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RUEHZN/ENVIRONMENT SCIENCE AND TECHNOLOGY COLLECTIVE

UNCLAS SECTION 01 OF 11 NEW DELHI 000008 
 
SIPDIS 
 
SENSITIVE 
 
SIPDIS 
 
FOR HHS SECRETARY LEAVITT FROM CDA STEVEN WHITE 
HHS PASS TO NIH 
STATE PASS TO USAID 
STATE FOR SCA; OES (STAS FEDOROFF); OES/PCI STEWART; OES/IHA SINGER 
PASS TO HHS/OGHA (STEIGER/HICKEY), CDC (BLOUNT/FARRELL), 
NIH/FIC (GLASS/MAMPILLY), FDA (LUMPKIN/WELSCH, GENEVA FOR HOFMAN) 
 
E.O. 12958: N/A 
TAGS: TBIO SENV AMED KSCA IN
SUBJECT: SCENESETTER PART II: THE DEPARTMENT OF HEALTH AND HUMAN 
SERVICES (HHS) SECRETARY LEAVITT'S JANUARY 7-11, 2007 VISIT TO 
INDIA 
 
REF: (A) New Delhi 5418 
      (B) New Delhi 3220 
     (C) New Delhi 5367 
     (D) New Delhi 4659 
 
NEW DELHI 00000008  001.2 OF 011 
 
 
¶1.  (SBU) Summary: (SBU) Mr. Secretary, this is the second 
scenesetter cable, which provides information and analysis on 
U.S.-India collaborations in life sciences, health sciences, and 
public health.  The third companion cable will provide information 
on the regulatory environment for drugs, vaccines, food, and medical 
devices as well as information on the topic of Import Safety. See 
Reftel (A) for information and analysis on political, economic, 
trafficking in person (TIP) and south India matters. 
 
¶2.  (SBU) Health in India reflects both the promise and challenges 
of India.  On one end of the spectrum the pluses include excellent 
institutions of higher education, burgeoning high-tech industries, 
and a middle class numerically larger than that of the U.S.  This 
provides opportunities for cooperation in the areas of technology 
and biomedical research, specifically the development and testing of 
new and improved vaccines and drugs.  On the other end, with a third 
of the world's poor in India, large segments of Indian society do 
not benefit from Indian education system, face basic public health 
problems, and demonstrate poor indices in overall reproductive 
health, infant and child mortality, and maternal mortality. 
Contributing factors include inadequate and unsafe water supply, 
poor sanitation, low immunization rates, and limited access to good 
quality basic health services and malnutrition.  End Summary. 
 
INDIAN MEDICAL AND HEALTH INSTITUTIONS 
-------------------------------------- 
 
¶3.  (SBU) In contrast to the abundant top-notch bio-medical research 
and health professionals who participate in our bilateral health 
programs in India as equals, the Indian educational system that 
produces such fine researchers and health professionals does not 
reach all children of India.  Education in India is a privilege 
rather than a right for her children.  One-quarter of all of India's 
rural children will never see the inside of a classroom, and only 62 
percent of children will reach Grade 5.  Selection becomes even more 
drastic at higher grades and institutes of higher education.  As an 
example, there are 30,000 applicants for thirty slots at the All 
India Institute of Medical Sciences (AIIMS), a premier Indian 
institution based in New Delhi with whic HHS has strong 
collaborations. 
 
¶4.  (SBU) Like the AIIMS, there are a few other good medical schools 
in the public and private sector.  But the large majority of medical 
schools in the public and private sector have inadequate staff and 
lack clinical and laboratory facilities for surgeries, treatment and 
detection of diseases. 
 
¶5.  (SBU) As compared to the inadequate health facilities in the 
public institutions, many state-of-the-art hospitals, such as Apollo 
Hospitals, Fortis Health Care, Escorts, etc. have emerged in the 
private sector in the recent years.  These hospitals have earned a 
reputation of excellence in clinical care and cater to large number 
of patients from overseas, who come to India for elective 
procedures.  The Government of India (GOI) is promoting medical 
tourism in India.  You may hear about this in your meeting with the 
Minister of Health and Family Welfare Anbumani Ramadoss and at the 
Confederation of Indian Industry (CII)-organized event in Chennai. 
 
HEALTH COLLABORATIONS PRODUCE HEALTH DIPLOMACY 
--------------------------------------------- - 
 
¶6.  (SBU) The USG supports world class biomedical research 
collaboration, state-of-the-art research capacity (supported by HHS 
agencies), specific disease control initiatives for TB, HIV/AIDS, 
and Polio (where HHS and USAID collaborate), and provides other 
support to national, state and district/city public health 
 
NEW DELHI 00000008  002.2 OF 011 
 
 
initiatives to improve the provision, and use of basic health 
services (supported by CDC and USAID). 
 
¶7.  (SBU) The HHS-India office plans and organizes highly focused 
workshops in the area of life sciences and public health on a 
regular basis with the Ministry of Health and Family Welfare, 
Ministry of Science and Technology, and with the Ministry of 
Agriculture.  These workshops which are developed in consultation 
with HHS agencies are designed to define the "next steps" in 
U.S.-India collaborations. 
 
