If We Can Build Mangalyaan, Why Can't We Do More in Health Sciences: New WHO Deputy Director General

Taking charge as WHO's deputy director general in December, India’s Dr Soumya Swaminathan speaks to The Wire about global health, where India stands on medical research and how women can get ahead in the workplace.

New Delhi: India’s Soumya Swaminathan has been appointed the second-in-command at the World Health Organization (WHO). Until now, she served as the director general of one of the world’s oldest research institutes for modern medicine, the Indian Council of Medical Research. In a wide ranging interview with The Wire’s Anoo Bhuyan, Swaminathan discussed her plans for working at the WHO and their controversial appointment of Zimbabwe’s recently-deposed President Robert Mugabe. She also discussed issues affecting Indian healthcare, such as the high burden of tuberculosis and the battle against tobacco. On medical research, an area Swaminathan has worked in for nearly three decades, she discussed the historical and current roles of the private and public sectors as well as the tensions between traditional medicine and pseudo-science. Finally, Swaminathan talked about women and success in the workplace.

On the World Health Organization, the controversy over Zimbabwe’s former President Mugabe and India’s role in the global health conversation

Anoo Bhuyan: Congratulations, Dr Swaminathan. It’s a big deal for India to be represented at the WHO and also, I think, a big deal for a woman to be doing that representation. So I’m particularly pleased about that.

Let me begin with your appointment at the WHO. This team that WHO’s Dr Tedros has is special for its democracy and its diversity. It was the first time the director general (DG) was elected (and not nominated). His team is 60% women and has representation from 14 countries. What does it mean for you to be part of this team – not the previous or the next team – but this team?

Sowmya Swaminathan: Thank you very much for that question. I think it is of course a great honour and privilege to be selected for this position and to be nominated by India. It’s a very special moment right now. For the first time we have an African DG of the WHO and that’s a big thing. And as you said, we have a leadership which is from different parts of the world, from different backgrounds. Nine of the 14 are women, but they also have very different life experiences and stories to share. So I think this is an opportunity to re-look at the way the WHO has been delivering and perhaps look at a renewed WHO that focuses more on impact on the ground, that engages much more directly with countries and that singularly focuses on improving public health. Dr Tedros has very clearly explained his mission and vision, and this new team is already working hard to achieve those goals in the next five years.

AB: With regards to India’s role at the global health table, we come with a lot of baggage. We have the highest burden of tuberculosis (TB). The Global Hunger Index recently put India at the bottom. We’re literally scraping the barrel here. The Indian media here has coined the term “death by breath”, where it is apparently possible to die by breathing. We’ve also seen deaths of babies because they’re not getting oxygen supply in government hospitals. This is the kind of baggage India carries. India is also trying to project itself as more than just a developing country in need of aid. How do we project ourselves at the global health table: Are we a giver? Are we a receiver? What are we contributing? What are we still taking?

SS: This is a very complex question that you’ve asked. No doubt that there are all these scenarios which are still quite bleak and that need a lot of attention. However, we’ve also shown that if we put our mind to something, we can deliver. I’ll just give you a few examples. We’ve brought down the total fertility rate to 2.2. Of course there’s still a few states which need to come to that. We’ve eliminated polio, which nobody thought India would be able to do. We eliminated tetanus. When I was training, I remember the number of babies we used to see with neonatal tetanus, and it’s really a horrible way for a baby to die soon after birth. We’ve achieved the Millennium Development Goals on infant mortality, again something people were not sure we would be able to do. I think the last ten years with the National Health Mission, with a focus on child and maternal health, we’ve been able to make a lot of progress there, and with immunisation. But yes we still have a huge amount of health challenges. Our population and our heterogeneity and diversity, both in terms of health systems performance which varies so much from state to state, and also in terms of health spending, I think we need to move rapidly on those fronts. So health work force and health systems spending, to ensure universal health coverage, becomes a reality, I think that really needs to be the goal for the next ten years.

