When I started working on this book many people from the industry told me, "What is not known about Kiran Mazumdar-Shaw that you'd write?". (Plenty, I'd tell them now.) Others said, "How do you think you'd get the story?" On hearing that I was speaking to many, many people, they said, "Ah, then you'd get close to the story". (I'd love to hear from them how close to the story did I eventually get.)
Even after 20 years of journalism, while working on this book I discovered a few things about the art of reporting. Here's some musings I wrote for Scroll:
“So what kind of a biotech book are you writing?” he asked. A busy chief executive of a large Indian pharmaceutical company, he had given me an hour, with the possibility of a few grace minutes, for a “conversation” on the subject. Yes, a “conversation” was what I was seeking with everyone so that they would let their guards down, settle for an informal chat, and not bother about involving their public relations machinery or fret over well-formed quotes.
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Okay, I used these big names in the headline to grab some attention. That said, few would disagree that there’s dire need for such unicorns to emerge in health care so that the benefits of network conditions make health care less expensive, more effective, and above all, participatory in managing chronic illnesses.
One could argue I am hallucinating: A tech-led revolution in a country where most medium and big hospitals have their basic ABCD broken? That’s a neat acronym I learnt from Swami Swaminathan, chairman of Manipal Integrated Services, where A stands for Admission and Appointment, B for Billings, C for Clinical records and D for Discharge. But only when the system is so utterly broken that radical ideas emerge. And as Dr Paul Salins of Mazumdar-Shaw Cancer Hospital says, the real solution lies in moving away from hospital-centric models of healthcare.
That’s the premise with which Axilor Ventures, and its founders, two of them being Infosys co-founders, SD Shibulal and Kris Gopalakrishnan, have started Healiate. It’s a guided innovation challenge to draw entrepreneurs, existing and wannabe, to gaping health care problems. The metaphor couldn’t be more appropriate – Healthcare needs healing, big time.
Moderating a panel discussion and listening to a bunch of passionate and brilliant entrepreneurs, I was clear about one thing: Only preventive and, to borrow Dr Salins’ term, “Interceptive”, healthcare can save India from looming health care catastrophes. To cite an example of "interceptive", Dr Chittaranjan Yajnik, a diabetologist from Pune, has shown that under-nutrition (and/or low birth weight) during pregnancy is linked to adult diabetes among Indians and it can surface as early as four years of age. Can something be done at a population level to correct that?
The larger question though is, unlike medicine which falls under the realm of science, health care is business and hence one needs to ask if preventative care is to be given, who is going to pay for it? At what stage, and how, will people make sacrifices for preventive health care?
One of the entrepreneurs, Siddhant Jena, spoke about his experience of 2009 when he was using phone-based sensors to screen for oral cancer in Karnataka. He found, “People just did not want to know about their cancer”. If individuals are not interested, then who is? Insurance penetration is so sparse that to assume insurers will be happy paying for preventive care so that their customers don’t need to go to the hospital is nothing but woolly thinking.
Can entrepreneurs then work with hospitals to provide such care – to keep people healthy, proactive in keeping their, say, blood sugar or pressure under control – in out-sourced manner?
Screening, counseling and diagnosis-driven preventive care is one where even the locally-developed medical technologies can find a life and business model. Forus Health has found it the hard way and iBreastExam is adopting it from the start. I’ve earlier argued, quite comprehensively if I may add, that diagnostics can be our savior against antibiotic resistance menace too.
There’s another advantage, too. Very few clinicians in this country undertake research -- they are either too busy treating patients (in public hospitals) or too focused prescribing battery of tests in the name of evidence-based medicine. Consequently, they either haven’t figured where to apply emerging technologies or they do not understand the underlying biology enough to “intercept”. In such an environment, entrepreneur-driven diagnostics and devices companies can gather a lot of valuable data which can then lead to further intervention. As Forus found in its screening of a couple thousand drivers that nearly 9 percent of them had colour blindness. Guess how they they managed to navigate traffic signals? By looking at the position of the three lights, not at their colour.
While inaugurating the event yesterday Shibulal said one of the ambitions he has for Axilor and Healiate is to make it the go-to-place for health tech, just as Koramangala in south-east Bengaluru was for IT, nearly two decades ago. At the end of the day I was wondering how apt the Koramangala analogy was.
Just as the IT product companies missed not having a market place – for merger and acquisition-- for the first decade or so, medtech entrepreneurs are groping for one today. Big enough healthcare companies to hunt-and-partner to innovate are missing. Private hospitals do not want or cannot absorb many of these technologies (for various reasons and it’s another story for another day), government hospitals have no money, nor any effective public procurement system.
Perhaps going directly to consumers, showing outcomes, and winning their confidence could be one way forward for preventive care.