¶8.  (SBU) The relationships and trust developed as a result of 
active engagement with technical, policy, and political leaders in 
the Science and Health Ministries, allow us to have first access to 
policy positions that are being considered by GOI.  These relations 
also make it easy for us to advocate USG policies and positions for 
bilateral as well as multilateral relationships.  Another important 
feature of our work in India is the support we provide to the U.S. 
biotechnology and pharmaceutical companies.  These companies reach 
out to us for guidance on technical and policy issues.  Two 
representative examples of this private sector interaction are: 1) 
re-entry of Merck; 2) resolution of the issue of pesticide in soft 
drinks (Pepsi and Coke). 
 
¶9.  (SBU) By working together with Indian academia, industry, NGOs, 
and Governmental institutions we are: 1) increasing Scientific 
Knowledge; 2) developing and evaluating vaccines and drugs; 3) 
building capacity and providing training; and 4) working towards 
detection, prevention, control, and elimination of diseases.  See 
Reftel (B) for background on the status of the Biotech industry in 
India. 
 
¶10.  (SBU) The benefits from these collaborations flow back to the 
American people, but also to the Indian people and, through the 
goodwill generated on both sides, to Indo-U.S. relations in 
general. 
 
OVERVIEW OF USAID PROGRAMS 
-------------------------- 
 
¶11.  (SBU) USAID's FY 2007 budget of USD 104,392 million for India 
included USD 88,713 (85 percent) for health.  Working in partnership 
with the Government of India, USAID contributes to improving family 
planning and reproductive health services; expanding basic maternal 
and child health services; supporting India's polio eradication 
efforts; and preventing and limiting the impact of HIV/AIDS and 
Tuberculosis.  USAID'P5R4e capacity of Indian health institutions, supporting 
public-private partnerships and mainstreaming successful program 
strategies into national and state programs to ensure 
sustainability. 
 
¶12.  (SBU) In reproductive health (RH), strategically-directed 
technical assistance is delivered at multiple levels.  Initiatives 
are targeted at three north Indian states (Uttar Pradesh, 
Uttarakhand and Jharkhand) - an area home to more than 210 million 
people.  Clinicians, NGOs, village leaders, and other stake-holders 
remain at the core of USG RH projects.  In addition, expansion of 
innovative public-private partner projects support health financing, 
social franchising, and various demand-creation approaches that are 
being implemented with substantial results. 
 
¶13.  (SBU) Improved maternal and child health also remains a 
priority.  In FY07, with USAID health program support, over two 
million children were treated for diarrhea, six million children 
were reached with Vitamin A, seven million children were reached 
with Diptheria Pertussis Tetanus (DPT3) immunizations, and nearly 
150,000 health care providers were trained in newborn/maternal and 
child health.  An urban health program focuses on improving Maternal 
 
NEW DELHI 00000008  003.2 OF 011 
 
 
and Child Health (MCH) indicators among the urban poor through 
technical, systems and policy interventions.  USAID supports polio 
eradication through surveillance, lab and social mobilization 
activities. 
 
¶14.  (SBU) USAID and HHS/CDC implement HIV/AIDS prevention, care and 
treatment as part of the President's Emergency Plan for AIDS Relief 
(PEPFAR).  India is a bilateral (lower priority) country under 
PEPFAR, one of the largest health care initiatives of its kind. 
PEPFAR efforts include HIV prevention in high prevalence states and 
among high risk groups; work to ease the suffering of children 
affected by or infected with the disease; provide care and treatment 
support to those affected; and training for those providing these 
services; and involve the private sector to help stem the spread of 
HIV/AIDS on a broader scale. 
 
¶15.  (SBU) In FY 2008, PEPFAR-India team is strengthening its 
support to the Government of India's National AIDS Control 
Organization (NACO) in line with the priorities of the third 
five-year National AIDS Control Program (NACP-3), 2007-12.  Under 
NACP-3, the Government of India (GOI) is scaling-up the delivery of 
HIV/AIDS services nationally through decentralizing the funding and 
management of service delivery to the district level.  Additionally 
PEPFAR will emphasize systems strengthening, capacity building, and 
quality assurance to support the national HIV/AIDS program. 
 
¶16.  (SBU) In the area of Tuberculosis control, USAID and HHS/CDC 
support, in consultation with the GOI and World Health Organization 
(WHO), focuses on technical assistance for DOTS enhancement, TB-HIV 
collaboration activities, and effort to contain drug resistance TB. 
Support has also been provided for TB control activities in the 
state of Haryana (pop. 23.4 million) by funding operational costs 
for diagnosis, purchase and delivery of drugs and monitoring. GOI is 
now assuming full financial responsibility for Haryana TB control as 
of March 2008. 
 