AB: I want to address something a bit more imminent, which is the situation in Zimbabwe. And it’s important also because of what’s just happened in the WHO: President Mugabe was appointed WHO’s goodwill ambassador for non-communicable diseases (NCD). He has been the president of Zimbabwe since the 1980s. Currently there’s a “coup” which Zimbabwe is undergoing. The military has taken control of state TV and ‘detained’ the president. When he was appointed there was a huge outcry by the global health community. Their objection was that a man with poor credentials on democracy, human rights and corruption can be made the goodwill ambassador. And now we’re having this mess of a situation. This was the first crisis your team had to deal with. The WHO took the decision to rescind his ambassadorship. I think there are people who would like to know, especially in light of this current emergency situation in Zimbabwe, what was the thinking in the WHO? Surely there are protocols and someone who is vetting the candidates. How is it that someone who can have a poor record on democracy, human rights and corruption, but perhaps has a good record on non-communicable diseases, can be made an ambassador? What happened in the vetting process?

SS: I wasn’t there. And in fact I still haven’t officially joined the WHO. So I won’t be able to really give you a lot of details on what happened. I think the DG made this announcement at the big NCD conference which was happening in Uruguay. And I think the aim was that Mugabe has been a leader in southern Africa for many decades. He has influence within Africa and apparently there are a lot of people who do listen to what he has to say. So I think the idea really was to use a voice that is a loud and important voice in the region. And to try and sort of use that to deliver a good message. However, I think after the outcry there were things that came to light about his own contributions and some of the things which were directly in conflict with WHO policies. So it was rescinded. But I don’t have any more insights on that episode since I wasn’t there.

AB: Mugabe is 93 years old. His own health is precarious and he apparently doesn’t use his own country’s healthcare system. He’s often in Singapore for his own healthcare. Do you see this as an embarrassment for the WHO, that the new team had to deal with this soon after coming in? Or in hindsight are you kind of relieved that you listened to the global outcry?

SS: I think in the long run one has to learn from these situations. So in the long run it becomes a sort of learning experience and one would need to think very carefully. I think for a goodwill ambassador, especially for an agency like the WHO, one has to check on a number of different things. And political affiliation is one thing. But also your own achievements, and your public face, is very, very important. So going forward, obviously we would like to have many more goodwill ambassadors for health. I think it’s very necessary to have advocates for health, and people who are outside the health community. Because we end up talking to each other. So you need celebrities and important people to be talking about this. But that individual who is chosen would obviously need to meet a number of very strict and very high criteria. And perhaps more consultation.

On India’s health infrastructure, tuberculosis, tobacco and the private sector

AB: Let’s talk about TB, because India has the highest burden of TB. And much of your work over the last 25 years has been on TB and HIV. India has set a very ambitious goal of eliminating TB by 2025. WHO’s own goal is 2030. What perspective should we see this goal – how realistic is it?

SS: If you ask me as a scientist, I will say it’s probably not feasible to eliminate TB by 2025, given the tools we have today. However, I think there’s a value in having this kind of an elimination target. It fires the imagination. It brings people on board. There’s political commitment at the highest level. I’ve never seen anything like this, frankly speaking, in the last 25 years, on TB. We’ve always been fighting for TB. In fact, we haven’t had the kind of civil society demands as we had with HIV, globally and not just in India. I think that’s one of the reasons TB has been forgotten. It’s a “poor man’s disease”. It kills slowly, chronically, and it never makes front-page news, unlike dengue or H1N1 where even one death makes it to the front pages of newspapers. So that way I think its hugely energising to see this. And to have the prime minister and finance minister talk about TB elimination shows commitment at the highest level. And that’s the first thing you need for any disease control programme to succeed. Now whether we technically achieve elimination or not by 2025, I think is a moot point. But I think what we need to focus on today is the roadmap. There’s no point just repeating the fact that we’re going to eliminate TB. There needs to be a very clearly-articulated road map, with practical actions and a large number of stakeholders involved. And I think that has been laid out in the national strategic plan. It’s been fully budgeted. Of course the funding needs to come up.

But very importantly for TB, unlike other infections, we still need new tools. So the investment in research is very important. For malaria we have a rapid diagnostic test – you can get a prick and a report in a few minutes, you have a three-day course for treatment and you’re done. And similarly for most infectious diseases. But for TB, you have molecular tests now but they’re not still available to everyone. Your treatment has to go on for a minimum of six months. If you have drug resistant TB, then for two years. Injections are painful and toxic. Anybody would lose hope and give up treatment. So that’s the challenge. And we don’t have a good vaccine. Polio could be eliminated because we had a vaccine.

