 Good afternoon everybody and thanks very much to Unni for that very kind introduction. And it's a real pleasure to be here with all of you today, both those of you who are in this room and those who are watching on the webcast. I think it's a great initiative to have this kind of an event by the MSF. Of course I've admired the MSF for many many years as I'm sure many of you in this room have and have always had a secret desire to work with the MSF perhaps one day that will come true. But I have met many colleagues and visited many of their field sites including in places like Swaziland where I saw the MSF project on MDRTB in really remote mountainous communities where they first tried to work with community volunteers giving injections of cannabis and to these people who otherwise would have to travel 30 or 40 miles every day to get their injections. And I'm also familiar with the work in Bihar on Kala Azar and also in Mumbai on MDRTB that you've all been listening to in the morning as well as work in the former countries of the Soviet Union again on MDRTB mainly. So I'm going to just share some thoughts with you today about what are some of the research priorities looking to the future for our region, the South Asian region. We share a lot of commonalities essentially most you know we all come from the same stock and also what NGOs can do you know how can NGOs contribute to research which is I think something which is really I should start by saying first of all that health research as such I think is neglected in this part of the world is not given the high priority that it should is underfunded and doesn't attract good people and I say this you know knowing that it can raise a lot of eyebrows very recently there was a paper published that many of you would have seen by Dr. Nandi and his colleagues and they looked they analyzed the research output from India the medical colleges and they found that more than half of India's medical colleges we have about 400 now 400 plus half our private half our government more than half produced less than five papers a year and many of them produce no papers at all in a year and only five colleges in India accounted for more than 80% of research output and you know you can count on one hand the number of medical colleges that are doing research so I think that says a lot about our training and this is where I think the Medical Council of India and others really have to we have to look at our medical curriculum and exposure that we give to our students and I think this is true probably of other disciplines as well it's not only medicine but today we're talking about medical or health research that medical students are not exposed to research at all and in fact we hardly ever hear the word research I think in during medical college in this part of the world anyway it is a contrast to the training in other parts of the world where students even in school and when they're in college are encouraged to undertake research do internships take a year off and so on and the other so that's one thing I think we have to focus on is really the exposure the training the building the capacity as well as giving opportunities to medical students at least those who are interested to pursue research and then of course the whole area of supporting research health research in a much bigger way having a strategic approach to developing the capacity within medical colleges so now that I'm talking about capacity I'll just mention a few of the schemes that the ICMR does have and which further need to be expanded one is the short term studentships we have for medical students in while they're still in second third fourth year of college they have to find a mentor write a proposal a short project which they can do in the summer holidays submit to the ICMR it's screened online by reviewers from all over the country and then a thousand of them are awarded every year so we start with this year we had five thousand applications so every year the numbers growing up so that's a very good sign it means people are interested and if there are opportunities they will take it we have a thousand of them they submit their reports the reports are reviewed and those which are very bad are not considered further the majority of them are good enough to be approved and get a certificate and also they get ten thousand rupees for having done that apart from that we of course have PhD scholarships and postdoc fellowships and junior and senior research fellowships but now we want to really expand that number and also start a whole program for junior medical college faculty so this is something that we're working on and hopefully we'll be able to come up with some good schemes similar to what the Department of Science and Technology has for faculty and universities a mentorship is very important part of this and as I visit MGOs you know around the country and they do such excellent work in the field all of you because you're in the community you have an understanding of the various facets of community life generally NGOs engage much more with the community than government is able to or does and you're based there and there's a certain commitment I'm talking about majority of the good health NGOs so an exposure for a student or a young faculty member who's more in an urban environment to an environment like that I think would be a real eye-opener so one of the things that you know again I was considering is how do we get people from medical colleges to move and perhaps do sabbaticals in NGOs the NGOs would also benefit because most NGOs are working with a handful of people usually overburdened with the clinical care or the community projects or whatever they're doing less time for research and even less time for documentation and writing up so lots of NGOs have done tremendous work but you can't read about it anywhere because they have not had the time or the inclination or the capacity to put it together and publish it so I think a scheme where we could have some