A research controversy

A Kerala Government move to allow Johns Hopkins University to establish a Rs.700-crore institute to promote multi-disciplinary studies, research and training in public health has kicked off a debate.

A PROPOSED move by the Kerala Government to allow Johns Hopkins University to establish a Rs.700-crore institute in Munnar to promote multi-disciplinary studies, research and training in public health has kicked off a debate on public health care in the State, which has a significant record in this field.

According to privately-circulated concept papers that outline Hopkins' plans, the institute proposes to train public health professionals from Asian countries and evolve strategies for disease control and prevention. Envisaged as a sort of community-based school on a 72-hectare campus in the hill-station that abounds in tea and cardamom estates, the papers say that it will be run as a non-profit, autonomous organisation that will be governed by an international board. The academic programme is to be handled by Hopkins with support from regional universities and health agencies in Asia. A network of teaching and experimentation centres covering every region of Kerala, and perhaps some other States, is proposed to be established. The concept paper says the institute and its network offer "potential for extensive population-based trials" which will benefit Asian nations, and particularly their basic industries.

The money for the project is to be mobilised from "corporate donors, regional nations and international donor organisations." Hopkins expects the State Government to provide land, road access and other infrastructural facilities free of cost.

The project, which was initiated by the former United Democratic Front Government headed by Chief Minister A.K. Antony, has drawn criticism from public health experts, doctors and policy planners. Critics fear that the institute will provide a cover for extensive trials of drugs and vaccines on local people. Some others question the very need for a Rs.700-crore institute, particularly in a State where other institutions are doing significant work in the area of public health research. They ask how far an "Asian institute" that is funded by corporate donors (including, presumably, multinational pharmaceuticals) will advance the particular interests of Kerala, or of India. Some see the institute as an instrument of "academic colonialism".

Following the criticism, the Left Democratic Front Government, which had welcomed the Hopkins proposal initially, appeared to distance itself somewhat from the project. Along with Hopkins University, it was to have hosted an international seminar, "Public Health Asia 2000", in Thiruvananthapuram from November 10 to 12; in the end, it dissociated itself from the seminar. The low-key seminar ended with a statement from Dr. Carl E. Taylor, Professor Emeritus, Department of International Health in the School of Hygiene and Public Health at Johns Hopkins, in which he expressed the School's willingness "to consider embarking on a one-year period of planning to understand better the potentials of mutual collaboration."

UNDER the terms of the draft agreement, the State Government will hold a fixed equity of 26 per cent (as the assessed value of land to be transferred) in the organisation, and will have two nominees (including the vice-chairman) on a seven-member board of directors. It appears that under this arrangement, the State Government will not have much influence in directing the institute's policies. The other board members, including the chairman, are to be the nominees of the Centre for Public Health in Asia (CPHA), a chartered organisation which was registered in the U.S. recently, and will oversee the "fund-raising, planning and management of the establishment of the institute."

The CPHA will have on its board of directors a few Hopkins faculty members and non-resident Indians who are from Kerala and some other South Indian States. A Hopkins faculty member explained that the CPHA had to be registered as a chartered organisation in the U.S. to comply with a legal necessity for mobilising funds at the international level. He also said that it was a strategy to keep the proposed institute from getting bogged down in financial and other technical formalities, and remain focussed on its academic programme alone. Critics of the project, however, claim that the question of who will control the activities of the institute and decide its programmes was a serious one.

Dr. Padmanabhan P. Nair, a senior Hopkins faculty member who is on the board of directors of the CPHA, told Frontline that the CPHA "is only a temporary body" which will become "defunct" when the institute's board of directors is established in India.

Neurosurgeon and State Planning Board Member Dr. B. Ekbal, one of the critics of the project, says: "Several points about the project are not clear - among them, the composition of the body that will control the new institute, the extent of control that the State and the Central governments will have in respect of decision-making functions, and the process of electing the governing body. How the State or its people will benefit from the project is also not clear." He argues that since the institute will look to corporate sponsors - including, presumably, pharmaceutical companies - for funds, it will serve their interests first and advance their agendas. Kerala, he fears, might be used "as one big laboratory" and the local people as guinea pigs in vaccine trials.

Top government officials and members of the Hopkins team, however, claim that such fears are unfounded. The Indian Council of Medical Research protocol (based on the World Health Organisation's Geneva Convention on human trials) requires that any human trial should be cleared by an ethics committee.This provision, claim the government officials, would provide sufficient protection for the local people.

The New Delhi-based Indian National Social Action Forum (Insaf) has, in a statement, appealed to the State Government not to associate itself with the project since the institute might distort public health priorities and programmes in Kerala. Concerns about the areas of research and methodology and about the implications of giving external agencies extensive access to the State's rich bio-diversity and native knowledge in medicine should not be ignored, said Insaf.

Critics of the proposal concede that such trials may yield beneficial results that advance scientific knowledge; however, public health expert Dr. C.R. Soman, says: "The results of such trials will not be available to the ordinary Indian. All the products that will be tested are products of private patented research in the U.S. and they cost a lot. Every drug or vaccine that is developed will be beyond the reach of the ordinary masses of Asia."

Hopkins team members who attended the Thiruvananthapuram seminar said that the local community would have "a great deal of control" over the institute's activities; in fact, they said, one of the main intentions of the programme was to empower local communities to manage their health requirement. Even this is a contentious issue. Critics claim that the institute's plans may run counter to the State-wide campaign under the panchayati raj system for planning and development through people's participation.

Dr. K. Mohandas, Director of the Sree Chitra Institute of Medical Sciences and Technology, which runs the only public health school in India, denies that the institute will be a threat to local institutions involved in public health research, as some critics have claimed. "Instead we see it as a challenge and an opportunity. It will motivate us to raise our standards and open up possibilities for collaboration." However, he says, "there is the question of whether you need Rs.700 crores to establish a public health institute."

Critics of the project argue that the project involved too many needless built-in costs: the campus will house huge conference and banquet halls, a helipad, playgrounds and swimming pools for its international faculty and students. They also ask how a handful of people who are in charge of establishing the institute can make long-term commitments on behalf of the institute.

Several organisations have appealed to the State Government to make a clear and public announcement on whether or not it still supports the proposal. During their recent visit to the United States, Chief Minister E.K. Nayanar and Health Minister A.C. Shanmukhadas are reported to have assured a Hopkins team that the project had the Government's support.

Asked whether the Government would now be forced to abandon the plan, a top government official involved in the negotiations said: "No. But the entire equation has changed. But we have lost the position of strength that we were bargaining from. They are not willing to discuss anything further until there is a commitment from the Government." Other States in India and some other Asian countries had shown an interest in establishing the institute, he said. "We have to go back to the negotiating table once again."

Dr. Ekbal says: "The idea for an Asian institute for public health education, training and research and to facilitate cooperation among public health professionals in the region is a great one. But it has to be an institute by Asians, and for Asians. We are grateful to Hopkins University for the idea. Our effort now will be to try and establish such an institute here based on a purely Asian initiative."