In India’s forgotten diseases, an opportunity

Peter Hotez

Innovative developing countries such as India have the capacity to produce a new generation of drugs, diagnostics, and vaccines.

India has the extraordinary opportunity to link its leading government research institutes and pharmaceutical companies in a unique public private partnership to address the diseases of the poor throughout South Asia.

Despite India’s dramatic modernisation over the last decade, it remains “ground zero” for some of the world’s most dreaded tropical diseases. A recent report in The Lancet reveals that 205,000 people in India die annually from malaria, mainly in Orissa and the surrounding states of Chhattisgarh and Jharkhand, with almost one-half of those deaths in children. Similarly, India and its South Asian neighbours account for one-quarter of the world’s intestinal worm infections such as hookworm and roundworm, and more than one-half of the world’s cases of elephantiasis, leprosy, and visceral leishmaniasis (VL). The State of Bihar alone accounts for a large percentage of the world’s cases of VL, a serious parasitic infection also known as kala-azar that affects the bone marrow, liver, and spleen, and is associated with high mortality. Thus, while much of the global health attention is largely focused on sub-Saharan Africa, the truth is that India and adjoining Bangladesh, Bhutan, Nepal, Pakistan, and Sri Lanka are just as devastated by neglected tropical diseases (NTDs).

A little known fact about NTDs is that they not only adversely affect the health of the poorest people in India and elsewhere, they also have the capability to cause and prolong poverty. For instance, the disfigurement and swelling of the limbs and genitals resulting from elephantiasis prevents adults from going to work or working effectively. Dr. K.D. Ramaiah of the Indian Council of Medical Research in Pondicherry has estimated that India suffers almost $1 billion in annual economic losses as a result of this NTD. Similarly, chronic hookworm infection occurring in over 70 million Indians stunts the growth and intellect of children to the point where a child’s future wage earning is reduced more than 40 per cent. In the first-ever comprehensive report on NTDs released in October, the World Health Organization (WHO) reported the economic burden of dengue costs India $30 million annually. NTDs can impoverish entire families and communities. The bottom line is that NTDs are one of the reasons why India is trapped in a vicious cycle of poverty.

The good news is that India is beginning to fight back and show global leadership in solving its own NTD problem and, to some extent, the challenge of NTDs among its neighbouring countries. According to the World Health Organization, the Indian National Vector Borne Disease Control Programme has scaled its mass drug administration programme to treat 85 per cent of the 600 million people at risk in India for elephantiasis. As a result, the overall prevalence of this disease in India has been cut in half since 2004, and there is the prospect that this ancient condition, which has affected the people of India for centuries, could be eliminated in the next decade. Similarly, India is aggressively implementing leprosy elimination through multi-drug therapy programmes, while in 2005 the governments of Bangladesh, India and Nepal signed a memorandum of understanding to eliminate kala-azar by 2015, with an emphasis on the border districts of these three countries where more than 50 per cent of the cases occur. Another notable achievement for India was the elimination of yaws in 2006, a chronic infection affecting the skin, bone and cartilage.

With these successes, India has the opportunity and indeed the moral obligation to take these NTD control and elimination activities to a higher level. India, together with nations such as Brazil and China, are sometimes referred to as innovative developing countries (IDCs). The concept of the IDC refers to the fact that while these countries may have chronic and debilitating poverty and high NTD prevalence, they also benefit from having top universities, medical research institutes and biotech companies. The track record of scientific publications and patents among the IDCs indicates that nations such as India have the capacity to produce a new generation of drugs, diagnostics, and vaccines for NTDs such as hookworm and kala-azar which require technologies in order to ensure that they can move towards disease elimination.

However, a big problem with new biopharmaceuticals for NTDs is that these products will almost certainly not become money makers. Almost by definition, NTDs occur exclusively among people living on less than $1.25 (or roughly Rs.56.4) per day. The people who need new NTD vaccines and treatments the most can never afford to pay for it. Hence, there is no financial incentive for India’s private industry to embark on research and development activities for NTDs. Therefore, India urgently needs new strategies to link its government institutions and its powerful private biopharmaceutical companies together in a public-private partnership to stimulate innovation for the poor. Examples of this include a handful of non-profit product development partnerships (PDPs) supported by the Bill & Melinda Gates Foundation and sources. The PDPs include a joint venture between Merck & Co. and the U.K.’s Wellcome Trust, which is now being established in New Delhi. Brazil has set a strong example through two well-established public vaccine manufacturers, FIOCRUZ and Instituto Butantan, that collaborate with PDPs, including the Sabin Vaccine Institute, where I serve as president. As a result Brazil is producing a new generation of NTD vaccines.

The reason there are not more than a handful of PDPs is the dearth of adequate government funding specifically targeting PDPs as well as well-financed private philanthropies beyond the Bill & Melinda Gates Foundation. In addition to increased support, there are formidable obstacles for applying complex technologies to solving global infectious disease problems, working with national regulatory authorities in low- and middle-income countries, and the difficulties of conducting clinical trials in resource poor settings.

Having had the pleasure of meeting the current and past leadership of the Indian Council of Medical Research, I know first-hand that a vision does exist that can link industry, government and the PDPs in an innovative partnership to address diseases of poverty.

An Indian public-private partnership for NTDs could produce a new generation of drugs, diagnostics, and vaccines that will benefit all of South Asia, and indeed the entire world’s “bottom billion” — the 1.4 billion people in the world who live in extreme poverty. Innovation for the poor could truly become India’s greatest gift to the world.

(Peter Hotez is president of the Sabin Vaccine Institute, a product development partnership for NTDs, which also hosts the Global Network for Neglected Tropical Diseases. He is the author of Forgotten People, Forgotten Diseases.)

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