movement of people who are interested in community-based research say from medical college public health departments or community medicine departments out into the field and spend a year or two years could not only give them that exposure to the realities of life in remote rural or in underserved urban areas as well as the other way around that they could bring if they had skills in epidemiology, biostatistics or IT could bring to that NGO the skills needed to take the data, capture it and help write it up so I think we have to try this out and see how many takers we'll have for something like this. The other thing of course is in India we've had a very long and rich tradition of NGOs working in the health sector and we've had several examples of people who won the Maxisee Award for example for the community-based healthcare programs including Dr. Bang and Dr. Rani Bang and also Aroles from Maharashtra, the Amtes, both brothers Vikas and Prakash, Amte and of course a father was a very famous person in leprosy but they continued that tradition and I name a few of these and there are many more including MSF, including JSS, Jansvastya Sai Yogan, Chhattisgarh and so on where there's a more academic or an intellectual approach also taken down it's not just serving the community but it's evidence generation as well and we know that again many examples of such evidence that have found their way into policy probably the most well-known one is Dr. Abhay Bang's studies in rural Gadchiroli where he used community health well they were just community volunteers, they were just ordinary women who volunteered to serve as sort of maybe the forerunner of the Ashaas they were given basic training, given a bag, basically focusing on maternal and neonatal care and then they delivered gentemisen injections to babies when there were signs of sepsis not randomly because I've gone with them out into the field they know how to look at newborns and find signs of sepsis, I mean it's quite based as much as possible on an algorithmic approach and they showed that you could bring down neonatal and infant mortality tremendously by this approach it was published in the Lancet, discussed globally, adopted globally now as policy but still there are always difficulties in implementing something like this through the government because there are so many issues which come up legal and other issues and you know so it's not always that evidence gets quickly implemented but you know the first step is to generate that evidence the other unique thing about I think NGOs doing research is that you tend to pick up the problems which are priority for the community ok so very often people sit here in Delhi or anywhere else and decide ok this is the list of research priorities for the country now let's go out and do it and you go into the community, I mean you talk to community members their priorities are completely different and I learnt this when I worked in Jawadu Hills which is a tribal area in Tamil Nadu where we went with a TB project we were trying to get youth volunteers from the villages to do case finding as well as to be dot providers this was in the early 90s and you know it was very remote at that time we had to walk to most of these villages and many of them said you know the first government team that's ever come to our village and so on we found also the life expectancy there was quite low because access was an issue but the interesting thing was that they said that why are you only talking to us about TB you know that's not our top problem so we have so many other issues before that you know we people have fractures they don't have any access to care our children are undernourished there were no Anganwadi's there because of the rules about Anganwadi's you know one for every thousand and these hamlets are all widespread and we realized the community was ok they went along with the TB project because we were very persuasive but we realized that they wanted a holistic solution to their problems they didn't want one team coming for TB another team coming for something else this is exactly what we end up doing in government similarly I think there I was talking to Dr. Bang actually when I was in Gadchiroli and he said that you know when they first went to Gadchiroli they thought that sickle cell anemia was a huge problem in the tribals as you know most of our tribal communities have a high prevalence of sickle cell trait anemia so that this should be the big problem here and that we should you know try to get ways of screening, testing, addressing it and then in a series of meetings with the tribals they said sickle cell I mean that's fine I mean we know it occurs it's been there for generations and that's not our major issue at all so we really don't want you to be focusing on sickle cell and here are our list of things TB actually came out as one of the very top ones malaria and snake bite and even till today that malaria is huge there so this is where I think that there's a diametrically opposite approach taken by government and by NGOs where the priority setting is done based on a participatory approach or should be anyway maybe everybody doesn't do it like that but that would be the ideal way to do priority setting is a more in a participatory way rather than a top down now there could be another way of also looking at research priorities and that is to look at what's the burden of disease what's the burden of disease today and what is it likely to be in the future and what really are the gaps in knowledge that we should be working on and that then takes you to a more systematic approach which is more based on the data that you have and all of you would have seen the global burden of disease reports which have come out and continue to come out and that showed very clearly that between 1990 and 2013 if you look at India the top 10 causes of death and the top 10 risk factors there's a clear shift from infectious diseases being the top killers it was TB, pneumonia, diarrhea up in the