India’s watchdog: A breath of fresh air

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(I met Sunita Narain, the charismatic leader of the Center for Science and Environment, while on a reporting trip to Delhi about Indian science. She’s extremely press-savvy, so I was certainly being shown what she wanted me to see, but after several disheartening interviews with government officials about AIDS and other pressing issues, I couldn’t help but be impressed with her efficient and single-minded approach. Nothing is simple in India, as even this article, which began as a straightforward profile of this organization, shows. The feature appeared in Nature in February 2007. You can download a pdf of this article.)

How often does independent research change laws as well as minds? A lobby group in Delhi is forcing the Indian government into new regulations. Apoorva Mandavilli meets its leader.

Sunita Narain

A decade ago the city of Delhi was choking. Fumes from the growing traffic rendered the air thick and foul with toxic chemicals, earning India’s capital city the dubious distinction of being the fourth most polluted city in the world. Levels of fine particles in the air were nearly 17 times higher than the permissible maximum. You could almost feel them as you breathed.

Visit Delhi today, and the difference is palpable. Green-striped buses and auto rickshaws rush past powered by compressed natural gas. Levels of sulphur in diesel have been brought down from 2,500 parts per million to 500 parts per million. Concentrations of particles in the air are still three times the national standard, but more bearable — the air feels unmistakably cleaner.

The improvement is largely due to the efforts of one small non-governmental organization, the Centre for Science and Environment (CSE). Founded by the science journalist Anil Agarwal in 1980, the Delhi-based group launched a relentless campaign in 1996 to replace diesel in Delhi’s public transport with a cleaner fuel: compressed natural gas. Its headline-grabbing tactics were what you might expect from a group founded by a science journalist: at one point it hired a booth at a Delhi car show and offered attendees lung tests. In April 2002, after years of legal battles, India’s Supreme Court forced Delhi’s public vehicles to switch to compressed natural gas. “It’s undoubtedly one of the most influential organizations in the country,” says Mahesh Rangarajan, a former Rhodes scholar and commentator on Indian politics based in Delhi.

So how did a small band of campaigning journalists evolve into a respected environmental pressure-group powerful enough to change laws and send multinational companies running for cover?

Petition aims to maintain cheap drugs

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(This article appeared on Nature’s news site on January 15, 2007.)

Court case in India threatens to derail generic medicines.

Free for all? Patent laws can make or break generic drug production.

The international humanitarian group Doctors Without Borders (Médecins Sans Frontières, or MSF) is ramping up their fight against the Swiss drug giant Novartis, urging the company to drop a lawsuit that could make it much more difficult for Indian companies to produce cheap, generic drugs.

With the case expected to come up for hearing on 29 January, MSF is pumping up efforts to collect signatures on a petition against the suit. Already they have tens of thousands of names, but are aiming to get many more. A win for the pharmaceutical company, they say, would deprive the world’s poorest people of affordable medicines.

Indian companies are known for making low-cost copies of expensive medicines, particularly AIDS drugs. More than half of the antiretroviral drugs used in developing countries, and about 80% of those provided by MSF, are made by Indian companies. “India is the pharmacy for the developing world,” says Ellen ‘t Hoen, director of policy advocacy for MSF’s Campaign for Access to Essential Medicines. “We largely depend on India.”

Business: Reinventing an industry

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(I reported this article when I was in India in 2006. Typically, I did not manage to get an interview with Kiran Mazumdar-Shaw till my uncle pulled some strings. Nature has less power in India than nepotism. Also, I’m proud of the fact that, along with an article I wrote about a famous Indian advocacy group, I managed to get photos of two Bollywood stars into Nature. You can download a pdf of this article.)

Two years after a radical change that brought India’s patent laws into line with international trading rules, the country’s drug makers are taking a new direction.

Star turn: Actor Shah Rukh Khan (left) helps Biocon’s Kiran Mazumdar-Shaw launch BIOMAb-EGFR.

Kiran Mazumdar-Shaw is India’s uncrowned queen of biotechnology. She started her company, Biocon, in a garage in 1978 with just Rs10,000 (US$225) in working capital and has built it into the country’s largest biotech company, with 1,800 employees and revenues last year of $180 million.

Said to be the richest woman in India, Mazumdar-Shaw was in the spotlight last September when her Bangalore-based company launched the first new drug to be developed, tested and taken through approval by an Indian company. The drug, BIOMAb-EGFR, is a monoclonal antibody for treating head and neck cancers.

This could be the harbinger of a brighter and more innovative future for India’s drug industry, which until recently relied on sup- plying cheap ‘generic’ copies of drugs — many of which were still under patent elsewhere.

