Guest Article: Indian Medical Institutions need to break the bottleneck of their research activities: Unmet need for health care

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By Saurabh Mandal
Email- mandalsaurabh93@gmail.com

The COVID-19 pandemic has turned the attention of everyone, toward scientists and researchers across the globe. Because, the general public is eagerly waiting for a vaccine or any targeted therapy, no other disease outbreak had seen such a situation before. It was 11thMarch 2020, when the World Health Organization (WHO) has announced COVID-19 as a pandemic. Since then, India is trying hard to suppress the virus spread. India became the second worst-hit nation in the world by the second week of September 2020, which has now crossed 8 million total cases and in the worldwide number reached around 47 million. It is observable that India’s daily testing capacity has increased drastically. Simultaneously, the country’s recovery rate has also started increasing every past day.

The mortality rate of India is still among the lowest in the world. The question here arises, how it is happening? Many researchers have deciphered the enigma which possibly playing a diverse role within the Indian population in providing immunity coverage against Coronavirus. Critical research literature reviewed the role of the Bacillus Calmette Guerin (BCG) vaccine from different perspectives. In particular, about India, researchers see a profound correlation between hidden immunity against COVID-19 and the BCG vaccine which is given to every child born in India. Therefore, researchers recognize the BCG vaccination as a reason for lower fatality among Indians.
However, WHO has avoided endorsing the possible effect of BCG vaccination, said there is no evidence found in their study that the BCG vaccine protects people against the COVID-19. While, many organizations worldwide are conducting clinical trials and India’s medical governing body, the Indian Council of Medical Research (ICMR) has also approved the clinical trial for the BCG vaccine on elderly patients for coronavirus treatment.

Further, Indians are exposed to a wide range of microorganisms throughout their life which in response provides heavy immune protection. On top of that, an unexpected immune-boosting coming from the ingredients used in the Indian foods which are basically phytochemicals, that exerts enormous biological properties. Interestingly, Indian has distinctive genetic makeup from any other ethnic group such as (1) Indian population immune response genes are genetically diverse (2) There is allelic variation in SARS-CoV-2 receptor angiotensin-converting enzyme 2 (ACE2) which affecting the susceptibility (3) Role of specific small Non-coding RNA (miRNAs) playing critical role (4) Natural killer (NK) cells percentage among Indian is higher in compared to other ethnic groups.

Despite all, the COVID-19 pandemic has exposed the country’s inadequate healthcare infrastructure, poor access to medical facilities, high-cost treatment, and shortage of doctors, medical staff w.r.t population. Well, health inequality is not new for the global population but it is not inevitable. We need to accept that India was unprepared for this havoc. Moreover, the low health investment within the country can’t be ignored. Anyhow, the country’s healthcare budget, that needs to be boosted.

The COVID-19 outbreak has also changed the way of doing research work around the world. A different level of pace and momentum can be seen. This is for the first time when so many researchers in the world are working on the same topic. Even, India somehow managed to shine in the global coronavirus research dashboard on the number of research papers.

The Dimension database analysis by November 2, 2020, shows that 5,041,986 academic publications have been published till now in which, coronavirus research publications consist of 1,86,288. The United States of America (USA), France, and the United Kingdom (UK) are the leading contributors followed by Spain, Italy, Canada, etc. including India. While, in 2019, the total research publications were 5, 590, 041.

What is impeding India in leading the global coronavirus research? Somewhere down the line, it is the serious biomedical research bottleneck at medical institutions across the country. ‘The Lancet’ in 2016 has published a report and described the sorry state of medical research in India.

The Lancet report figures have shocked everyone, that from 2005 to 2014, 332 out of 576 (~57%) medical institutions have not published even a single research paper. Over the same ten years, the total research output of the Massachusetts General Hospital, USA, and Mayo Clinic, USA has 46311 and 37633 publications respectively. These many publications were nearly four times more than what India’s prestigious medical Institute, All India Institute of Medical Sciences (AIIMS), New Delhi has published at that time.

However, it was also estimated that whatever the publications coming in medical science, those are from some of India’s medical institutes who always holds the top-ranking position. Even today, according to the Microsoft Academic database, it is only AIIMS, India who has marked its presence at rank 55th in the list of institutions working on coronavirus research worldwide. However, this particular rank is only in the publication category. Since, there are other categories too like saliency, prestige, citation, and H-index. Unfortunately, in other categories, no Indian Institutes got rank.

