Earlier this year, we had the opportunity to talk to Prof. Virender Chauhan who has been working for some time in the field of Malaria Vaccine and Drug Development Research. He was the Director of the New Delhi Component of the International Centre for Genetic Engineering and Biotechnology (ICGEB). He served as a Group Leader at the Malaria Research Group at International Centre for Genetic Engineering and Biotechnology from 1988 to 1998.
His Group at the ICGEB has developed procedures to prepare recombinant vaccine target antigens and with industrial partners, vaccine formulation has been developed for clinical trial, in India. His work on understanding the mechanism of actions of antimalarial drugs like chloroquine and artemisinin has led to the development of high throughput screens for malaria drug discovery. He holds his Masters and Ph.D degrees in Chemistry from Delhi University and D. Phil from Oxford University, UK.
Here is a taste of some of his thought provoking responses to our questions:
- “just recently, I saw in the print media that in Delhi, 65 babies per 1000 die before the age of 28 days, which is simply unacceptable even in a developing country.”
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- “India and China are going to be the largest spenders on anti – diabetic, anti -cancer and cholesterol lowering drugs. It is ridiculous that we should be spending so much on these drugs; we should not have our cholesterol going up to begin with.”
- There is a lot of malaria in India but it’s located in different pockets or locations. Places such as Orissa and Chhattisgarh which is a tribal area -have the maximum incidence of Malaria.
- “One third of population has no access to even those basic vaccines that we produce in huge amounts. So this paradox is difficult to understand. There is no excuse for not having provided the anti tetanus injection to the whole country, specially to women who have just delivered a child. But in India, there are political issues and economic issues which are not scientific that have an impact.”
- “I feel that there are going to be strong lobbies in health and education. There is a sense among vested interests that India will spend huge sums of money in health and education. It will be important for all of us working in the fields of health and education to remove the layers of corruption and vested interests. “
Interview
A. The following questions are related to your views on the status of health in India.
1. According to you, what should be the top three health priorities in India?
It is absolutely imperative that the top priority should be to spend much more money in general on health. Currently, the money spent on health with regard to the GDP is just too low, even for a developing country. We need to first increase our spending on health and at the same time carefully monitor where and how the increased money is spent.
We need to look at the provision of health services. We may argue that India has the best medical facilities but that’s accessible to not more than 5% of the population, at best. So my second major concern would be on how to make health services available to a very large number of people – especially those who need it the most.
Thirdly, my own work in malaria and tuberculosis has taken me to the places where these diseases are serious problem. I have realised that you need not provide health services to people only after they become sick- you can stop them from being sick to a large extent by prevention of these diseases. Provision of basic amenities such as sanitation, hygiene, clean drinking water, and education are desperately related to the health. If people are educated, their awareness of health automatically increases.
I have worked in this country in both areas of health and education. During the 70’s, 80’s and early 90’s. for whatever reasons (political, ideological, financial, poverty) both health and education, which are interrelated got completely ignored. It is only when the economy improved some attention was paid to education. But, by that time the population had grown to a size of almost unmanageable proportions, so it is a huge task for the government. That said, the government effort in both these sectors has seen positive trends but more needs to done, urgently.
2. What make you proud about health in India?
Health provisions in many parts of this country are poor to say the least. But at the same time as I have traveled ,visited and collaborated for my work and I have been amazed by the abilities and the competence of trained doctors and nurses which work in the government sector. For example, I am absolutely amazed at the number of patients examined by doctors in a day at places like the All India Medical Institute (AIIMS), Safdarjang Hospital or in most Government hospitals in Delhi or elsewhere. It makes me incredibly proud and humble to their work. But more are needed, urgently.
3. Where is India falling behind the world in health?
The question that has defeated me for years is why India produces such few doctors? Our ratio of the doctors to the number of patients is pathetic. It is lower than many very poor countries. We have opened many engineering, law and management institution but for some reason, we do not have enough medical colleges and are not training enough doctors. Health and education have to be our top priority. Our general facilities are very poor. We need to at least be double our spending on health immediately. We need to get our infrastructure in place: have enough doctors who are interested in treating patients and have access to up to date technologies, in many more locations. The new All India Medical Institutions in different locations in India is a good step but should have been done decades earlier. All 29 states in India should have at least one All India Medical Institute like facilities! Some states may be two or three.
4. Can you give examples of fast growing economies, which are handling their health problems better than India?
China and Vietnam, both successfully are making sure that they have enough doctors who are available, accessible and not concentrated in only few locations. Brazil has done it very well. However, in the same breath I will add that the job in front of us is much more complex than Brazil, for example. We need expansion of services at a much larger scale – the number of hospitals or referral places we need to make available will be very significantly more.
5. If you think about India in 20 years’ time, what will the citizens of 2033 wish that we had done in 2013?
They would wish that we had provided access to basic amenities like clean, drinking water and basic hygiene. We do not even have toilets in many schools. Young girls don’t have access to toilets which is vital for their healthy being. I have been involved with school education and I have seen places which are indescribable in terms of the ‘lack’ of basic facilities. And just recently, I saw in the print media that in Delhi, 65 babies per 1000 die before the age of 28 days, which is simply unacceptable even in a developing country. Yes, they would wish that we has provided for basic infrastructure, both for basic education and for health.