OVERVIEW OF HHS PROGRAMS 
------------------------ 
 
¶17.  (SBU) HHS maintains in India a technical staff from the 
National Institute's of Health (NIH) and the Centers for Disease 
Control and Prevention (CDC), who work with Ministries of Health, 
Science and Technology, as well as NGOs and academic and federal 
institutions.  In addition to the Health Attach, a total of ten 
full time equivalent staff from HHS agencies work on HIV/AIDS, avian 
influenza, TB, and polio.  Five of the ten FTEs are seconded to the 
World Health Organization to work in support of polio, childhood 
immunizations, TB, and avian influenza programs in India.  The total 
funding from HHS agencies is in the range of USD 30 million to 35 
million, which includes funding of peer-reviewed grants, support for 
infrastructures and capacity building, polio elimination programs, 
avian influenza program, and scientific workshops. Equally important 
aspect of HHS collaboration in India is the technical staff on 
ground from NIH and CDC as well as nearly 300 TDYers per year who 
visit India for technical consultations. 
 
¶18.  (SBU) The NIH has provided funding to over 180 research 
projects in India, a marked increase from zero in 1990, 17 in 1998, 
and 67 at the end of 2003.  Recipients of these peer-reviewed grants 
are distributed throughout the country and cover a wide range of 
cutting edge research priorities established by NIH, such as 
HIV/AIDS, tuberculosis, malaria, and rotavirus.  NIH builds research 
capacity and collaborative opportunities in India through 
investigator-initiated grants, direct financial and technical 
support for a primate research center in Mumbai, an International 
Center for Excellence in Tuberculosis Research in Chennai, targeted 
workshops and training activities, and postdoctoral research 
training in the U.S. for over 250 Indian scientists.  Through the 
Office of AIDS Research, NIH is conducting a series of workshops on 
clinical research and clinical trials.  These workshops are designed 
to impart good practices training to Indian researchers and 
 
NEW DELHI 00000008  004.2 OF 011 
 
 
clinicians engaged in or interested in conducting clinical trials. 
 
¶19.  (SBU) The CDC is partnering with India in a wide variety of 
bilateral and multilateral programs.  CDC's extensive polio 
eradication efforts make it one of the largest supporters of polio 
eradication in India.  Through HHS/CDC's Global AIDS Program (GAP), 
CDC is strongly engaged in providing support for GOI efforts to 
control the country's HIV epidemic in a manner that strengthens 
systems across the board (e.g. quality lab systems and surveillance 
data quality.)  CDC provides substantial technical support for 
seasonal influenza surveillance and preparedness for avian 
influenza, emerging and re-emerging diseases, tobacco control, field 
epidemiology training, and prevention and treatment of Tuberculosis. 
 
 
¶20.  (SBU) The Food and Drug Administration (FDA) regulatory 
inspection staff routinely conducts inspections of Indian 
pharmaceutical facilities to ensure that products imported into the 
U.S. meet stringent safety and efficacy standards.  FDA scientists 
also collaborate with Indian scientists on infectious disease 
research.  As a part of President's Emergency Plan For AIDS Relief 
(PEPFAR), FDA worked closely with finished dose and Active 
Pharmaceutical Ingredient (API) producers in India for expediting 
the review of generic antiretroiral drugs for the treatment of 
HIV/AIDS.  FDA's expedited review of drug products from the 
pharmaceutical industry in India was critical to the overall success 
of PEPFAR, since India produces a large portion of the available 
supply of generic antiretroviral HIV/AIDS drugs. 
 
¶21.  (SBU) HHS maintains eight highly productive ongoing bilateral 
agreements with Government of India counterparts in the Ministry of 
Science and Technology and the Ministry of Health and Family 
Welfare.  These bilateral agreements are: 
 
- Vaccine Action Program (NIH is the nodal agency) 
- Maternal and Child Health (NIH is the nodal agency) 
- Contraceptive Research and Reproductive Health (NIH is the nodal 
agency) 
- Expansion of Vision Research (NIH is the nodal agency) 
- Low Cost Health Technologies (NIH is the nodal agency) 
- HIV/AIDS and STD Prevention (NIH is the nodal agency) 
- Environmental and Occupational Health (CDC is the nodal agency) 
- Emerging and Reemerging Infectious Diseases and Disease 
Surveillance (CDC is the nodal agency) 
 
¶22.  (SBU) In addition to these bilateral programs, NIH is planning 
to establish formal bilateral agreements on Translational Research, 
International Center of Excellence, Mental Health, and Retirement 
and Aging.  There is an interest in initiating training programs 
jointly funded by the Indian agencies and NIH.  The attractive 
feature of this new, yet-to-be formalized program is the opportunity 
for U.S. researchers to work in Indian institutions on a long-term 
basis, including work on clinical research.  This is a new beginning 
that would allow U.S. investigators to conduct research in Indian 
universities and federal institutions. 
 
