year and we award 1,000 STS fellowships. We’ve also now started giving awards to the best papers that come out of this.
When I travel around the country and meet medical students, there is a huge demand, from dental students and physiotherapy students that we should extend the scheme to them because this really ignites that spark. Colleges also take pride--they tell we had eight successful STS this year or 10 last year and so on. So that's starting with medical students.
Then we have schemes for MD students. We offer financial support for an MD thesis, which is competitive, and screened by an expert committee. The top 50 MD theses receive a fellowship of about Rs 50, 000 to help write it up, publish it as a paper and things like that. I think we need to have more such schemes.
We also need to make the environment research friendly. If you’re working in an institute or medical college which does not have facilities, it wouldn't make a difference even if you have ideas for research. Projects require basic lab support, basic team you need to undertake it, research cannot be done by a single individual. Better the research, the more multidisciplinary the team. So you need lab scientists, field workers, statisticians and social scientists. In a regular medical college these things don’t exist, even those few faculty who are interested they often get frustrated and give up.
For infrastructure, the department for health research has a scheme called the multidisciplinary research unit which provides funds to develop a high quality lab in government medical colleges.
The other thing is that in many of the states that permit private-practice, this is a big disincentive for research because then the faculty member just wants to finish their work in medical college and then go and start their private practice. Research needs time, extra time beyond your working hours, you have to think a lot, work a lot, you have to go to the field. That is why we find...that if you look at these 40 institutions…the 25 institutions that contributed to 40 % of research output would probably not allow private practice. Where you don’t allow practice, faculty members are all the time thinking about their own field so they are much more likely to engage in research.
The next big issue is the need for mentorship and role models. If you have never met or interacted with anybody who has done research, it is very unlikely that you would take it up. We are going to launch a new mentorship programme that will connect young faculty with experienced researchers both within India and outside India who are willing to spend some time in guiding ,mentoring and supporting young researchers.
There is another issue in India which I think we need to address that is the lack of collaborative spirit, a team spirit. Secondly, a kind of hierarchical approach which should not apply in our scientific institutions. Just because you are the director of the institution, does not mean you know everything about everything, you can only be an expert in one area and therefore you have to be open minded and encourage your younger scientists to look at other areas and maybe they become the world expert in that area. The seniors need to be able to accept that some of the juniors will excel, be brilliant and they need to be encouraged and not put down.
Also, to be really successful, you need to collaborate, you have to build teams. If you look at the top papers in journals like Science or Nature Today, sometime you find there are hundred co-authors. Today scientific disciplines have developed so much that you tend to become a great expert in one area and therefore you need people in other areas. Modelling is a good example; you may be a physician or even a statistician but if you don't have those modelling skills, you need to collaborate with a mathematician who is also a good modeller to be able to develop a good model.
Q: Is research limited by the quality and timeliness of data in India?
It is an important issue because we have a large number of sources of data in our country and sometimes, some of those data sets are more available to people, than others. The NFHS (National Family Health Survey) is a good example of data that is made available to researchers both within and outside the country for secondary analysis and for further use, once the main report is out. That’s a best practice kind of a thing but there are many others data sets which are not available and secondly there are many different agencies collecting data on the same thing which are often not pooled.
One of the pillars of ICMR’s new research strategy is on data depositaries and data warehouses. We would like to create a data warehouse of all health data from the country especially those that are collected using public funds. ICMR now has a network of labs that collects data on vector-borne diseases like Dengue. The NCDC (National Center for Disease Control) has their network of IDSP (Integrated Disease Surveillance Program) labs, while there are other agencies which are supporting projects, such as the the CDC (US-based Center for Disease Control) which also runs labs. Now unless we all pool our data we will not be able to see what is the national number for dengue for a particular year.
Similarly for antimicrobial resistance all labs need to start reporting data into a common source or platform, that should be perfectly transparent and available not only to the scientist but to the public as well. We are moving in that direction, saying whatever research we fund through the ICMR that data ultimately should come back to us and put into a public database, publicly available. Publicly available database means that if anybody wants to utilize it there should be a system by which they can access the data. I think we have lots of data that is not fully utilized in India so I think there is a lot of scope here. I think the government has realized that so all of us are working to see how we can better utilize the data and make it available in a form in which others can use it .
There are a lot of things happening now. We’ve been working with the Registrar General of India (RGI) to utilize the SRS (Sample Registration Survey) data, and with the global burden of disease (GBD) group in Seattle--the IHME (International Health Matrix Evaluation Institute) to develop state level disease burden estimates. Every year the GBD brings out an update on the global burden of disease, so India figures there. But we know that for us, India as one dataset does not make much sense because we have huge variations between states. State health secretaries want to know what is happening in their own state so that they can actually modify the policies. We expect to, by the end of the year, release the first report on the state level disease burden estimation. Then every year we will keep refining it.