- Is there any technology that will make a big difference to health outcomes in India over the next twenty years?
Any technology that helps in early diagnosis ensures faster and better treatment and will make a huge difference to health outcomes. Thus, we need access to diagnostics, and therefore access to a doctor and facilities. Also, we could reduce at least half of disease conditions by precaution. There are several diseases such as papilloma virus infection which leads to cancer and it is completely preventable now that a highly efficacious vaccine is available. It has become controversial in India but it is not at all in the rest of the world. Therefore, preventive technologies such as vaccines can make a big difference.
7.What do you enjoy most about working in the health services field? What do you like the least about working in this field?
For me, it is just the possibility and hope to be able to do something which alleviates people’s ill health and suffering either by prevention, treatment or by the way of control. And, since at ICGEB we have worked largely on diseases such as malaria, dengue and tuberculosis, if the incidence figures for all these can be reduced to at least half, then in itself it would be an enormous achievement. So it excites me that my work may have actually be useful in alleviating lot of grief.
India is matured with regard to its pharma, bio pharma and biomedical research and has huge potential. However, when you actually work in the field, you also realize that there are layers of hindrances in the bureaucratic systems or processes and these make work very tedious. Things can move much faster but they don’t.
B. These next few questions are on immunisation and prevention.
1.Many say that India will face a wave of non-communicable diseases. What can the country do to prevent this?
Diseases such as cancer, diabetes, hypertension etc are termed as lifestyle diseases. We have about 300-350 million middle class and upper middle class Indians and a very large number of them are affected by diabetes and obesity. Our life style have changed dramatically, and so is the landscape of these disease; India has more diabetics than anywhere in the world. However, we will not find an obese rickshaw puller, an obese construction worker or an obese farmer we need a lifestyle change to prevent or at least reduce the incidence of many such diseases.
Early detection is vital for prevention. Cancers in very early stages are treatable and those treatments are available. Exercise is very important to prevent obesity and heart diseases. I find that a substantial part of the younger generation in India are at least physically aware of their bodies -they want to be healthy and look good and they work at it. So this message should spread. You can, and should, actually eat fresh, seasonal fruits and vegetables. I say this with great caution because I am aware that a large number of the population have no access to fruits. I am addressing this to people who have access and can afford to eat fresh fruits and vegetables and still do not eat them; healthy eating and exercise are very crucial for good health.
Also walking one hour walk every day is not a big ask at all. India and China are going to be the largest spenders on anti – diabetic, anti -cancer and cholesterol lowering drugs. It is ridiculous that we should be spending so much on these drugs; we should not have our cholesterol going up to begin with.
2. Many say that India is a paradox. It manufactures about 40 per cent of vaccines used in universal immunisation programmes across the world. However, a third of all immunised children are Indian. As a specialist in the field, what are your comments on this?
There is simply no justification. Again it boils down to access. India can produce more Hepatitis-B vaccine than what the whole world needs! Then, the obvious question one might ask is why access to these in India is so limited. Is it the government? Is it the vested interest of different lobbies? There is another group that thinks vaccines in general are harmful. Luckily their number is very small but they can create confusion in people’s mind and unfortunately adversely affect the decision making even by government agencies. You have rightly said that a one third of population has no access to even those basic vaccines that we produce in huge amounts. So this paradox is difficult to understand. There is no excuse for not having provided the anti tetanus injection to the whole country, specially to women who have just delivered a child. But in India, there are political issues and economic issues which are not scientific that have an impact. Non-scientific issues tend to take over in this country. You can blame it on democracy, lobbying or whatever you like but this needs to be addressed. Even access to life saving methods becomes a political issue.
In India education and health are state government’s responsibilities. Implementation of health policies is still in the hands of the state administration. I think in the health sector, the amount of pilferage and corruption is monumental.
3.What is the biggest obstacle to universal immunisation? Is it finance, access, or lack of knowledge about the importance of immunisation?
A good question again. There are some states which are way ahead of others. So, in the same country, similar cultures, same background, some states are doing much better than the other states. So to my mind it is really the seriousness with which a given state government takes up the issue of health. If any central Government health scheme is implementable in one state, it should be implementable in others too. We must have access to education and we must have access to health. But having said that, there has to be more money also and an efficient, honest structure to see that the money is not pilferaged, as now.
4.How hopeful are you that India will find new ways to reduce the risk of contracting malaria?
Malaria research is one of our focuses at ICGEB.I don’t see much new on the horizon, to be very honest. Fortunately, malaria is treatable and early detection is very critical. Prevention of malaria by vector control is also very important. With existing detection and treatment tools, much of malaria can be controlled. Once again access to health care system is a major challenge in malaria endemic areas. There is a lot of malaria in India but it’s located in different pockets or locations. Places such as Orissa and Chhattisgarh which is a tribal area -have the maximum incidence of Malaria.