An estimated 1.7 million people died from TB in 2016. Credit: PTI

“I will say it’s probably not feasible to eliminate TB by 2025, given the tools we have today.” Credit: PTI

So on all three fronts – diagnostics, drugs and vaccines – we have a long way to go in terms of new drug discovery. With drug resistance coming up, we will need a pipeline of new drugs. So this is where India has to step up, I think along with other BRICS countries. We should no longer wait for other countries to do the research. This is a disease that affects us. One-fifth of the world’s TB is in India. TB cannot be eliminated globally unless India eliminates it. I think that’s where the ICMR has been advocating for increased investment and networking globally on a mission mode, to develop these new tools, for TB.

AB: I completely agree with you, it’s important to see commitment at the highest level, and for that commitment to be vocal. Which I think the government has got down pat. For about 15 years, India had been underreporting TB, which we discovered only recently. It’s one thing to increase monitoring and finding new cases. But that simply just increases your burden. You have a demand-supply issue. Is that burden being met, not just by the political commitment, but operationally, what can we say we have done so far and upto 2025?

SS: There are a number of different things which have actively happened and which continue to roll out quite rapidly. One is diagnostics. We were still depending on this microscopic examination of sputum smears – it’s very insensitive. It all depends on if the microscope is functioning or not. Now the aim is to have a molecular diagnostics, a PCR test available, which is point of care, which is made by an Indian manufacturer. We have validated it. It can actually be kept in the primary health centre and can be used to diagnose not only TB, but also the same equipment can also be used for other infections as well. So if we’re able to do that, every possible patient with TB will be able to have a test done, which will also tell about drug resistance. So you’ll start diagnosing many more people.

Second is the private sector. The reason we were under reporting is that even today, about half of the TB patients in the country were being managed in the private sector, either by qualified people or even by quacks and unqualified practitioners. And we have no idea what’s happening to these patients. So this whole concept of notification and reporting, only in the last couple of years has picked up. It was made mandatory in 2012, but it has taken several years for it to really pick up. Now we’re seeing a couple of 100,000 cases being notified every year. At least slowly that will tell us how many patients are out there.

Thirdly, I think we have moved to a daily regimen, which means we don’t expect people to come three times a week. We’re going to give them the drugs but of course we also have smart ways, IT-based monitoring systems, where we can keep track of who’s taking the drug and who’s not.

Finally, there’s going to be now social support and incentives built into the programme. So that for every month you are regular with treatment, there will be a cash transfer into the account of the person, so that will help them with some nutrition and food and so on. And hopefully serve as an incentive so that they will complete the full course of treatment. There are other kinds of support mechanisms also being considered for TB patients. So this whole package is a fairly holistic package. It looks at all aspects of the patient, including their own social and economic needs that they have. And hopefully will help turn around.

The private sector engagement is one piece that still is weak, I would say. Because the government has a good structure and the government expects the private sector to collaborate. Patients have their own views on who they want to seek care from. They may prefer to go to a practitioner who is sitting in their locality till 10 o’clock at night, rather than a government clinic that works certain hours. And the private sector believes that the relationship between patient and doctor is sacrosanct, that confidentiality must be maintained, that there’s no need to report and so on.

So bringing these different viewpoints together, and convincing everyone that the only way to eliminate TB from India is if all these constituencies decide that we have to collaborate, like we did with polio… We’re trying to do a demonstration project in Chennai, to see if we can actually set up centres of excellence within the private sector, within private practitioners, and say, “Okay, don’t refer cases to the government, there’s no need to do that. But we’ll give you free drugs and free treatment. Let the patient benefit, so that the patient is not spending out of pocket expenses. At the same time you need to report these cases in, follow them, make sure they complete treatment and tell us what happens in six months.” So here, we’re not interfering in their practice or the patient-doctor relationship. But at the same time, what’s important for us is that every patient should be diagnosed using proper methods and treated till they’re cured. And the family members need to be traced, because very often you find that about 3-4% of family members have TB. So it’s very important to do the screening.