Q: As of 2015, 90% of India's cause-of-death data were incorrect/ incomplete or missing, thus reducing its utility for public-health. What could be done to change this and give a complete picture of India’s disease burden.
It is a big lacuna, and we need to strengthen this in two ways. One, deaths that occurs in hospitals need to be properly certified, which means doctors need training on medical death certification which we all don't get during our under- graduate post-graduate days. Even if a doctor is certifying cause of death, they write cardiac arrest which does not help.
Second, we need to be able get the cause of death of people who are dying at home. In rural areas most deaths occur at home. We need another system whereby a local health functionary, whether it's the ANM or someone else, who can go and do a verbal autopsy. Then the doctor in that PHC (Primary Health Centre) needs to be able to certify the cause of death based on the details that are available. Unless we do this we will not improve cause of death data, and we will have to continue to depend on surveys and other indirect ways of finding out.
We need to move in the direction of all developed countries which have a good vital registration system where cause of death is carefully reported. Then we don't need surveys and all.
Q: How could medical research help solve major health problems in India? For instance, India had 27% of the world’s new TB cases in 2015, at 2.8 million. In 2015-16, India accounted for 5% of the under-five deaths (296,279 children) from diarrhoea & pneumonia globally, and malaria still affected 1.1 people in 2015.
The third pillar of our strategy is evidence to policy and the fourth pillar is implementation research. Both of these basically aim to fill the gaps in knowledge and to make sure that the evidence that is generated goes into policy making.
We have a special focus on diseases that are to be eliminated. We are working with the ministry of health on Kala Azar, filariasis, measles, malaria, and tuberculosis. Our job here is to identify gaps in knowledge and try to develop tools to address those gaps. The gaps could be epidemiological in terms of not knowing the true burden of the disease. If you don’t know the true burden of TB, or the true burden of leprosy in the country then it is difficult to gauge progress. So we can do a survey to find that out.
Second could be a good diagnostic test that could be used in the field to detect. For example, for malaria, we have this rapid diagnostic test. For Kala Azar we have a rapid diagnostic test, for TB we still don’t have something.
Similarly, for Kala Azar we had this long one month treatment with injections then it became this one month-long treatment with oral drugs, today we have a single dose treatment that’s come out of clinical trials at ICMR institutes and other institutes.
For diabetes we are looking at several clinical trials looking at yoga and other Ayurvedic medicine to slow down the progression from prediabetes to diabetes.
We are supporting a number of mental health projects. This year we started a new program, to see how best we can implement the district level programme, because the National Mental health programme was approved in parliament but the implementation of this policy requires a lot of innovation. This is health system research.
We support everything from basic science to developing new technology, new vaccines, and all the way through health system research. This year we also began engaging with the private sector because without them, we can’t make much progress especially in the areas of drugs and new vaccine. We have already partnered with a number of companies to help them and to work together with them to either transfer technology developed by a scientist to industries so that kits can be marketed.
Another way of collaboration is to evaluate something they have developed. We can field test their product, or do clinical trials.
Third, we engage together on projects like we’ve done with Sun Pharma for malaria elimination in Mandla district of Madhya Pradesh. That’s a public -private partnership where we bring the technical expertise, they bring in funding and the state government brings their workforce and supplies drugs and bed nets.
Q: India has seen progress in tackling visceral leishmaniasis (kala azar), a neglected tropical disease (NTD), eliminating yaws, a chronic skin disease that mostly affects poor children, and in treating lymphatic filariasis (elephantiasis). How could research help other disease control programs?
I think the learnings are that research plays an important role not only in developing program policies but also in evaluating them and modifying them from time to time. Whether it’s which insecticide to use, unless you know whether the vector are developing resistance or not, when the insecticide should be sprayed, how much should be sprayed, and all that has to be found out through research studies.
For a long time we use chloroquine (for mosquitos), It was research that found out that the entire northeast plasmodium falciparum (which causes malaria) had become resistant to chloroquine. We changed the national policy to an arsenate based combination treatment for the northeast. That monitoring has to continue to ensure that those drugs are still working.
One is surveillance and feedback but the other is developing new strategies. For example, the government has started this National Program for Prevention and Control of Cancer, Diabetes, and Stroke. How is going to be implemented on the ground? What are the best ways that we can do cancer screening, what age group should we be screening, what technology should we use for breast cancer for cervical cancer?