top 3 and it's completely moved now to cardiovascular disease cerebrovascular disease and chronic lung disease and TB is still up there in the top 5 but the other causes have plummeted diarrhea has gone down because of ORS and better water and sanitation pneumonia has gone down childhood pneumonia because of immunization and as we roll out more and more childhood vaccines that's likely to go down further and also with of course you need also access to antibiotics in remote areas if you look at the risk factors the top risk factors in 1990 were things like under nutrition, unsafe water and I don't remember the third one but they were all again related to water and sanitation issues and if you see the top risk factors today in 2013 it's hypertension number one, diabetes and air pollution so there's environmental air pollution and indoor air pollution which we must not forget in South Asia is a huge risk factor for millions of women who are still using solid fuel so both environmental ambient pollution and indoor air pollution come in the top 10 risk factors and added together they end up being the third most important risk factor for us which in turn lead to the burden of disease so this I think really gives us a lot of food for thought that as we are controlling the infectious diseases due to the number of things I said general overall improvement in the standard of living access to clean water and sanitation of course we still have a ways to go better immunization policies more availability of antimicrobials and so on the infectious diseases are coming down and this is just totally going out of control and there are many reasons for it which we won't be able to go into in a lot of detail today why hypertension and diabetes has become such a huge problem a lot of it is lifestyle related urbanization and so on but a lot of it why is it a problem in urban and in rural and tribal areas most of us think you know they have a nice eco-friendly lifestyle they still live in a much more fresh environment and they have access to fresh food but it's not true and survey after survey has shown that the rates of hypertension especially hypertension but also diabetes in rural and tribal areas is as bad as the urban rates within a few percentage points of each other there's no great big difference remote tribal communities are showing so if you look into the reasons why Lakshad after post tsunami the community now is provided with everything from the government rehabilitation measures including the PDS supplies and most tribal communities who now moved out of forests and cannot no longer depend on forest for their livelihood are now eating what's provided in the PDS and what are we giving in the PDS we're giving polished rice or wheat, sugar, some dal and some oil perhaps but it's essentially a very carbohydrate heavy diet and if you can't afford to buy fresh fruits and vegetables and you can't go into the forest to collect it then this is what you're going to eat and our National Institute of Nutrition in Hyderabad which is one of the biggest ICMR institutes has done many surveys over the years now looking at dietary patterns and what Indians are eating and the average Indian is taking less than 10% of the recommended allowance of fruits and vegetables of green leafy vegetables and fruits and calories where quite a few Indians are still having less calories than they should but the calorie gap is not so much, the protein gap even is not so much the gaps come in the micronutrients and because of the imbalanced diet so this is one big reason and salt and sugar are the other two things which are contributing to this and of course the reduction in exercise because of the availability of transport and so on and I think lack of knowledge and awareness is a very big thing in communities as to what is a good diet if you go by the television and advertisements and if you go by what the wealthy are eating naturally then everybody wants to have pizza and noodles and even when you go to urban slums, I often see the children are eating all these packaged you can get them in small packets now, 5 rupees packets so it's not a big expenditure for the parent so the children pester the parent till they get that 5 or 10 rupees and they go and I used to work in a fishing community in Chennai and I used to say but your diet is so healthy, it's fish and rice and why are these children so malnourished? they said well they don't want it, so they want noodles or they want to have some chips and things like that and the parents give in because maybe for whatever reason so I think we need in India now to stop if you have to put a break on the rate at which we are progressing in the NCD, whatever you want to call it, epidemic or whatever there are huge interventions in many areas I would say policy interventions yes and that's particularly we're talking about tobacco that it becomes very relevant again in rural Ghatchiroli I was surprised to find that over 60% of the population takes chewing tobacco and starting in childhood so we saw many young children who were already addicted and we know that so we just released our cancer data some of you would have seen the press coverage last week so the data from our cancer registries from 2012 to 2014 we have now about 29 population based and 29 hospital based cancer registries which are the best source of data for cancer in the country and you can see trends, you can see what's happening in different parts of the country there's a lot of heterogeneity you find overall breast cancer increasing in women that's number one cancer today again related with urbanization so if the breast cancer risk for an Indian woman is 1 in 40 it's 1 in 20 for a woman in Delhi in men lung cancer number one but colon cancer increasing and of all the cancers 30% are tobacco related 30% overall and 40% in men are cancer are tobacco related and the registries in the northeast of the country are very very worrying because first of all 60% of cancer in the northeast is tobacco