“We’ve brought down the total fertility rate to 2.2. Of course there’s still a few states which need to come to that.” Credit: Reuters

“We’ve brought down the total fertility rate to 2.2. Of course there’s still a few states which need to come to that.” Credit: Reuters

AB: What you’re saying about private sector involvement – I think India’s health and education sectors are both trying to grapple with this. It is true in India, despite our poverty, the preference for a lot of people is the private sector. The data certainly shows that. But given that TB is particularly unique, is India’s TB burden more serviced if it is consolidated in the government sector?

SS: That’s something that we have been debating. Because there are counties like Brazil and China where TB drugs are not available outside the government sector. You can’t just walk into a pharmacy and buy TB drugs. That in way, helps to completely control it. … The reason it hasn’t been done in India, or we haven’t thought it’s a serious possibility, is because of the huge geographic reach you will have to have for delivery and access. We cannot afford to have any situation, any corner of the country, where a patient ends up with no access. And there are large parts of the country today which are only serviced by private practitioners or at least geographically, very far away from a government health centre. So that’s one of the reasons why that step hasn’t been taken. But this has been on the table for some time and it needs further discussion. It would certainly help cut down on misuse of anti-TB drugs, so it would help perhaps to curtail drug resistance emergence. And secondly it would ensure that all TB patients got standardised treatment, standardised follow-up and diagnostics, and they were all recorded into our systems. The only downside is, what if some people are left out of this? If we get to the point where we’re confident that we’re able to reach everywhere, I think it’s actually a good thing to do.

AB: Because in TB the follow up and keeping to the regimen is very important.

SS: Very important.

AB: Especially because we’re dealing with drug resistant TB and that’s an irreversible situation. When you say that it’s important that every part of the country has access and no part of the country should feel like you don’t have an option, if we can talk about the situation with Bedaquline and Delamind. Because this is the one drug that’s coming after about 40 years. It’s an option. It comes with problems. But in India it’s available in six centres. This year, an 18-year-old woman, in her diminished state, had to keep coming from Bihar to the Delhi high court, just to get access – the court had to give her access even though there’s a government programme for it. The court cannot keep on doing this on a one-by-one basis. So what is the hold up? Even the supply of Bedaquline and Delamind is a gift – it’s coming from USAID. There’s not a lot of procurement happening and when there is, there’s not a lot of roll out. So what is the knot and how can we untangle it?

SS: In the beginning, why it was restricted to these six centres is because of the concern of toxicity of Bedaquline, and the necessity to observe these patients very carefully. So six big centres with capacity were selected. However, this was very soon after the first 300 patients or so had been given treatment and it was clear that the drug was tolerated well and there was no out-of-the-blue side-effects. It was scaled up to all those states. So while the centres were there, the patients across the state were permitted. Now there is a nationwide access. The programme had to go state by state, training all the staff, to do this. Because you need to monitor them for certain side effects so there needs to be a pharmacovigilance programme built in. so there’s a fair amount of training that needed to be done. But today I think, there’s no question of, there’s no problem with access for any patient.

We have a donation from USAID. Maybe upto 10,000 courses. We have had the first instalment of 2,000 and another 2,000 now. But I think we need to think long term what are we going to do- because have over one lakh patients who develop MDR TB every year. And maybe about 8000-10000, of XDR TB. They desperately need not just one but perhaps both the new drugs. The donation for Delamind is only 400 courses that the company has offered to the country. And Bedaquline is up to 10,000. But this is not going to last very long. So I think we need to start thinking about the strategies. And there are a couple of options. But the government would need to discuss that with these companies to ensure that continued access. Because if you start access, then we have to keep it going. Right now as I said, there are no other alternatives. We need both these drugs in order to give these patients a good chance of survival.

AB: On TB you’re talking about the important role that the private sector is playing. And earlier on in this you mentioned NGOs also need to be taken on board. On this I want to ask you about tobacco. Because tobacco control is a stated policy of the government. We hosted the last Framework Convention on Tobacco Control. The health minister has been given an award by WHO for his work on tobacco control. So supposedly this is a big thing and we’re completely on board. Yet we’re seeing NGOs who work with the government, to implement the government’s policy, are being asked by other government agencies – the home ministry, other security agencies – as to why they’re working on tobacco control. Why is there no communication between the health ministry and other ministries?