That all changed in January 2005, when India brought itself into compliance with the Trade-Related Aspects of Intellectual Property Rights (TRIPS) — international rules that forbid the copying of patented drugs.

The transition has gone smoothly. “Companies are playing by the rules,” says Frederick Abbott, a professor of international law at Florida State University who knows the Indian drug industry well.

Polio’s return traced to lapses in India

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(This article was #60 in Discover Magazine’s top 100 stories of 2006.)

In May a 39-year-old man in Namibia tested positive for poliovirus, marking the country’s first case in 10 years. Since then, the outbreak there has reached 20 confirmed cases.

This year 10 other formerly polio-free countries are once again battling the disease. Genetic sequencing has traced cases in five of the countries, including Namibia, to a polio strain in India, where the virus remains endemic. As of October 2006, a total of 358 cases have occurred in the poor, densely populated north Indian state of Uttar Pradesh alone, up from 29 in 2005.

The World Health Organization has taken India to task, saying its outbreak is endangering efforts worldwide to keep the disease at bay. To protect a high-risk community from polio, at least 95 percent of the children must be vaccinated; but in late 2005 and early 2006 the vaccination rates in Uttar Pradesh dipped to between 85 and 90 percent.

The Indian government, vowing to eliminate polio by 2007, has discussed a pilot project using an injectable vaccine in addition to oral drops. The injectable vaccine is thought to offer better protection against polio infection in children with diarrhea, which is common in the area.

Health agency backs use of DDT against malaria

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(Nature asked me to write this article after the editor saw my feature in Nature Medicine on DDT’s return. The feature came two months ahead of the announcement that the WHO would back DDT. This article appeared the week after the announcement, in the 21 September 2006 issue.)

After decades of being shunned 
as an environmentally damaging chemical, the pesticide DDT is once again being touted as the most effective way to fight malaria.

The World Health Organization (WHO) announced on
15 September that it will support the indoor spraying of pesticides generally, and DDT specifically, to control mosquitoes in countries with high rates of malaria. The US Agency for International Development signalled a similar shift in policy back in May.

Although these agencies never formally opposed DDT, they did not fund countries to purchase it, and instead actively promoted the use of insecticide-treated bednets. Malaria rates have continued to rise in the meantime, claiming more than a million lives a year, mostly in sub-Saharan Africa. The agencies now advocate combining the two approaches.

“I have to pinch myself a little to believe that they’ve done this, but I’m really, really happy they have,” says Amir Attaran, professor of law and medicine at the University of Ottawa, Canada, who has long criticized the agencies for their malaria policies.

In sharp contrast to its previous stance, the WHO also admitted for the first time that it stopped supporting DDT despite evidence of its effectiveness. “There are 
lots of data there, but people are 
so emotional about the issues,” says Arata Kochi, director of the WHO’s Global Malaria Programme. “Science comes first and we must take a position based on the science and the data.”

DDT, or dichlorodiphenyl-trichloroethane, is an organochlorine that is more effective, cheaper and longer-lasting than the alternatives. Fears about its use date back to the 1960s when Rachel Carson’s book, Silent Spring, famously chronicled its devastating effects on the environment. In the years that followed, the United States and many European countries banned DDT.

These countries once used thousands of tonnes of the pesticide for agricultural purposes. But the use of DDT for malaria control is very different: small quantities are sprayed once or twice a year on the inside walls and ceilings of houses.

Following widely publicized success with DDT in some countries such as India and South Africa, others began clamouring for the pesticide. “A lot of countries, especially in southern Africa, have become bullish about the use of DDT,” says Richard Tren of the non-profit group Africa Fighting Malaria.

PDF: Health agency backs use of DDT against malaria

Make anything, anywhere

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(I wrote this article for Nature in August 2006. I spent a day at the FabLab outside Johannesburg, South Africa, amazed in particular at the unusual projects that housewives dreamed up. I was also convinced I would never make it out of Johannesburg alive, but that’s a story for another day. You can download a pdf of this article.)

Can everyone use technology creatively? Engineers at the Massachusetts Institute of Technology think so and have launched ‘Fab Labs’ around the world to prove it.

Valentina Kwofie, electronics pioneer

Neil Gershenfeld has been teaching a class called “How to make (almost) anything” to some of the brightest young adults in the United States for years. But it took an eight-year-old girl in a small village in Ghana to show that anyone, any- where, really can make just about anything.

One evening in June 2004 — the day after Gershenfeld had left Ghana having taught a week-long version of his class in the village — little Valentina Kwofie began cobbling together a circuit board.