related and there's a high incidence of apart from lung, esophageal and stomach cancer which could be related apart from tobacco to other dietary risk factors maybe smoked meat, could be forms of alcohol could be other risk factors in the diet we don't know maybe infection either I mean needs further investigation and of course cervical cancer number three among women the rates are coming down overall especially in urban areas the rates are coming down quite dramatically but again it's one of those cancers which could be prevented by widespread HPV vaccination policy and of course early detection is very important one other thing the registry brings out is that only 10% of people are coming for diagnosis in stage one so 90% are in stage two and above and that obviously makes their outcomes poor so that's the other risk factor is tobacco and obesity is fast catching up we still have high rates of stunting and malnutrition in the country many of you would have seen the data the NFHS data that shows that it has come down a little bit in children under five still way above 30% stunting and under nutrition and this whole debate about is it genetic or is it true malnutrition I think is a false debate because when you look at children from the same ethnicity you are growing up in a good environment with clean water sanitation and good nutrition you can see that within a generation the heights going up so it's a question of the environment being poor and very interesting work now being done also in malnutrition to look at interventions so we know now that it's not only food it's not only what you're taking in but it's also the absorption and availability of those nutrients which are important and if you have a lot of infections then you're unlikely to respond to that increased food so what is the answer is it deworming and the trials that have been done for deworming have shown very marginal improvements over a period of time both in cognitive function as well as in nutritional status is it more food supplementary food micronutrient deficiencies of micronutrients which need to be corrected or is it something else and studies in Belor by Dr. Gagan Deepkang and all where they replaced it was a randomized trial where they gave one group of people clean water because they felt that maybe it's the water that's the issue the food part of it was the same in both communities these were very poor slum communities and after a year they found no difference the rates of infection had come down in the children who were living in the area with the water but there was no change in nutritional status and now we have this concept of an entry of an entropathy an infectious entropathy which develops early in life in children who live in poor sanitary conditions it's not just worms but it's an entropathy due to multiple infections which prevent growth even when the children are getting calories and protein and so the interventions have to be holistic and they have to be early in life but the point I'm making is that there needs to be evidence generated as to which approach or which combination of interventions will work similarly we know from our iron and folic acid program has been in operation for a long time and yet the rates of anemia and women and children remain high almost static they just don't budge is it a question of just compliance with the iron and folic acid tablets or is it something more than that it could be availability of the iron because of the kind of diets that we take high phytate diets which prevent iron absorption or is it other causes of chronic anemia which are not responding fully to iron and folic acid so we've been discussing with the ministry as well as to what kind of implementation research should be built into programs so this brings us back again to the whole area of evidence for policy making and so I think this is really something that would be is very much needed and which will help our health programs actually put in better interventions or to change track midway when you see the things are not working so going forward we're looking at within the ICMR at focusing on few key areas of research I mean there's so much to be done in India and the infectious disease part of it obviously has not gone away it's just that the balance has shifted it used to be 60% infectious 40% non-communicable and now it's gone the other way 60% non-communicable disease burden and the mortality and 40% is due to infections plus maternal and child causes of death so we're actually doing a much more detailed exercise now along with the public health foundation of India first of all to do state level disease burden estimations but also look more closely at all the surveys that have been done especially the health surveys and nutrition surveys to see whether we can do more analysis and interpretation to find out what the possible interventions could be and the state level disease burden estimates will be very helpful for state policy makers as you know health is a state subject in India though policies can be made in Delhi they can be modified and implementation has to be done by the states so obviously the burden in Chhattisgarh may be totally tilted towards malaria and under nutrition and TB whereas the burden in Kerala would be diabetes, hypertension, cardiovascular disease would be where they need to really focus so I think this is important for a country like India and in fact the national level estimates really don't help anybody in policy making so much more we have to go into much more detail and perhaps even down to the district level the prime minister when he spoke last week to the secretaries about he has a program where he monitors programs and after the secretary had made his presentation he said that you know we need district level data we should focus on district level performance and do interventions at that level and it's true for other diseases like leprosy as well where at the national level we've eliminated leprosy we've gone down to less than 1 in 