SS: It’s hard to really generalise because we know that as far as the FCRA status of NGOs is concerned, the home ministry has recently reviewed it for a number of organisations, both government and NGOs, and put out a list of those who were not complying. Some of them were minor irregularities, some were major. Obviously they know the details and we don’t, and they have to provide a satisfactory explanation to the home ministry. So we can’t take a very generic stand on this.

But as far as tobacco is concerned, I think the one thing we have to realise is that the tobacco companies are just huge, and the kind of machinery and resources they have, and the kind of tactics they are willing to use to further their interests, I don’t think we can even begin to imagine or fathom, and at what levels they are able to operate. So this is where I think we are either naïve – we think everybody should believe tobacco is bad for health and therefore it should be obvious to people and so on – but there are lots of factors here that are playing. I think the health ministry, I must say has been extremely strong about this whole thing and not succumbed to any kind of pressure, whether it’s the pictorial representation or other kinds of advocacy for increased taxation on tobacco products. But then there’s the other lobby you’re fighting all the time, which has money-power and also no compunctions of any kind. So it’s going to be a constant battle with tobacco, both globally and in India.

And for us we have an added problem of chewing tobacco, which actually, in rural areas and among poorer communities, is more common than bidi or cigarette smoking. So we need to pay more attention to chewing tobacco, which is equally harmful. A lot of the oral cancer and upper gastrointestinal cancer in our country comes from tobacco. So we can’t let up at all on this battle. But as you say, we have to keep facing these challenges as and when they arise, and be able to speak up.

Cigarettes and a health warning label are seen in this May 24, 2017 illustration photo. Credit: Reuters/Thomas White/Illustration

“…it’s going to be a constant battle with tobacco, both globally and in India.” Credit: Reuters/Thomas White/Illustration

AB: Is there some sort of difference of opinion as it may seem, in the government? Because it’s not just a few NGOs whose FCRA could have been contentious. A lot of solid reporting has been coming out of Reuters, including the massive investigation on the WHO and on the FCTC that we hosted, and about how big tobacco companies were lobbying with government officials even in India. This is not something we did not know, but they showed you the entire paper trail that led to it. There seems to be a particular grouse with people like Michael Bloomberg who is a friend of the WHO, and has also put in a lot of money into tobacco control in India. Is there some sort of a misunderstanding in the government between what the health ministry thinks about tobacco control and what these other wings think?

SS: Yes, I think perhaps the understanding is not as comprehensive as it is within the health ministry. But I do think government departments need to work together on this, particularly for something like tobacco. They also made a differentiation between receiving funds for advocacy and for scientific research and not cross using funds. Those are very technical points which I’m sure can be clarified quite easily. But these are the subversive ways in which tobacco companies act and these ministries also need to become much more aware so that they can watch out for these. Because obviously, it will not be done directly. But I think more awareness in the concerned ministries will be a good way. So that we’re not slowed down in our battle against tobacco.

On India’s research story, the copy-model of pharmaceuticals, pseudo-science and AYUSH ministry

AB: Let’s shift tracks to talk about medical research and the work that you’ve been invested in for the bulk of your career. What would you say are your highlights from your time at ICMR and what would you say is your unfinished business for your successors?

SS: Okay, so I think one of the highlights of the last year and year and a half is that we have all engaged in a process of coming out with a strategic plan and a vision document. And this clearly lays out what the priorities for ICMR are. Very clearly one of them is building health research capacity in the country because I think that’s where we are at the moment, quite weak. And for our level of development, we need to have much better strength in biomedical research, in our medical colleges, in our academic institutions and universities. So that’s going to be a huge priority for the department of health research in the ICMR in the future.

The other one is really going to be focusing on how to bring evidence to policy in a much more strategic manner and not have to take many, many years before we realise that we should change the policy. So I think ICMR and similar institutions have a very important role to play, in synthesising evidence, in convening people.

I can give you an example of the HPV vaccine. When I took over as DG ICMR, I was told we’re not even going to touch HPV vaccine, that this is a very contentious issue and we’re not going to get embroiled into this. But I decided that this was an important public health issue that needs to be discussed and debated. Why are we not discussing it? So now in the last two years, we’ve seen states like Punjab and Delhi start a vaccination programme for their school girls. Other states are looking at how to do it. Part of the issue is getting the funding for it. And the central government is actually considering incorporating HPV into its immunisation programme. So this shows that if you start discussing with evidence on a technical issue, and not on an emotional or political angle, you can achieve things. So I think evidence to policy is one.