POLIO ERADICATION INITIATIVE - BREAKING THE CYCLE OF POLIO 
TRANSMISSION IN INDIA 
--------------------------------------------- ---- 
 
¶23.  (SBU) Before the implementation of polio vaccination campaigns 
in India, there were an estimated 50,000 to 100,000 annual cases of 
paralytic polio.  With the successful implementation of the Polio 
Eradication Initiative (PEI), the number of paralytic cases 
decreased to a historic low of 66 in 2005.  Despite reducing 
paralytic polio to record low numbers, this enteric virus continues 
to circulate in India.  In 2006, an outbreak of polio was recorded 
with 676 cases.  The continued presence of poliovirus in the Indian 
environment presents a global public health threat. 
 
¶24.  (SBU) After intensifying efforts to deliver the polio 
 
NEW DELHI 00000008  005.2 OF 011 
 
 
vaccine to the 165 million children under 5 years old, India 
recorded the lowest number of polio cases in 2005.  From 1,600 cases 
in 2002, to 225 cases in 2003, and 134 in 2004, 66 in 2005, and 676 
cases in 2006 respectively.  The increase in the number of cases in 
2006 was attributed to epidemiologic, operational, and social 
factors.  The intense national vaccination program is showing 
overall very encouraging results this year. 
 
¶25.  (SBU) As of December 21, 2007, the number of cases of type 1 
poliovirus (P1) is 67 compared with 648 in 2006, the number of type 
3 poliovirus (P3) is 431, and P1 plus P3 is 2, bringing the total 
polio cases for 2007 to 500.  The last ten months have been of 
special significance with the number of type P1 cases dipping even 
in endemic areas of Western Uttar Pradesh, where the poliovirus has 
thrived and moved to re-infect polio free Indian states and other 
countries.  The P1 virus has caused most of the damage in India 
accounting for 95 percent of the cases in the last five years and a 
large number of outbreaks such as in 2002 and 2006. 
 
¶26.  (SBU) The success against P1 can be largely attributed to the 
extensive use of monovalent oral polio vaccine type 1 in the endemic 
areas of Uttar Pradesh and Bihar, and the number of initiatives 
taken by the Government of India to boost the quality of polio 
immunization rounds.  Western Uttar Pradesh and parts of Bihar are 
the most difficult places to eradicate polio because of their 
uniquely challenging conditions like high-population density and 
sanitation.  Sustaining the gains made in the recent months and 
further improving the quality of polio vaccination rounds remains 
the focus of all immunization activities in the coming months. 
 
¶27.  (SBU) The resurgence of P3 in Uttar Pradesh and Bihar is not 
unexpected and is consistent with the strategy to first eradicate 
P1, the more dangerous of the two remaining poliovirus types.  Given 
the higher efficacy of monovalent type 3 vaccine, P3 is being 
brought under control and will be eliminated soon after P1 
eradication is achieved. 
 
¶28.  (SBU) Along with Rotary International, UNICEF, and the World 
Health Organization (WHO), the USG through HHS/CDC and USAID is a 
leading partner for the polio eradication initiative globally, and 
specifically, in India.  HHS/CDC has made substantial contributions 
since 1997 when the PEI began in India.  The HHS/CDC, as a partner 
in PEI, provides technical assistance and funding support to WHO's 
poliovirus surveillance, including a strong laboratory network. 
Through assignment of staff to WHO at regional, country, and 
district levels, HHS/CDC provides expertise in disease surveillance, 
program operations, and management support.  HHS/CDC also provides 
UNICEF with significant support for the polio vaccine and country 
program operations. 
 
HIV/AIDS IN INDIA 
----------------- 
 
¶29.  (SBU) The first case of HIV infection in India was identified 
in 1986.  In 2007 the estimated number of people living with HIV in 
India was lowered by UNAIDS from 5.7 million (range 3.4-9.4) to 2.5 
million (range 2.0-3.1) or about 0.36 percent of India's population. 
 This widely publicized reassessment of HIV/AIDS burden was due to 
the use of revised, improved estimation methodology.  The down 
revised estimates still place India third in the world, behind only 
South Africa and Nigeria in the numbers of people living with 
HIV/AIDS (PLWA).  The total number of AIDS cases reported to the 
National AIDS Control Organization (NACO) in 2006 was about 125,000 
but most AIDS cases go unreported due to poor surveillance and high 
stigma. 
 
¶30.  (SBU) Over 70 percent of PLWHAs live in five states 
(Maharashtra, Andhra Pradesh, Karnataka, Tamil Nadu, Manipur and 
Nagaland).  Like other Asian HIV epidemics, India has a concentrated 
epidemic: mostly affecting "high risk" groups and their partners. 
Although 2007 NACO data has revealed a stable-to-lowering HIV 
 
NEW DELHI 00000008  006.2 OF 011 
 
 
prevalence in Tamil Nadu, in Andhra Pradesh, Karnataka, Maharashtra, 
and the Northeastern States the prevalence is increasing in 
high-risk populations.  There is also a concern of "hidden epidemic" 
in the northern states of Uttar Pradesh and Bihar.  The entry of 
virus into these states is by migrant workers, who work in 
high-prevalence states. 
 