The Lancet report has withdrawn huge criticism, and then the Medical Council of India (MCI) in 2018 has made necessary changes in the syllabus of medical education after more than two decades. One of the key changes is ‘introduction of elective subject’ in which before the final year, medical students can opt for 8-week training in the various areas of medical science like genetic engineering, biomedical engineering, psychology, health economics, and research. These changes are like a seed that will bear fruits only if planted in the right way.
Similarly, MCI has brought new guidelines in 2019, stressing the need for research papers as a minimum requirement for the postgraduate teacher of medical institutions. Later, due to an unhappy response from the medical fraternity, MCI has relaxed the norms.

The habitual reasons cited by the medical institutions are lack of funds, infrastructure, and overburden of patient care duties. At a certain limit only, such reasons sustain, but at a deeper level, it appears a dearth of research spirit and scientific temperament in the medical institutions. Medical education needs continuous research activities and that will keep evolving the domain.

Well, some strategies can give momentum to the stagnant situation. Research-based learning should be adopted from the beginning of the undergraduate program. Research methodology and Publications should be prioritized. The faculties should focus on building inter-institutional collaboration with life sciences, biotechnology, or other applied science researchers. There is a need for a hassle-free platform for researchers and the health practitioners basically to address the funds acquisition process, project proposal clearance, research work-related ethical concerns followed with awards, rewards, and incentives to keep the morale up.

India is the second-largest populated country and the population is regionally diverse and ethnically variant. The Indian population disease profile, their susceptibility, immunity level, and drug response have peculiar characteristics and such a patient pool makes it, a Holy Grail for whole Indian medical research.
In this unprecedented COVID-19 situation, the medical professionals are the frontline corona warriors who are leading the battle from the front. Concurrently, doctors say that they have learned a lot and made them more confident.

But, some questions remain unanswered that why we were not prepared or how much we were prepared?
From the beginning, if the intense research activities would have been there in medical institutions then perhaps the scenario could have been different. Firstly, one could have expected that the drug development process could be faster based on the information gleaned by the medical scientists on severe acute respiratory syndrome (SARS) viruses which caused the epidemic in 2002. From the beginning of SARS-CoV-1 infection followed with SARS-CoV genome sequencing project completion, the Chinese researchers were actively involved in SARS virus research to channelize the vaccine development process. This is one of the reasons, why Chinese organizations seem to be front runners in the new vaccine development race.

Secondly, India is recurrently facing the shortage of testing centers and skilled manpower to carry out the Real-time Polymerase Chain Reaction (RT-PCR), regarded as the gold standard COVID-19 test. Therefore, the test reports are not being generated timely. RT-PCR is a highly sensitive and widely used molecular biology technique especially among life science and biotechnology researchers.

The chances of mistakes remain high when agencies try to train the general technical persons to do RT-PCR. So, cell and molecular biology techniques must be taught in every medical course robustly with exhaustive practical experiments.

On the other side of the coin, the story is evident, India is the third country in the world after China (Rank 1) and the United States of America (Rank 2) in the publication of the scientific articles in science and engineering, says recent National Science Foundation (NSF), USA report. In that, research publications contribution are majorly comes from different research labs under the Department of Biotechnology (DBT), Department of Science & Technology (DST), Council of Scientific and Industrial Research (CSIR), Institutes of National Importance such as the Indian Institute of Technology, Indian Institutes of Science Education and Research (IISER), National Institutes of Technology (NIT), Indian Institutes of Information Technology (IIITs) and many public and private universities, etc. Although, India’s National Gross Expenditure on Research and Development (GERD) in science and technology is just around 0.7% of Gross Domestic Product (GDP). This spending is extremely low in comparison to many developed nations and even emerging economies.

Today, various research labs are finding new ways to diagnose, and treat all types of diseases with potential drugs, devices, methodologies, and protocols but medical professionals need to coordinate to translate those new findings for clinical purposes. Unless, medical institutions do not develop generous intent for research, till then it will remain unfeasible to flourish evidence-based treatment and to accomplish better patient care. However, the government also needs to invest strenuously in the research ecosystem to encourage researchers and public health practitioners for translating the discoveries from bench-to-bedside. Otherwise, it will always remain tough to confront a situation like COVID-19 which is challenging the survivability of the human race.

References

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Disclaimer: These are the author’s personal views. Saurabh Mandal is a 4th year Ph.D student at Manipal Institute of Regenerative Medicine, Manipal Academy of Higher Education, Bangalore, Karnataka, India.

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