Implementation research is another pillar of our strategic framework. And what I mean by this is to implement things that we know are good. So there’s knowledge and there’s acceptance that that’s what one should do. At the same time, you’ll find on the ground it’s not happening. So working with the implementers and policymakers to actually show how something can be done in different ways is implementation science or implementation research. And that’s somewhere we can show gains very rapidly.

The other areas are around data. We have huge amounts of data collection in our country, survey after survey. And everything sits in different ministries or departments. There’s no one place where you can go to for say, a health repository. So my big hope was that ICMR should become the health data repository for the country, a one-stop-shop and that data should be accessible to people – because this was all data collected using public funds, taxpayer money. Hopefully, it will happen.

The last area is traditional knowledge. We bring our traditional knowledge not only from our AYUSH systems like Ayurveda and yoga but also from our traditional healers and folk healers and medicinal plant people who have a lot of knowledge on our medicinal plants. So can we actually work with them, to first validate their claims and secondly to maybe do drug discovery? So there’s a lot of scope for new drug discovery. Here we need to work with other agencies like ICMR but also with industry, because I think without working with the industry it’s going to be impossible to do any kind of drug development work in this country.

AB: I want to ask you about the industry angle perhaps just after this. But before that – there was a time a few decades ago when we looked at the scape of science in India and we looked at it with much pride. Perhaps within the scientific community, there’s a lot of buzz and excitement. But I feel like for us on the outside, it’s been a long time since we heard something exciting coming out from Indian science. Your own father, M.S. Swaminathan, was and is someone who we would call ‘a person of note’. He was a leading scientist in his time and continues to be one. But I feel it’s been a long time since we have been invigorated by either a person, an institute or a path-breaking discovery. What is India’s research story? Is it a generation that is past or do we still have much to offer?

SS: That’s an interesting question. I think one thing is we have bureaucratised our institutions. So I think at that time in the 1960s, there was less bureaucratisation. Scientists had access to stay the prime minister. And things moved because once there was a national mission or need, full freedom was given. Whether it was the space programme with Vikram Sarabhai or the atomic energy programme and also agriculture as you mentioned. These were all areas where there was freedom given to scientists. There was constant support from the political system. And so it became a reality. Science was translated very rapidly and we made huge achievements. I always think: if we can do this in space research, for example building Mangalyaan and all that with the same kind of resources, why can’t we do more in the health sciences. So one thing, our institutions got bureaucratised. But when I look around me, I see that there’s a lot of cause for optimism and hope. I see a lot of young people, very many of them trained abroad, who come back to India because they actually want to work here. They have startup companies, they want to contribute and they’re doing wonderful work around the country. I think we just need that next ecosystem to give them that little helping hand, which of course includes financial support to them at critical points so that they can make that leap.

AB: Let me ask you about something you mentioned, which is, India’s priority when it comes to biomedical research, whether it’s on disease or drugs. Should that priority be in the public sector or private sector? You mentioned today that you can’t do this without the private sector. And we see in the US and UK, the bulk of this discovery happens with taxpayer money in public institutions, and then it’s sold off to private companies who then make it inaccessible to the public who funded it. India is certainly not at that level, but what should be India’s approach to research – public or private?

SS: That’s a very important question. I think we need to have our own model and that model should be that the government has to invest in the basic discovery. Private industry will not. It doesn’t do it anywhere else in the world. We can’t expect our pharma industry to start doing it. So early discovery work, the basic research and development, must be funded by the government. And then, once we create that knowledge and intellectual property, that should be used for public good. Unlike the US, where you mentioned that there’s a double-price being paid by the public. Of course, industry plays a role because they need to produce the product, but they produce it at a price which then becomes affordable for people to use.

RCEP, TRIPS, healthcare, medicines

“Because just doing generics, and now with a patent regime and everything being challenged, sooner or later our population is not going to have access to the drugs we need.” Credit: Reuters

AB: And in India, what would you say has been our approach to this? Have public institutions picked up the slack, or have we been hoping private players will come into it? What exactly has been our legacy here?