¶31.  (SBU) The Indian private sector has yet to fully engage in the 
fight against HIV/AIDS.  During your visit you will meet 
stakeholders in HIV prevention, care, and research in the public and 
private sectors.  In a round table session you will have the 
opportunity to discuss relevant and timely issues with key policy 
makers, faith-based organizations, NGO's, representatives from the 
research and academic community and the business sector.  Due to the 
rapid economic and IT sector growth, there is a building boon in 
southern urban areas. Currently, USG and NACO are targeting 
prevention activities to these people but have minimal support from 
the private sector clients. 
 
¶32.  (SBU) The GOI has shown signs of a deeper commitment to the 
fight against HIV/AIDS.  The Parliamentary Forum on HIV/AIDS, which 
brings together politicians from local, state, and national levels, 
has had highly successful annual meetings.  The meetings provide 
rare occasions where the Prime Minister has spoken.  These meetings 
have been successfully replicated at the State legislature level 
also. Political leaders' willingness to address HIV/AIDS continues 
to improve at both the state and national level, but much more needs 
to be done. UNAIDS has the lead for this activity. 
 
¶33.  (SBU) India has submitted proposals and received funding from 
the Global Fund for HIV, TB and Malaria in six of the seven rounds. 
So far, a total of USD 161,749,320 have been disbursed for funding 
for all three diseases against a total of USF 326,168,292 that has 
been approved.  USAID participates on the country coordinating 
committee and in-country USAID and CDC staff has provides technical 
assistance for Global Fund programs. 
 
¶34.  (SBU) USG's strategic priorities through PEPFAR: 
 
- To support the efforts of the Indian National HIV/AIDS Control 
Program to achieve its key HIV prevention, treatment, care, capacity 
building, and monitoring and evaluation objectives; 
- To work with other partners and leverage resources to bring 
programs to scale; 
- To continue to implement prevention programs for most-at-risk 
populations; 
- To promote a sustainable network model that integrates prevention, 
treatment, care and support services in the public and private 
sectors; 
- To support the efforts of the Government of India to build 
capacity for policy and program development at the national and 
state level; 
- To build indigenous capacity for program management and 
implementation; and 
- To implement programs within the framework of the "Three Ones," 
which calls for one agreed upon AIDS action framework, one national 
AIDS coordinating authority, and one national monitoring and 
evaluation system. 
 
¶35.  (SBU) As part of USG efforts, and in response to a request from 
the National AIDS Control Organization, donors are now being asked 
to support new Technical Support Units (TSUs) in the states, that 
will be responsible for building the technical and managerial 
capacity of the State AIDS Control Societies (SACS) in HIV/AIDS 
implementation through NGOs.  The USG will support TSUs in six 
states and will continue to fund technical consultants who work 
directly with the SACS on a short-term basis. 
 
¶36.  (SBU) Given the magnitude of the problems in HIV, TB and 
malaria and the size and complexity of India, it is not surprising 
that some many NGOs and state governments have expressed frustration 
 
NEW DELHI 00000008  007.2 OF 011 
 
 
with the process.  Both HHS/CDC and USAID have supported the GOI to 
be more proactive approach in NACP-3 to engaging and involving NGOs. 
Good progress has been made. 
 
TUBERCULOSIS CONTROL IN INDIA 
----------------------------- 
 
¶37.  (SBU) India has the world's highest burden of tuberculosis, 
with an estimated 1.8 million cases per year.  Nationwide 
implementation of Directly Observed Treatment Short Course Therapy 
(DOTS) was achieved in March 2006, and in that year alone India's 
national Tuberculosis (TB) program treated over 1.4 million persons. 
 Yet, enormous barriers remain for the national TB program to 
implement all components of the Global Strategy to Stop TB. 
 
¶38.  (SBU) The quality of DOTS implementation remains quite poor in 
many areas, and effective and affordable treatment for multi-drug 
resistant (MDR) TB is extremely limited, with the first two 
DOTS-Plus facilities just beginning to treat MDR patients. 
Meanwhile, widespread unregulated and unsupervised use of 
second-line anti-TB drugs to treat presumptive MDR TB risks the 
development of extensively drug resistant (XDR) TB. 
 
¶39.  (SBU) In 2006, only 5 percent of TB patients were known to have 
been HIV tested, resulting in missed opportunities to identify 
HIV-infected persons. These HIV testing referrals are increasing, 
however, largely as a result of improved coordination between the 
national TB and HIV/AIDS programs and the increasing availability of 
HIV testing nationwide. 
 
¶40.  (SBU) USAID provided USD 4.7 million of assistance for TB 
activities in India in FY2007.  The bulk of USAID funds support 
technical assistance (TA) to the national TB program through a WHO 
umbrella grant.  This activity delivers TA through a network of 
central and field consultants, focused on improving basic DOTS 
implementation, strengthening public-private partnerships, and 
confronting emerging issues in TB (MDR, TB-HIV). 
 