Hours passed. Several times Kwofie’s par- ents stopped by the lab Gershenfeld had set up, imploring, “Valentina, let’s go home, let’s have dinner, let’s go to bed.” It was the first time any- one in the village, Takoradi, had made a circuit board: people crowded around, watching her nimble fingers manoeuvre parts half the size of a grain of rice. Finally, long past her bedtime, she crafted a board that worked.

Gershenfeld, director of the Center for Bits and Atoms at the Massachusetts Institute of Technology (MIT), hadn’t known what to expect when he put the fabrication laboratory, or ‘Fab Lab’, technology that he worked with at MIT into the context of rural Africa. What he got was inspiration. “This eight-year-old girl in Ghana was making microcontroller circuit boards for the love of it, for the joy of discovery,” he recalls. “That ordinary people can do it and want to do it was very surprising.”

The Fab Lab in which Kwofie made her circuit has been followed by others around the world, each equipped with the same key machines. Today, there are ten Fab Labs — above the Arctic Circle in Norway, in Costa Rica, India and South Africa — and within the next year, fifteen others are planned, of which five will be in Africa.

Together, these labs are showing that giving people the ability to make things for themselves can be the fastest way to solve their problems, particularly in communities with little access to education or technology.

Visual neuroscience: Look and learn

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(For me, this story, published May 2006, had the perfect blend of basic neuroscience, public health implications and human interest. You can download a pdf of this article.)

Prevailing wisdom says the adult brain cannot learn to see if it had no visual stimulation during childhood, but blind people in India seem to be breaking all the rules.

After 29 years of being officially blind, SK is learning to see — and defying neuroscience in the process.

Doctors gave SK his first pair of glasses in July 2004. He had been too poor to afford a pair before — but then he was a 29-year-old blind man, what use were glasses to him? Had he been given glasses as a child they might have helped him overcome his congenital aphakia — an extremely rare condition in which the eyeball develops without a lens. Yet his chances of being diagnosed, let alone treated, in the poor Indian village in which he was born were slim. As a result, SK was living in a ‘hostel for the blind’ with no running water when the doctors arrived from New Delhi.

SK’s doctors weren’t sure how much sight he would gain, or if he would comprehend what he saw. For the first year, he had only the most basic visual skills. He could recognize simple two-dimensional objects but anything three- dimensional, even an everyday object such as a ball, was beyond him. All this was consistent with the idea of a ‘critical period’ in vision: that if you haven’t learned to see by a certain age, you never will.

But 18 months after getting his glasses, SK surprised everyone. He had begun to make sense of his world, building his visual vocabulary through experience and recognizing more complex objects with varying colours and brightness. In doing so, he turned one of the most fundamental concepts in neuroscience on its head.

“Twenty-nine years without any normal vision? I would have said that’s a life sentence,” says Ron Kalil, a visual neuroscientist at the University of Wisconsin in Madison. For Kalil and other experts, the impossible now seems possible. And while the scientists might be amazed by the brain’s adaptability, the real winners are the countless blind people — both children and adults — who had been considered untreatable.

The coming epidemic

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(Reporting on this article was one of the most emotional experiences of my career. I met many, many sex workers, drug addicts, activists, truck drivers and housewives who had never heard the word AIDS before they were told they were dying from it. As someone born and raised in India, I found the many individual stories heartbreaking, and the denial of the officials deeply sad and scary. This article appeared in Nature in July 2005 as part of a special package on Indian science called Nature Outlook: India. A couple of years after the article appeared, the Indian government revised its numbers drastically downward. I’m deeply skeptical of its estimates, but haven’t yet been able to dig into the truth. You can download a pdf of this article.)

A staggering 5.1 million people are estimated to be HIV positive in India. Apoorva Mandavilli finds a country on the brink of a crisis.

Our son was born in June 1998. He was healthy but after eight months, he had diarrhoea and fever all the time. He was in the hospital many times. The sixth time, they diagnosed him with AIDS. That was when we found out that my wife and I have HIV. Our son died 12 July 2002. I also started to get sick. I didn’t take my medicines regularly; they didn’t tell me not to do that. Now my health has become worse. I haven’t worked in six months.We’ll be paupers. I don’t know what we’re going to do.

— Suresh, air-conditioning technician

Suresh is sitting in a small, dark room at an AIDS clinic in the southern Indian city of Chennai. This city is where the first cases of HIV in India were discovered in 1986 after a police sweep of sex workers. Nearly 20 years later, there are an estimated 5.1 million cases in India, a number second only to that in South Africa. The difference is that in India the epidemic has not yet peaked. According to the CIA, the number of cases in India could top 20 million by 2010.