SS: We’ve done some. There have been drugs that have come out of the CSIR system for example, which are on the market today. But there could be many more and it could be done much faster. So now what happens, because of a lack of resources, somebody makes a discovery but then to get to the next step – in the West, they say you need a couple of billion dollars to take something from a discovery to a drug in the market. A multinational corporation would take that much. In India, we can do it in 80-100 million dollars. We can actually develop a new drug. But even then, you need that 80-100 million to be available. For example, I know startups now that have got drug molecules to fight drug-resistant bacteria. They need support to do their pre-clinical testing, animal testing and get into phase one human trials. There again we’re hoping to set up some phase one trial centres in public sector institutions in India. So I think 100 million dollars is not a huge amount of money for a new drug, especially if it’s an antibiotic. So we have to think of investing at that scale to be able to do this.

AB: The Indian model has been for pharmaceuticals and has really been about generics. But that also means we have been occupied with the copy model. That we’re very happy to just copy what’s been done by somebody else. Should we remain with that because that’s our strength, and leave it to people who have more money, the 100 million dollars, to do this stuff? Or should we try and do a bit of everything?

SS: I think there’s no choice. We have to do it. Because just doing generics, and now with a patent regime and everything being challenged, sooner or later our population is not going to have access to the drugs we need. So we need to do more in the discovery and our own research and development ecosystem needs to be really geared up.

AB: ICMR seems to have a bit of competition. From what some would call pseudo-science. There’s a lot of pressure in India right now to put focus, money, policy interest into what some would call pseudo-science. What do you feel about that? We have a government-appointed panel which is looking into the benefits of cow urine and its derivatives, with the Ministry of Science and Technology, CSIR on it. I think ICMR has been left out of it. We also have competition from the Ministry of AYUSH. We have herbal remedies that are being recommended to prevent, not just to treat things like dengue. Is there a bit of a crisis? When you say, ‘bring evidence to policy,’ that there was a time in the 1960s when there was a lot of political interest in fostering these kinds of things. But what is the tension right now that is seeing so much importance giving to things like this?

SS: I think the keyword is evidence. And wherever there is a knowledge gap, we need to generate the evidence. If there is already a lot of evidence available, then you need to synthesise it. I mentioned to you that one of the pillars the ICMR strategy now is actually leveraging traditional knowledge. So I think we have a lot of traditional knowledge which is very well accepted and validated but we need to validate it using modern methods like clinical trials. You mentioned dengue. So we’re actually working with AYUSH, with the council for Ayurveda, and doing a clinical trial using one of their products to treat dengue patients. We’re also going to work with the Tamil Nadu government to test nilavembu kudineer for dengue. And papaya extract. Some of these in the lab have shown anti-viral activities. Of course, they need to be tested on dengue patients to see whether they are preventive or reduce the severity of the disease. I think there’s no doubt we need the scientific validation of these claims. And then we’ll have to accept the findings. It could be negative, it could be positive. So I think wherever there are these systems, they are mostly oral systems, traditional systems, and of course, they don’t even use words like dengue in their systems. They have a very different approach to treating humans, a more systemic approach. But I think there’s a lot of scope for us to work together. So we do actually have a partnership with AYUSH. Things like turmeric are now globally accepted for their health benefits. So we can do much more work on using turmeric, say, as an adjunct therapy for malaria or TB. So these kinds of studies can only be done in India. And the Chinese have an edge over us. They have been able to validate quite a lot of Chinese medicine. Because they started many years ago and had a very focused approach. I think if we take that approach, we can probably validate and make globally acceptable some of these treatments. But I think there will be many treatments where we may not find the evidence and then we must be courageous enough to accept that.

The World Health Organisation (WHO) logo is pictured at the entrance of its headquarters in Geneva, January 25, 2015. Credit: Reuters/Pierre Albouy/Files

AB: If there is a mood in the country in the last many decades to explore these areas, I think the mood is certainly now. Over the last three years, we have even had a separate ministry set up for AYUSH. However, when you talk to people who are skeptical about this, for them the question is, “Why would you do clinical trials for a homeopathic cure for dengue?” So when you say: “There are knowledge gaps, and we need to bring the knowledge to fill it up,” there are people who would say that this is criminal to even go this far. What happens to people who put themselves through those trials, or all that money that was invested in something which by and large we know, for those who are skeptical, is not the solution? Earlier this year I had the opportunity to speak to the outgoing secretary of the AYUSH ministry. He said what you said: that these things should often be adjunct, along with something else. But there’s also a mood here that says, “let’s focus on this as the way, truth and life.” How do we resolve this? Is this an expenditure well made? Is this ethical, prudent in terms of our finances to be doing something like this, when there’s already a lot of evidence that says homeopathy may not work?