¶41.  (SBU) Staff from CDC working with the GOI's Revised National 
Tuberculosis Control Program (RNTCP) are engaged in a number of 
ongoing technical activities.  These include, improving RNTCP's 
surveillance and monitoring systems, establishing electronic 
connectivity with implementing districts and assuring smooth drug 
logistics for the DOTS expansion activities. 
 
¶42.  (SBU) The USG has provided specific support for TB control in 
the South East Asia Region as follows: 
- WHO-SEARO: (USD 198,000 FY2007) Support for WHO-SEARO tuberculosis 
unit activities (meetings, publications, short term technical 
support activities) 
- India: (USD 4.28 million FY2007) Financial support DOTS 
implementation in Haryana, India (21 million population, 2% of 
India); Model DOTS project with Tuberculosis Research Centre (TRC) 
Chennai, for DOTS impact assessment and operational research 
support; Network of  Field Consultants (via WHO) facilitating DOTS 
expansion and new activities of the Global Stop TB Strategy. 
- India/WHO-SEARO: (USD 350,000 FY2007) Technical support via CDC 
medical officer detailed to WHO. 
 
¶43.  (SBU) Since the introduction of DOTS in 1998, 100,000 lives 
have been saved.  Under the RNTC Program, India's goal was to extend 
TB control to 100 percent of its population by 2005.  As of August 
31, 2007, almost three quarters of the country has been covered. 
 
AVIAN INFLUENZA (AI) SITUATION IN INDIA AND SOUTH ASIA 
--------------------------------------------- ---- 
 
¶44.  (SBU) Mission has constituted an AI working group that meets on 
a monthly basis.  HHS, CDC, USAID, and USDA work very closely with 
the Ministries of Health and Family Welfare, Agriculture, Science 
and Technology, and Environment. HHS/CDC has posted scientists at 
 
NEW DELHI 00000008  008.2 OF 011 
 
 
the Mission, who coordinates CDC's AI and Influenza programs in 
India.  HHS/CDC has also posted an epidemiologist at WHO/SEARO for 
avian influenza work. The Mission provided technical and advisory 
support to the GOI for planning and conducting the New Delhi 
Ministerial Meeting on Avian and Pandemic Influenza (Reftel C). 
 
¶45.  (SBU) India has had three outbreaks of highly pathogenic avian 
Influenza (HPAI) in 2006 and 2007.  The two H5N1 outbreaks in Feb 
2006 took place in poultry in the western India in the neighboring 
districts of Nandurbur and Jalgaon in Maharashtra.  Both commercial 
and backyard poultry were affected by the outbreak.  Both of the 
outbreaks occurred over a span of 12 days with high mortality rates 
(>1 million poultry culled).  The third outbreak took place in July 
2007 in the North-eastern state of Manipur (bordering Myanmar) in 
India.  The outbreak took place in a small poultry farm and an 
estimated 336,000 birds were culled. 
 
¶46.  (SBU) Massive culling and containment efforts in all three 
outbreaks led to successful control of infection, and no subsequent 
outbreaks have been reported.  Genetic sequence data and 
phylogenetic analysis has revealed a distinct lineage of virus 
belonging to Clade 2.2 H5N1 viruses.  Rapid containment and active 
surveillance in affected areas have resulted in no human infection 
to date in either of the outbreaks. 
 
¶47.  (SBU) The total HHS funding for AI in India for FY2007 was 
about USD 2 million.  This funding was used for increased Influenza 
surveillance and detection capacity, and for training and 
preparation of Rapid Response Teams (RRTs) in India.  Several 
training activities, workshops and international symposiums have 
been conducted and are being planned in collaboration with the 
Ministry of Health, the Ministry of Agriculture, and WHO. 
 
¶48.  (SBU) With HHS/CDC technical and funding support the  nine 
surveillance centers in India are conducting surveillance to provide 
virologic characteristics of the Indian seasonal influenza isolates. 
 Over 200 isolates have been contributed to the HHS/CDC global 
Influenza network by India.  Future activities include estimation of 
Influenza disease burden, better description of epidemiology of 
seasonal influenza, and adoption of a standard data collection and 
reporting system for seasonal influenza by CDC global Influenza 
network members. 
 
¶49.  (SBU) HHS/CDC has provided technical guidance and funding for a 
series of workshops to strengthen avian/pandemic influenza 
surveillance capacity in India.  The RRT roll out is currently being 
carried out by MOH and WHO at regional level train the trainer 
sessions with the help of training material provided at the 
workshop.  Additional RRT training has been completed in Eastern and 
Western India with the northern and southern regions to follow. 
These collaborations build on our existing collaboration with GOI on 
emerging and reemerging diseases. 
 
¶50.  (SBU) HHS/CDC continues to stress prompt reporting and sample 
sharing, and close coordination by agriculture and human health 
authorities to control avian influenza in animals and to prepare for 
a possible human pandemic.  Unfortunately, neither the 2006 or 2007 
isolates have been shared with international agencies by the 
Ministry of Agriculture.  However, the National Institute of 
Virology (NIV), at Pune, was successful in isolating H5N1 from dead 
poultry and sent 2006 isolates to CDC for creation of reverse 
genetically modified H5N1.  The modified Indian reassortment has 
undergone safety testing at USDA and is in the process of being 
classified as being non-pathogenic.  The modified virus will be sent 
back to NIV for future studies. 
 