Seeking care

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(This is a sidebar to The coming epidemic, an article about the AIDS epidemic in India, and part of a special package on Indian science called Nature Outlook: India.)

When you’re trying to manage an AIDS epidemic and you have limited resources, preventing infection is the logical priority. But where does that leave those who are already infected?

Treating people with AIDS is not easy. At the very least, it requires trained medical staff and the resources to make sure patients take the drugs on time. Nobody knows that better than the doctors at Tambaram Hospital.

Built in 1928 as a sanatorium for patients with tuberculosis, the government centre is 45 km outside Chennai and has more AIDS patients than any other Indian hospital. There are often more than 900 inpatients for its 776 beds, so some have to sleep on the floor. Every hallway is flooded with patients who look skeletal, with shrunken limbs and sallow skin. Outside the wards, hairy black pigs roam beneath drying laundry, accompanied by the rancid smell of sewage.

The hospital was one of eight government centres that together were meant to roll out antiretroviral drugs (ARVs) to 100,000 people over five years. In the first year, which began April 2004, it treated fewer than 1,000.

“From the outside, you may think it is a low number, but for people working here, there are a lot of problems,” says S. Rajasekar, the hospital’s deputy superintendent. Despite repeated requests, he says, the centre has the same resources it did in 1993, when it had just two HIV-positive patients. In 2004, it saw 14,991 new patients and had 140,000 hospital visits from HIV-positive patients. “With just 25 doctors,” says Rajasekar. “Amazing, right?”

By June 2005, government centres, including Tambaram Hospital, had doled out ARVs to 8,000 people. In the same time, since April 2004, small private and non-profit clinics reached an estimated 30,000 sufferers. But these clinics are in a constant struggle for survival.

One such centre is the Naz Foundation’s orphanage in New Delhi. Of the 24 children there — ranging in age from 19 months to 17 years — 10 are on ARVs. Despite one child dying two years ago, only the oldest one knows that she is HIV positive. To spare the children from stigma, their status has also been kept secret from their teachers and neighbours.

One child’s monthly supply of ARVs can cost about Rs900 (US$20). The home was funded by the Gere Foundation until March 2005, but since then money has come almost entirely from small, private donations. “Care is something no traditional donor wants to fund,” says the centre’s director, Anjali Gopalan. “They see it as a black hole, as one donor told me. There’s no return on the dollar.”

Scrambling to treat their patients, doctors at some clinics use medicines that are past their expiry date; others bring free drugs they are given in the United States or elsewhere. Staff at the YRG Care Clinic in Chennai last year began asking people to donate just $10 each. “It’s always beg, borrow, steal, donations, fundraise. That’s how we get funds for care,” says Suniti Solomon, who runs the
YRG. “We cannot save the millions out there. The government has to do that.”

The epicentre

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(This is a sidebar to The coming epidemic, an article about the AIDS epidemic in India, and part of a special package on Indian science called Nature Outlook: India.)

In Bangalore, the bustling capital of the southern state of Karnataka, people drive shiny new cars, work in gleaming new buildings and carry mobile phones. Just a few hundred kilometres north, the residents are poorer than many in sub-Saharan Africa. In Bangalore, dubbed India’s Silicon Valley, the land is green, but here it is brown and dry. This is the home of one of India’s two AIDS hotspots.

“Someone’s got to wake up to the fact that there are two Karnatakas,” says Ashok Alexander, director of Avahan, the Bill & Melinda Gates Foundation’s AIDS programme in India.

Driven by poverty and unemployment, women from northern towns such as Bijapur and Belgaum travel across the border to work as prostitutes in the richer cities in the adjoining Maharashtra state. When they return home, they bring the money they’ve earned — and HIV. On a map (right), the districts along this ‘AIDS corridor’ are immediately visible. “This is the epicentre of the whole Indian AIDS epidemic,” Alexander says.

He has discussed his theory with several people in the government. “We entirely agree with him because those pockets are surely high-prevalence,” says S. Y. Quraishi, director-general of the National AIDS Control Organization.

Yet until Avahan — meaning ‘call to action’ in Sanskrit — was launched in April 2003, Karnataka was largely ignored by AIDS groups. Most donor agencies ‘adopted’ other high-prevalence states: the US Agency for International Development earmarks its money for Tamil Nadu and Maharashtra, for instance, and Britain’s Department for International Development champions states such as Andhra Pradesh.

Avahan has already spent more than US$17 million working with sex workers, truck drivers and drug users. It is also backing research on migration patterns in the corridor, large-scale surveys to measure behavioural changes and mathematical models that chart the epidemic’s course. “We’re going to be here as long as it takes to make an impact,” says Alexander.