10,000 but there are many many districts in the country about 130 or 140 where leprosy new case detection is still above 1 and leprosy certainly is not eliminated so now the target is from by 2019 that we target elimination of leprosy at the district level by doing more active case finding and by ensuring treatment and compliance and perhaps putting in a couple of new interventions for prevention among the household and neighborhood contacts we're looking at actually using a vaccine called the mycobacterium endicus pranae a vaccine that has gone through many clinical trials and has an efficacy of about 60% against leprosy so if we are able to vaccinate contacts not only household but social contacts as well for every leprosy patient can we actually drive transmission down or drive down the new case detection over a period of years so this is a question that hopefully we will begin to answer through an implementation research project that we are planning with the ministry so there are several other diseases like Kalazar where MSF has contributed a lot in Vaishali district of Bihar in generating the evidence for the single dose amphotericin B, liposomal amphotericin B treatment which is now policy as well as diseases like phylariasis where the mass drug administration we've been doing now for many years but a recent survey has found that again there are many districts where the rate of phylaremia or antigenemia has not dropped down below the 1% that we are looking at so again one has to ask what the problems are is it compliance or is it that the drugs need to be supplemented so we are going to do some implementation research for phylariasis as well where we are going to add ivermectin to the two drugs which are already used which is DC and albendazol in a couple of districts high prevalence districts in Karnataka to see whether that because it's been tried in a small population of Papua New Guinea and they found that by adding a third drug to the two drug MDA you could really bring down a microfylaremia almost a zero in the people who got it but that needs replication and it needs evidence before the policy can be changed so we are hoping to start that also in the next few months so there is a drive also towards the diseases which are going to be eliminated I think there there's research needed because the last mile is always different when you're left with a handful of districts now in Bihar and Jharkhand where Kalazar is a problem similarly 100 districts in the country where leprosy case detection is still high another 100 districts where phylariasis is not going down but we want to eliminate all these in the next 2-3 years so research towards elimination of some of these infectious diseases is certainly still very important and I think this is where again the NGOs can take a lead because what is often missed in many programs are the socio-behavioral aspects so you can go around distributing tablets but if people don't take their tablets for whatever reason or people refuse to be vaccinated for whatever reason then the program isn't going to work so we have neglected this I think you need social scientists as part of I think all research at least anything that involves a community which is public health research there has to be a social scientist as part of the team preferably health economists as well so that one can look at cost effectiveness of interventions towards building up the evidence to policy in a more formalized way we are looking at setting up a health technology assessment board which is similar to NICE in the UK which is similar to Hightap in Thailand many other countries have established such boards which would look at the way the evidence that's available including cost effectiveness analysis aspects of equity and access and make recommendations to the government as to which of the possible interventions should be adopted and of course then the government there has to be a system where the ministry then takes the recommendations of this independent high level board like the NICE in the UK which have often given recommendations which are not popular at all where there's been a lot of opposition from various groups but ultimately you know you have to be in that position where the decisions are made openly, transparently and based on evidence where you can stick by it and the government then usually does accept in such a situation so we're working towards that it will take I'm sure a couple of years to really put in place the whole structure where it's functioning at that level but we're starting the process with the NICE UK helping us research capacity we talked about implementation research is a third pillar the fourth one is leveraging traditional medicine where again I think India can play actually unique role South Asia overall but certainly the rich traditions that we have in India various forms of medicine and also outside that we have so many non-codified practices so many herbal practitioners traditional healers especially in our tribal communities that have this wealth of knowledge of all the medicinal plants available in their region there is a lot of scope I think for us to use modern biomedical approaches and the technology that we have today to first of all of course try to discover and develop a drug from medicinal plants like artemisonine from malaria like ivermectin like so many other drugs that we have but also to validate traditional practices we cannot sweep them all with the same brush in the sense that yes there are many quacks who operate in these remote areas but those quacks are actually using allopathic drugs and exploiting people that certainly has to be discouraged and controlled but there are true traditional medicine healers who have knowledge of plants and many of the time those things have definite medicinal properties many plants have, we know that and so many drugs have come from plants so it's a question of studying, documenting verifying, validating doing clinical trials where necessary and then taking