One of the new initiatives is the health technology assessment program--we call it the medical technology assessment board--which we have set up under the DHR to look at questions regarding universal health coverage. How will you define health coverage and what are the things that can be included under that because, for an individual patient his or her treatment is important. Even if it costs Rs 1 crore, that individual is going to say that you must provide me with the treatment, whether it’s for a rare cancer or a rare genetic disease. But the public health program looks at different aspects, at effectiveness, cost effectiveness and also at equity considerations. You can use your Rs 10 crore to treat three people, or you may be able to treat a thousand people.
Our job is to have an unbiased, transparent, and evidence-based approach so this board will really have to consist of people who are above all these vested interest, conflicts of interest etc. This was done in the U.K, where the National Institute for Health and Care Excellence and Health Intervention and Technology Assessment Program (HITAP) in Thailand, which are two successful program. We are collaborating with HITAP, which is similar to our program, and an independent body whose recommendations are generally accepted by the government of Thailand.
Q: As we’ve seen India is seeing a shift in its burden of diseases. Deaths due to diabetes increased 50% in India between 2005 and 2015, and is now the seventh most common cause of death in the country, up from the 11th rank in 2005, according to data published by the Global Burden of Disease (GDB). Has ICMR conducted any research on why Indian's have a higher risk for diabetes and cardiovascular disease when compared to other populations?
Today its non communicable diseases and cardiovascular disease and stroke which are two top causes of death in India and the underlying risk factors for these are hypertension, diabetes, and poor air quality--both indoor and outdoor air pollution--and then come other risk factors such as smoking, obesity, nutritional dietary deficiency. For risk factors , in 1990 unsafe water and nutritional disorders were the top two risk factors, today hypertension and diabetes are the top two disorders in the country. Now we have to ask ourselves why this shift.
There are many reasons. One is the changing demography. As you age on-communicable diseases will increase. Second, with better immunization and access to treatment, antibiotics, infectious diseases are coming down. Maternal and child deaths are coming down because of improved health services and this is likely to keep coming down further as we wipe out one infectious disease after another or we’re able to control them. And the population is aging at the same time.
Third reason are changes in our lifestyles. We all know that in the last 25 years India has urbanized, people have become more prosperous, physical activity has gone down, diets have changed. We are no longer eating fresh home cooked food. We are eating a lot more of outside food, processed food with increased sugar, salt and fat. Another factor is environmental pollution. India has double burden of indoor air pollution because of solid fuel use, which today luckily is declining rapidly because of the scale up of LPG. But also in cities environmental pollution is becoming a huge hazard. These risk factors are leading to an increase in cardiovascular and cerebrovascular events.
Q: What is the way forward for India to tackle non-communicable diseases.
NCDs requires action at different levels, one is at the policy level, the government level, in terms of what can we do to reduce the risk factors. A lot of it has to do with individual and personal habits and behavioural changes and there people need to realise and not wait. You see young people today in their 30’s who are developing diabetes because of their lifestyle. They have motorised transport to get to the office, you get to the office, you tend to eat more than you need, you don’t have regular exercise, and of course smoking and alcohol are additional risk factors. This is where I think a huge massive awareness campaign needs to start so at least our young people today become aware. The same thing happened in the West; they went through this period where they were over eating, then the young people in the west realised these were risk factors and began to take care of their health.
The government can look at policies on food labelling, salt content, sugar and on what is made freely available at subsidised rates. Today if we look at the Public distribution System (PDS), and the National Food Security Act, we supply rice and wheat at very low rates to people, Rs 2 and Rs 3, and in some states there are lentil dals and millets. But what is our diet deficient in? Our diet is deficient in micronutrients. The ICMR’s National Institute of Nutrition has been doing a number of nutrition surveys over the years and the latest surveys show that over 80% of individuals in most of the states we’ve looked received less than 50% of the recommended dietary allowance of vitamins and minerals--important vitamins like vitamin A, D, iron, Zinc etc.
This could be one of the reasons why we are still having very high rates of malnutrition in the country. The latest NFHS-4 data show that stunting and underweight has declined from NFHS-3 but not to the extent which we had hoped. This shows there is still a huge issue of malnutrition despite all our schemes--the ICDS (Integrated Child Development Scheme), the Anganwadis, the Mid-day meal, the PDS. That is why we have to think of the malnutrition problem not just in terms of the quantity of food but quality of food. If don’t get micronutrients in your diet you only get carbohydrates and some protein, you're not going to grow well. If you have worms and other infection you’re not going to absorb the nutrients well so we need to look at nutrition in a holistic way not just how much food you're eating.
(Shah is a reporter/writer with IndiaSpend.)
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