India is at crossroads in the field of healthcare delivery and research. It is in that peculiar phase of transition when old maladies like malaria, dengue, diarrhoeal diseases, tuberculosis, etc. have not left it while non-communicable diseases (NCD) such as cancer, diabetes and cardiovascular are increasing in burden. It is multiple whammies for our population and policy makers.
What are required are innovative solutions that can only be conceived and proven by competent health and life science research. Unfortunately, originality and creativity are rare traits–not inherently so but by habit and circumstance. Researchers, including in the field of cancer, quickly realise that to get 'grants' one needs to formulate 'fundable' projects. Never mind the fact that the same question (if indeed the research project has a question) has probably already been answered multiple times over. Because of this 'me too' proclivity, very few research projects that have the potential to make a real impact on the cancer scenario get written or funded. One reason for this systemic neglect is the singular lack of appreciation of the enormous potential and power of clinical trials. Cancer care has progressed in most advanced countries as a direct byproduct of high quality evidence generated by meticulously planned and executed clinical trials in the past four decades. Unfortunately, there isn't a single agency that has earmarked dedicated funding for this activity.
There are several honourable exceptions to this rather pessimistic scenario. For example, in recent years, several clinical research projects, such as those involving questions of surgery in oral and breast cancers and common problems in India, have been presented and published to worldwide acclaim by researchers at Tata Memorial Centre (TMC). Furthermore, these trials have changed clinical practice, not only in India, but all over the world. These trials were conducted on relatively small budgets, much less than the fashionable cancer research projects that are usually funded in our country, but provided enormous bang for the buck.
Cost effective, widely implementable solutions to uniquely Indian diseases like cervical and gallbladder cancers need to be conceived and implemented. As an example, the public health trial of community level screening for cervical cancer using a robust technique called acetic acid visualization by researchers at TMC, has proved beyond doubt that it is possible to reduce deaths due to this disease. This was achieved using trained healthcare workers to implement this technique in the community. As another example, indigenous radiation equipment, now widely available in many centres in India and other countries, was developed as a collaborative project between Department of Atomic Energy and TMC.
We have to recognize the fact that good, practice changing and lifesaving cancer research costs money and human resources. Our health research grant providing agencies such as DBT, DST, ICMR etc. have budgets that are woefully inadequate by any yardstick. Unless attention is focused on remedying this situation, we will lag much further behind than we already are. Further, these agencies have to acknowledge the utility of clinical research in solving Indian cancer (and other NCD) problems and allocate a considerable fraction of their budgets to this enterprise. The entrenched system of allocating a vast fraction of their grant budgets only to 'highbrow' (but esoteric, completely unrelated to Indian problems and often replicas of western originals) research has to be broken, for this to be achieved.
Finally, we need to create a cadre of high quality, thinking clinician-scientists who can bridge the span between laboratory, clinic and community level research. This is potentially the most vital link in the chain of creating a cancer research enterprise that will provide solutions to our cancer-related health problems in the years to come. Innovative, 'out of the box' modifications of our education and training system will be required for this to be achieved. We will need to be ready to exit our zones of comfort.
In Dickensian parlance, it is the best of times, it is the worst of times, it is the age of wisdom, it is the age of foolishness, we have everything before us, we have nothing before us.
Dr. Sudeep Gupta is Professor of Medical Oncology, Deputy Director, ACTREC, Tata Memorial Centre, Mumbai
