‘India Nearly Eliminated Malaria in the 1950s, but The Success Was Mismanaged’

Srinagar-born biochemist, Dr Altaf Lal wore many hats in his career. A researcher, and a public health expert, he has been into health diplomacy, the first Kashmiri American who was posted as a diplomat in Delhi. Currently, a Senior Advisor for Global Health and Innovation at Sun Pharmaceuticals, India’s premier pharmaceutical company, Dr Lal detailed his life story, experiences, and ideas in a free-wheeling interview.

KASHMIR LIFE (KL): Malaria is not endemic to Kashmir but it still is a major crisis.

Dr ALTAF LAL (DAL): We do not have Malaria in Kashmir because the parasite cannot survive in the mosquito midgut at this altitude. So, the malaria-carrying vector exists here and so does the dengue-carrying vector, but both of these diseases are not endemic to Kashmir. That does not also mean there cannot be malaria cases in Kashmir. Malaria cases associated with travel would be there, but these would not cause additional cases through transmission by infected mosquitoes.

Malaria is an ancient disease. India came very close to eliminating malaria in the 1950s, but for a variety of reasons, it eventually came back. Most of it is attributed to mismanagement of success. However, the burden of malaria has been reduced significantly; with some estimates indicating the reduction of over 80 per cent of cases in the last decade or so. This is a remarkable achievement and indicates that the country is moving towards zero malaria.

However, India contributes the largest number of cases in the South East Asia region. Plasmodium falciparum and Plasmodium vivax are the two predominant species of malaria parasites. Compared to this, Plasmodium falciparum causes most of the morbidity and mortality in sub-Saharan Africa, with a greater than 96 per cent burden of diseases and death. The clinical manifestations of disease in Africa are anaemia, cerebral malaria and pregnancy-related adverse outcomes in women.

There is a global mission to eliminate malaria by 2030, and around 40 countries have eliminated malaria completely. Sun Pharma started a malaria elimination demonstration project in district Mandla as part of its CSR activity. Using existing diagnostic tools and case management and vector control tools, we were able to eliminate indigenous transmission in over three years.

So, we now have scientific methodologies, processes, and tools needed to eliminate malaria.  The results from the Mandla malaria elimination project have been published in peer-reviewed journals, and the lessons learned can be used for malaria elimination in the rest of India and other countries in the region with similar epidemiology.

KL: How has your journey been in this field?

DAL: My journey started in Kashmir. I  did BSc Honours in Botany because it was the only subject offered with honours at that time and also maybe because I was trying to differentiate myself from the rest of my peers and colleagues. After my BSc, I went to the University of Kashmir for MSc in Botany, but it was quite hard for me to understand certain things. It seems a dry subject to me and I could not decipher it. Then I went for Zoology, which also didn’t work out. Then I opted for chemistry which turned out to be good but somehow, I couldn’t connect with the teacher community.

After battling with all of this, I got to know that there were forms out for MSc Biochemistry in Lucknow and I applied for that and got admission there. This is how I got started in my career in biomedical sciences and malaria.

After completing my MSc in Biochemistry at Lucknow University I enrolled for PhD at the Central Drug Research Institute in Lucknow.  After that, in 1980, I went for a post-doctoral fellowship at theNational Institute of Health (NIH). In 1989, I was recruited by the Centre for Disease Control and Prevention in Atlanta to start a programme on molecular biology and immunology of malaria parasites, which took me to Kenya, India, Brazil, and Papua New Guinea for field studies.

In 2003, I was appointed as the Health Attaché and HHS Regional Representative for South Asia at the US Embassy in New Delhi.  I was the first Kashmiri American to serve as a diplomat in India. In addition to expanding US-India collaborations and partnerships in health sciences and public health, I contributed to US-Pakistan bilateral work on health policy and programmes.

In 2010, I took over as the CEO of Hilleman Laboratories, which was a joint effort by Merck and the Wellcome Trust, with a goal to produce low-cost and easy-to-use vaccines.  In 2013, I was appointed as the head of the US FDA India office. So, you can see my professional activities and responsibilities have been very enriching.  I must say it was a beautiful time of my life when I got to explore new things, help people and see the world.

Dr Altaf A Lal, a diplomat and a medical scientist

KL: What were the takeaways from your PhD that helped you understand human chemistry?

DAL: When I was in Lucknow at CDRI (Central Drug Research Institute), I worked on amoebic meningitis, a rare brain infection and a very deadly disease caused by a free-living amoeba. Generally, people get it when they swim in contaminated water and whosoever gets it dies.

Talking about malaria, there is a very interesting story to share. I used to constantly get one or more questions regarding malaria in every grade from tenth grade onwards.  I was fortunate that I found most of my professional career thinking about the why, how, what and where of this disease.  I started working on malaria at a time when the genes that encode key proteins had been cloned and sequenced.  This was a great time in vaccine research for malaria.  I worked on the genetic diversity of malaria parasites in India, Kenya, Papua New Guinea, and Brazil.

KL: How did these researches and interactions or investigations help you, handle the health diplomacy?

DAL: I learned that failure is part of growing up.  I was wrong many times and I corrected the mistakes to take the next bold step in a peaceful manner by combining knowledge with the desire to do more and to communicate with precision and soft diplomacy. These skills allowed me to navigate throughout my career as a scientist, health professional, bureaucrat, technocrat or in engaging with political leaders.

KL: You have worked in a diversity of cultures. Given your experience, how can we grow a better future generation and how holistic education might be created?

DAL: Holistic education is a deficit not only in Kashmir but also in various parts of the world. It is all about the structural deficit. One needs to have a base, whether that might be in biology, chemistry, economics, or physics. You need to have a purpose to go for things you want to achieve. Education systems in the US are multidisciplinary and holistic that are designed to create a student who is better prepared to enter higher education.

KL: Despite the twenty-first century being the peak of exploration and investigation, science says that they barely know the four per cent of the human body. So what are the new challenges?

DAL: We now know that there is 99.5 per cent genetic similarity between humans and only 0.5 per cent of genetic material separates us.  While the genetic basis of diseases and ailments are not yet fully understood, it is an active and well-funded aspect of biomedical and clinical research in many countries. The larger reality is that what we know has hugely helped mankind to live better.

We can create interventions in the human body. We can treat TB, Diarrheal disease, Malaria, and Dengue and within a year we were able to produce many vaccines for Covid19. All this is very significant.

In the US, the life expectancy in the 1940s was 60 years for men and 65 years for women. And now people live 80 plus years.  The drugs, vaccines, diagnostic tools and medical devices developed through decades of Research and Development (R&D) and clinical research have given us new and improved treatment and prevention tools as well as medical procedures.

KL: You have an important role at Sun Pharmaceuticals, India’s major pharma company. What are you doing to combat malaria in India?

DAL: Sun Pharma took a conscious decision in 2016, as the world was itself organizing to eliminate malaria. So, we gave it a thought that let us demonstrate that we can do it and we chose a harder district, a challenging area where malaria was intense. We developed some management and operational framework and in three-plus years we bought the intensity to near zero.

I believe that we were able to do it because I managed that programme as if I was managing a business. I had structural controls in place in management, finance and also technical controls. It was run as a business, not for the sake of business but to get the job done and hold people accountable. I think that was the reason our project succeeded, and we made sure that everyone was looked upon for a particular matter.

(Umaima Reshi processed the interview)

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