¶51.  (SBU) Challenges include: 
- Complacency: Maintaining the interest and need for continuous 
training is challenging, especially with limited trained/available 
staff and resources. 
- Northeast region a hotspot: Worries about H5N1 becoming endemic in 
 
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neighboring Bangladesh and Myanmar. NE region has porous border with 
both Myanmar and Bangladesh. 
- Containment strategies: Challenges with population density, poor 
healthcare infrastructure. 
- Need guidance for disaster management strategies. 
 
¶52.  (SBU) USAID-India AI Program commenced in year 2006 with an 
initial obligation of USD 530,000 and was primarily aimed at 
strengthening AI Cell at the national level, conducting situational 
analyses, preparing guidelines and standards for AI management and 
training of personnel. In FY 2007 USAID has obligated USD 1 million 
to WHO and FAO to support a broader range of AI activities, for 
example, epidemic preparedness, surveillance and detection, response 
and containment and communication. 
 
GOI IS TAKING PUBLIC HEALTH SERIOUSLY 
------------------------------------- 
 
¶53.  (SBU) During your predecessor's visit to India in 2004, then 
Minister of Health and Family Welfare, Sushma Swaraj, requested help 
for establishing one or more schools of public health in India. 
Health Attach worked with the Ministry of Health and convened an 
Indian National Consultation on Public Health.  Representatives from 
13 U.S. schools of public health participated in this meeting as did 
the leadership of the Association of Schools of Public Health. 
 
¶54.  (SBU) The result of this partnership was the creation of the 
Public Health Foundation of India (PHFI), which receives management 
support from Mackenzie and Company and funding from the GOI, the 
Bill and Melinda Gates Foundation, and a few individuals of high net 
worth.  The Prime Minister of India launched the foundation in March 
2006, and at this time PHFI is working towards starting three 
schools of public health.  The PHFI plans to launch a total of 7 new 
schools of public health in the next 5 years.  Faculty for these 
schools is being trained at several schools of public health 
overseas, with the majority being trained in the United States. 
Complementing the PHFI initiative, the Indian Council of Medical 
research has also launched an initiative to establish schools of 
public health.  Indian experts, however, believe that the ICMR 
initiative is not a serious effort and may not produce credible 
institutions. 
 
PLANNING FOR FUTURE PARTNERSHIPS 
-------------------------------- 
 
¶55.  (SBU) The last 4 years have seen unprecedented growth in 
programs and projects supported by HHS agencies in India.  Two new 
bilateral agreements were established and a third bilateral 
agreement was operationalized.  The number of NIH-funded grants has 
doubled in the past 4 years and the average time it takes to clear 
grants by Indian nodal agencies has significantly reduced.  A series 
of focused scientific workshops have led to new U.S.-India 
partnerships at academic and industrial levels. 
 
¶56.  (SBU) Recognizing the growth of the clinical research and 
clinical trials sector in India, Health Attach initiated 
discussions with the leadership of the Indian Council of Medical 
Research and the Department of Biotechnology for promoting 
collaboration on translational research.  These discussions also 
included staff from different institutes and centers of NIH. 
Several meetings have been conducted over the past year on this 
topic, and a letter of intent t establish a formal agreement was 
signed by director of NIH, Dr. Elias Zerhouni, and Minister of 
Science and Technology, Kapil Sibal, during Dr. Zerhouni's visit to 
India in October, 2007 (Reftel D).  In addition to NIH interest in 
collaborating on translational research, Boston University, MIT, and 
Stanford University are also initiating collaborative programs on 
translational research in India. 
 
¶57.  (SBU) Health attach has shared his position with Indian policy 
and political leaders on successful partnerships in translational 
 
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research, stating that translation from molecules to medicine would 
be faster when collaborations in the private and public sectors are 
enhanced, when policies are developed that spur investment and 
entrepreneurship, attract investment in vaccine and drug 
development, and promote the use of drugs and vaccines in public 
health programs.  He has also advocated that these individual 
components must link in order for the tools of biotechnology to 
deliver public health goods at local, regional, and global levels. 
 
¶58.  (SBU) Over the next 12 months, HHS-India will organize a series 
of focused U.S.-India Partnership Meetings on Disease Burden, 
Control, and Elimination with the Indian Ministry of Health and 
Family Welfare and the Public Health Foundation of India.  We will 
focus on cardiovascular diseases and diabetes, mental health, 
malaria, and measles.  These topics have been chosen due to interest 
at the HHS agency level, and because they provide opportunities to 
initiate new programs, and will "force" India to recognize the need 
to invest in these programs at technical, policy, and funding 
levels. 
 