SS: The way we approach it is we usually set up an expert committee which is composed of people of many different backgrounds and expertise to look at a problem. You’re right, we also have limitations in terms of resources and have to pick the high priority ones and work on that. If they came with a list of 80, we might pick four or five, and go ahead with clinical trials on these first. Because of the disease burden, or because there’s already evidence from long use. So far we haven’t ventured into any homeopathy trials but there are many things in Ayurveda, and similarly, yoga has documented benefits in many conditions, particularly things like hypertension and diabetes, where yoga can possibly have quite a lot of benefits. Here we feel more clinical trials are needed to document [the benefits].

AB: Among the pillars of AYUSH – Ayurveda, yoga, unani, siddha and homoeopathy – homeopathy actually gets the second largest amount of funding. Where do you stand, personally as a scientist, on homoeopathy? Is it something we need to explore, or do you have your conclusions?

SS: My personal opinion is there is no scientific basis for homeopathy. And therefore, there may be people who believe the opposite but I would need to be convinced.

AB: Strongly convinced. Which will really go against the grain of the last many decades?

SS: Exactly

On women in the workplace

AB: Let me just end by asking you to speak about slightly more personal dimensions but also political dimensions. What advice can we give young women, about women doing well in the workplace, about women being on top? What is it that’s keeping women down? Because it’s extremely heartening for me to see that India will be represented at the WHO by a woman. So what is it that you have seen over your many years in public service and what advice can you give young people who want to enter [the field]. If you can speak generally but also about women in STEM.

SS: I think one thing is of course, right from the beginning, you should feel you can achieve whatever your male counterpart or colleague can. Very often girls or young women tend to start off with a premise that they would have to take a little bit of a back seat because of the other demands of the family that come up. One thing is to be very clear that you can do bot because men do both. And be a little more ambitious. Very often we underrate ourselves and think that “I’m not fully ready for that job.” Whereas a man in that same position thinks he’s perfectly ready and approaches it quite confidently, even though he may or may not be. Perhaps women are more sensitive or whatever.

But I think having a little more confidence and ambition, and believing you can do both justice to family and career… At times you do have to make sacrifices. I also think it’s important to have a supportive family. I think if your husband and family are not supportive, then it’s really very hard for a woman to keep pushing against that. But I think now more and more if you assert yourself, if your family sees that you’re so passionate about your job and career, I think they end up being quite supportive.

And role models is the other thing. In the past, we haven’t had too many role models, so we need to really start creating and talking more about role models for young school girls. I’ve had a number of school kids write to me saying they want to do medicine and public health and so on. And then being represented at leadership levels. We’ve seen now there’s a conscious move to have more women in selection committees, to look for women for top positions. I was at an interview today where there were 20 men and one woman who had applied for this job. It was one of the directors of one of the leading institutions in the country. This happens more in some fields like physics, math and engineering. In the biological sciences and life sciences, particularly medicine, the ratio of women to men is much better. But even then when you look around at directors, vice chancellors, you see a clear divide. We’re just not reaching for that because we feel that it’s just not possible to do justice. So it’s more a mental thing.

AB: When you say women underrate themselves, do you also feel that perhaps women have to do more, in the sense, we have to do double? What has been your mantra: just do your work, be honest about it, or, do you have to do extra?

SS: I don’t think you have to do extra-extra. I think the ambience, in a particular place where you work, a lot depends on that. But I never felt I had to do anything different as a woman to be recognised. I think if you do your work and you do it well, you will get credit for it. But it’s important not to just take a back step. When the time comes one should put oneself out there and be counted.

AB: Alright, thank you so much, Dr Swaminathan, lovely to speak to you.

SS: Thank you very much, I enjoyed it.

Note: One of the questions erroneously stated that homeopathy gets the largest amount of funding among the pillars of AYUSH. This has been corrected; it gets the second largest amount.