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Every once in a while comes a researcher who by the sheer intensity of his visceral interest in a phenomenon, or a nagging question, changes the course of a discipline. Psychiatrist and bioengineer at Stanford University Karl Deisseroth is one such scientist. Former IISc director P Balaram, while introducing him at the TNQ-Cell Press lecture last evening, aptly compared his work to Galileo’s construction of a telescope using which the Italian astronomer, philosopher made pioneering observations about stars and the universe.
Deisseroth has enabled pioneering – making a single cell photosensitive so it can be controlled and studied at millisecond scale -- observations about the brain. He has led the creation of a new discipline called Optogenetics and has developed a chemical engineering technique called CLARITY which, simply put, renders the opaque brain transparent, a see-through object which can then be studied with unthinkable thoroughness.
Over 90 minutes, Deisseroth walked us through the understanding of brain disorders over the past century. The JN Tata auditorium in Bangalore was packed, like bees in a honeycomb; it seemed Deisseroth had inspired one and all just by being there.
I won’t summarize his talk here, for two reasons. One, there are dozens of videos where he talks about his work in very non-geeky ways and this New Yorker profile from 2015 gives a peek into his personality as well. Two, the Chennai publishing company TNQ Books and Journals, which has been organizing and hosting this lecture series with Cell Press for six years, put a condition before the audience, like always. At the end of her inaugural note every year, Mariam Ram, founder and managing director of TNQ and wife of N Ram, former editor of The Hindu, formidably announces that recording of the lecture in any form is not permitted. When the lights are dimmed in the auditorium for the speaker’s presentation, if you are not recording, you can’t get anything worthwhile in long hand. TNQ also doesn’t allow media interviews. In 2008 when David Baltimore kicked off the lecture series, I was at Mint and tried very hard for a sit-down interview with the scientist but I wasn’t successful. (Those days I was also freelancing for Cell and tried that connection too, but no luck.)
Fair enough, if the organizers want it that way -- exclusive access for The Hindu journalists -- no complaints. In any case, isn't media all about control these days?
However, one thing that struck me about his talk, and which Deisseroth also emphasized at the end, was how basic research in the microbial proteins rhodopsins - since they were first discovered in the 1970s as the light-driven ion pump - has enormously contributed to Optogenetics.
This graph illustrates two points: That science stands on the 'shoulder of giants', one of whom is Deisseroth, of course. Secondly, how he, after first few years of struggle – from 2004 to 2009 when he was getting the systems and tools in place – propelled the field into a phase when not only have research findings exploded, they have begun impacting the understanding and practice of clinicians. (The Nature Neuroscience paper cited above contains all that Deisseroth talked about, and some more.)
I bring this up now because under Mr Modi, there’s a new focus on applying research to solve Indian problems. Early last year, Prime Minister Modi visited an energy research lab in Bangalore where he was told the direction of the applications would be clear in six to eight months. I learnt that after six months, the lab began receiving frequent calls from the PMO on the progress and that frazzled the researchers, most of whom do not have bench-to-market cycle in their scheme of things. Later in the year we heard about the Dehradun Declaration for CSIR ,where each lab has been asked to send a report card of its work, list the discoveries which can be commercialized, and prepare to become self-sufficient in two years. Budgets across sci-tech-health have been cut and if adjusted for inflation, most are in the red. (Why CSIR and how it came to this state of reduced-relevance is another story for another occasion.)
Who could disagree with the government’s desire to have Indian scientists and engineers solve Indian problems? But as the bean counting begins, let the decision makers not smother promising ideas and projects in basic research. Efficiency and accountability is one thing, expecting the road to innovation to be linear is another.
Modern scientific advancement is littered with examples where discoveries from completely unrelated fields have yielded useful, commercial results. Take the case of RNA interference, or RNAi, which is the basis of the so-called third-generation biotech drugs. RNAi therapeutics are expected to dominate the treatment regimen after 2020, a sort of post-biosimilars era. They arrived on the scientific application landscape when scientists were trying to manipulate the colour of Petunia – they wanted to make a really purple Petunia and added extra copies of the gene for the extra purple pigment. To their surprise, researchers found some flowers had patches of white and no purple pigment at all. It turned out, in their process of gene manipulation they had silenced some genes. Bingo! They had discovered a method by which genes could be silenced, as it is done in nature. From cancers to Huntington’s disease, the prospects of RNAi in silencing faulty, disease genes are profound.
Under Mr Modi the Delhi bureaucracy, or at least a major part of it, seems to be on steroids. I hope some of the technocrats are able to hold their ground and convince the government that blue sky thinking in Indian labs needs to remain ‘blue’, and not get cloudy.Click here for the full post