NEWS OF INTEREST 
---------------- 
 
¶59.  (SBU) Mission would like to provide you information on topics 
that were subject of news reporting in the last few weeks.  You may 
encounter questions during your interactions with news reporters in 
India. 
 
¶60.  (SBU) The Ministry of Health and Family Welfare has announced 
plans to unilaterally grant recognition of medical degrees from four 
English speaking countries, England, Canada, Australia, and the 
United States.  This may be a policy to attract medical 
professionals to help support the growing medical tourism sector in 
India. 
 
¶61.  (SBU) India has established a new National Disaster Management 
Authority, within the Ministry of Home Affairs. Health disaster 
work, including outbreak responses, would have to be done by the 
Ministry of Health and Family Welfare in coordination with this new 
authority. 
 
¶62.  (SBU) The Health Minister has been very active in pursuing 
anti-tobacco programs, but the government has not been supportive of 
his plans.  The tobacco lobby is being implicated in opposing 
anti-tobacco reforms and regulations. 
 
¶63.  (SBU) A recent HIV/AIDS vaccine trial in Pune, India, which was 
sponsored by the New York-based International AIDS Vaccine 
Institute, has come under criticism.  This trial was being conducted 
in Germany, Belgium, and India. The trial was stopped in Belgium and 
Germany a year ago because vaccine did not elicit optimal levels of 
immune responses.  Despite these negative results in the other two 
countries, the vaccine trial was continued in India.  An 
investigation is underway. 
 
¶64.  (SBU) Another US-India collaboration on mother-to-infant 
transmission of HIV/AIDS, supported by NIH, was topic of intense 
debate between the US and Indian scientists.  The Indian scientist 
complained that the U.S. institution submitted the results of the 
study to a scientific conference without consulting with them.  The 
Indian investigators also complained that all results of the study 
were not being reported.  The Indian investigator threatened to go 
to the press, at which point Health Attach intervened and suggested 
that all investigators of the India team should meet to discuss and 
analyze the results.  He stated to the Indian PI that the comments 
of the India team should be formally shared with the U.S. and other 
international collaborators in a collegial manner.  The Indian team 
has agreed to do this and will convene a meeting in the second week 
of January. 
 
Final Comment 
 
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------------- 
 
¶65.  (SBU) As we look towards the future of enhanced U.S.-India 
collaborations, some important factors are worthy of mention.  The 
U.S.-India collaboration will likely result in obtaining the "final 
answers" to important questions of pathogenesis, vaccine and drug 
efficacy, genetic, biologic, and immunologic factors involved in 
protection and transmission of diseases.  From a public health 
perspective, partnership with India allows us to encourage India to 
focus on the why, where, how, when, and what of diseases as well as 
development of capacity and public health institutions. 
 
¶66.  (SBU) From a private sector perspective, however, the following 
important issues emerge for promoting bilateral programs and 
collaborations: 1) provision for data exclusivity; 2) full 
protection of intellectual property rights; 3) facilities needed for 
transportation and storage of biotechnology products; and 4) legal 
systems needed for expeditious litigation involving trade and 
Intellectual Property Rights (IPR) issues.  There is some progress 
to report on many of these issues, including aspects of bilateral 
cooperation in IPR.  However, the GOI still lags on IPR enforcement 
and may be considering a data exclusivity policy that would not 
provide the pharmaceutical industry with a sufficient level of data 
protection. 
 
¶67.  (SBU) In your meetings with the Prime Minister (PM), we 
recommend you speak about the importance of staying the course on 
polio eradication and inform him that USG is a committed partner of 
India.  You should also suggest India appoint a high level official 
in the Ministry of Health, one who would only focus on polio for the 
next 3 years or so.  He/she would engage with the technical teams 
and report to the Health Minister and the PM.  Citing USG 
experiences with PEPFAR, the President's Malaria Initiative and AI 
may be very effective and appropriate examples in this context. 
 
¶68.  (SBU) In your meetings with the Ministers of Health and Science 
and Technology, we suggest you share views on the importance of 
expedited review process to clear collaborative grants, so that 
investigators of the approved grants can start their work without 
delays.  In your meetings with the Health Minister and Agriculture 
Minister, we would like you to talk about the need for science-based 
decision making in import of U.S. agricultural products.  These 
Ministries have not always been forthcoming on using science-based 
decision making in issues related to import of wheat, apples, and 
other agricultural products.  Your meetings with these two ministers 
will provide an opportunity to share your views on sample sharing 
for avian influenza as well. 
 
¶69.  (SBU) Your meeting with the Minister of External Affairs will 
provide an opportunity to share information on a variety of 
U.S.-India programs on health as part of our overall relationship 
with India.  He would appreciate hearing your views on polio 
eradication in the global context and AI outbreak sample sharing. 
He will also be looking forward to hearing your views on import 
safety and initiating dialogue for establishing one or more 
agreements on import safety with the Government of India. 
 
¶70.  (SBU) Our suggestions for your meetings with GOI Ministers on 
the Import Safety issue will be conveyed in the third scenesetter 
cable 
 
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