them forward so I think this is where China has done very well and in contrast perhaps we haven't focused on this because there are two streams they're not talking to each other and again there's very little interaction and exposure between the allopathic stream and the non-allopathic doctors whether they are Ayush doctors so we have an institute in Belgaon I was there last week where they really identified a whole lot of traditional healers from that area, mostly tribal communities in the western Ghats which as you know is very rich in biodiversity and medicinal plants and they now have an integrated clinic where these traditional healers can come and practice their medicine at the same time we can do observational studies to see what is happening similarly we have a clinic sitting with Ayurvedic doctors and allopaths the Ayurvedes have a herbal remedy for dengy where they say you can actually prevent the platelet count from coming down this obviously needs to be validated so I think in this season we'll start a clinical trial to validate or to look at the efficacy of this herbal extract or it's a combination of seven medicinal herbs in preventing the platelet count decline in dengy so those are examples of that piece of work the last priority or area where we want to focus is in setting up data platforms data warehouses and repositories I think that is an area where again the whole world is actually looking at what's the best ways of sharing data of making it available as quickly as possible on platforms where people can access it because I think data that's been collected especially using public funds must be made available to people as rapidly as possible as transparently as possible and of course paying attention to the individuals or the principal investigators who collected that data they have a right to use it first but I think more and more policies are shifting both of the science agencies that support research as well as of journals that accept papers many journals are now encouraging a pre-publication online you can submit in a repository NIH and all the other funding agencies have rules about when you have to make your data available especially the publication as well and there's a lot more open access publishing happening so in this area also we hope to be able to work over the next year or so to develop the data warehouses where we can put say for example all the nutrition data that's being collected in so many different surveys that people are doing there's TB data, there's cancer data there's a lot of data which if available then will be useful for researchers in different institutions to access and be able to so again a lot of policies have to be developed SOPs have to be developed and then one has to have the capacity to so finally before I end I think that I'm a strong believer in collaboration and collaborative research and I think that we now you look at journals and you try and look at high impact publications sometimes at the list of authors runs into pages it's in the hundreds so this shows that the era of individual yes there's always going to be individual excellence, competitiveness I think that also needs to be there to advance biomedical frontiers but at the same time I think to have impact you need transdisciplinary interdisciplinary collaborative research where you have people from different streams actually coming together to solve one common problem or to do it in a mission mode so we're trying to do something like that for tuberculosis now and we're at an advanced stage of planning now for a TB research consortium or we're probably going to call it the India TB Research Foundation the idea is to really have an independent body that looks at priorities for TB research identifies problems that need to be solved and then is able to fund groups of people who want to come together to solve a problem whether it's a point of care diagnostic for TB that can be done on a drop of blood or in saliva that's what we'd all like ideally is to be able to diagnose TB with a rapid diagnostic test like we do for malaria now or for dengue or whether it's a short regimen for treatment of MDR-TB using new combinations of drugs a better vaccine or a strategy it could be strategies in the community as well to improve TB compliance so this foundation hopefully would see the light of day very soon it will be completely public, private, corporate everybody's invited to really join in we'll have to do a lot of fundraising some funds will come from government a lot of it will come from outside and it will also, we'll try to involve as many people as possible who are interested in solving the problem of TB so this is an example of trying to address a problem rather than funding individual projects which very often look at small pieces of the puzzle but then those never really get put together was talking to a group of PhD students yesterday and if you look at the PhD thesis that we produce every year a lot of it probably has very valuable leads that they have found but they get shelved and after that the guide is busy with something else he's got his next set of PhD scholars the PhD student has gone on and is doing a postdoc with somebody who's interested in something completely different so I think we're really missing an opportunity similarly for academics who are working in a lab they have funding to do certain amount of work they may have a very important lead finding for a drug target or a diagnostic but they cannot take it forward without additional support as well as involvement of industry so this sort of a platform where people can come together and work as a team to have a product at the end of it is what we're looking at and I welcome all those of you who are interested in TB to really join this we should be able to make a public announcement I hope in the next few weeks so I think I'm going to stop there and thank you all once again for the very patient hearing and happy to to have any discussion if you feel it's appropriate thank you