There are simple tools and technologies for prevention of many diseases. For example, sickle cell anemia in Gujarat, Madhya Pradesh and Chhattisgarh. All you need to do is scan the whole population and make sure that somebody who carries the defective gene does not marry another person with that same gene. Therefore, in two or three generations, you can get rid of sickle cell as it is located only in few pockets. Likewise with different tools, kala azar which is mostly located in Bihar, can be largely controlled.
So what stops us from actually doing these things? I would say a lack of commitment and a fragile but corrupt structure we could so easily be much better in controlling and eradicating the diseases.
5. What do you think is happening to the patterns of malaria outbreaks that were getting and other mosquito borne infections in India?
About 15- 20 years back, when one would have hardly heard of dengue infection. Mosquito vector for Dengue is now well established in large cities in India. But in a city like Delhi of a population of 18 million that live within 1000 square kilometres , it is extremely difficult to get rid of mosquitoes. The next best step you can take is to create huge awareness and vigilance about hygiene. Standing dirty water such as in water coolers or flower pots are the breeding grounds and if you cut down these areas where the Aedes grows by 50 percent, you will control the disease spread.
Patterns of malaria have not changed very much but malaria is now in new locations also. For instance, there was little or no malaria in Rajasthan. But recent mining or construction activities, digging canals etc. led to arrival and spread of malaria there. I do think that the total number of malaria cases are much more than what is generally accepted; India actually has a very huge of load of malaria. It is just that the locations where the malaria incidence is high are not on any active radar.
6. Of the efforts and initiatives that are taking place to control malaria, which ones excite you the most and which ones are you skeptical about?
Historically, there was a lot of malaria in countries such as Italy and Spain in the 30s and 40s . After the world war, after the economy improved, they got rid of Malaria completely by putting in huge efforts for basic health infrastructure, sanitation and hygiene and awareness. Some locations in Africa the use of impregnated bed net have shown huge promise in bringing down the infection rate. So if I were to control malaria in twenty villages where there is high malaria load, I would think of bed-nets as one of the options. But, again where people have no access to food, they certainly are not going to have money to buy bed nets and therefore the government has to provide them. But provision of bed nets have to be supplemented with awareness, access to medical infrastructure.
I am not sure that Malaria control is a dominant priority in India. Look at HIV spread in India. There was an amazing effort put into HIV control; including awareness, access to medical help, drugs etc. The polio vaccination programme has been an amazing success. So it’s all doable. If you can do it for HIV why not for TB or Malaria? Fortunately there is a new generation of researchers and new improved tools for research in infectious diseases. A major coordinated effort to control these diseases is what excites me the most.
C.We would like to know about your work:
1. How did you first get involved in this field?
Actually, in my generation we did not have advisers to guide us in our career decisions. I was interested in chemistry so I went to Delhi University. I was also interested in fine arts and if I had advisers at that time, I may have done something else. I was a good student and I became a lecturer at St. Stephens College, New Delhi at the age of 21 and also won the Rhodes scholarship to study at Oxford University where I did my D.Phil. On my return I taught at IIT Kanpur. I love my work and I tell my students that I get paid to think, create and make a difference and nothing can be better than this.
2. What do you think will change in this field over the next five years? What sorts of trends do you see?
I feel that there are going to be strong lobbies in health and education. There is a sense among vested interests that India will spend huge sums of money in health and education. It will be important for all of us working in the fields of health and education to remove the layers of corruption and vested interests. We need good governance for India to move forward and become a developed country. It cannot happen without a strong political will and clear vision.
3 What’s the best thing to happen since you started working in this field?
There have been many good things. If your students and junior colleagues are happy, they’ve been trained well and hopefully you’ve been able to convert them into good human beings, then these are all achievements.My biggest satisfaction is to see young people whom I have taught doing well.They are the foundation for India’s future. I have seen a very large number of my students flourish and that’s a sense of achievement in that. But within the narrow boundaries of research in my work at the ICGEB till now, is the ability to do the basic research in malaria: pick up the leads from basic research, produce a vaccine construct, go through the whole rigmarole of government approvals through the drug controller, getting an industry interested and setting up the first phase 1 vaccine trials in India. Nobody else has ever done it before. At ICGEB, we created a path for others to follow. This was done by a whole group and we were all proud of it.
4.What do you do when you aren’t working ?
There is hardly any time but I enjoy listening to Indian classical music. I used to be a national level runner when I was younger. I used to run about 15-20 kms a day and ran for Delhi University, Delhi State and Oxford University. I have a huge interest in sports. I am also involved in organising some high end scholarships for Indian Graduates, including the Rhodes scholarships.
5.What might someone be surprised to know about you?
Contrary to the impression created by others around me , I am actually very easy to talk to and it is easy for people to get to know me and bully me! Another thing that might surprise people is that I love classical music and I can sing. And, that I was a serious national level athlete.
