The Indian Institute of Technology Madras (IITM) organized on August 14, 2010 a symposium titled “Medical Education and Research in Independent India: A Critical Review and Projected Role of IITs in Post-graduate Medical Education and Research” at its campus. Apart from the Director of IITM, Professor M S Ananth, two eminent medical professionals, Professor B M Hegde (a noted cardiologist, former vice-chancellor of Manipal University and a recipient of the Padma Bhushan award) and Dr C V Krishnaswamy (a renowned diabetologist and a pioneer in affordable diabetes treatment for the needy through the Voluntary Health Services, Chennai) delivered critical review lectures. An eminent chemist, Dr Lalitha and a reputed physicist Dr Srinivasan provided additional perspectives as panelists.
The symposium raised several open issues with the very relevance and appropriateness of modern medicine as is taught and practiced coming under serious critique by the two distinguished invitees. Both the speakers are well-known for their erudition as well as campaign against exploitative medicine. Both the speakers consider the human body as a technological energy-house, capable of rewiring itself and requiring only a minimalist medical or surgical intervention. It is not surprising therefore that Professor Ananth admitted that he stood confused after listening to their lectures. If the symposium was intended to lay a charter for the IITs in medical education, the purpose was far from accomplished. Yet, the very act of focusing on the potential role of the IITs in medical education is a ground-breaking thought. Dr Ananth deserves kudos for germinating and pursuing this thought.
The proposition of medical education in the IITs appears highly counter-intuitive given that the IITs had been established solely for excellence in higher technological education and research. The proposition appears to go against the Indian educational eco-system which for decades saw engineering and medicine as two distinct (and almost non-complementary) streams of education. So much so, at school finishing level itself the students are required to choose between a mathematics-physics-chemistry stream, which is a prerequisite for engineering education, and a biology-physics-chemistry stream, which is a pre-requisite for medical education. Given the resource scarcity in higher education in India it is also debatable if additional resources of the IITs should be spent on diversifying into medical education and research or on deepening the core competencies in scientific and technological education and research. Though the proposition, on the above counts, appears counter-intuitive to the Indian context there is a strong case for analyzing the proposal with due objectivity.
The macro-case for the IITs
The Indian Institutes of Technology (IITs) are a group of 15 autonomous engineering and technology-oriented institutes of higher education established and declared as Institutes of National Importance by the Parliament of India, and hence established directly by the Central government. The IITs were created to train scientists and engineers, with the aim of developing a skilled workforce to support the economic and social development of India after independence in 1947. In order of establishment, they are located in Kharagpur (1950; as IIT 1951), Mumbai (1958), Chennai (formerly Madras) (1959), Kanpur (1959), Delhi (1961; as IIT 1963), Guwahati (1994), Roorkee (1847; as IIT 2001), Ropar (2008), Bhubaneswar (2008), Gandhinagar (2008), Hyderabad (2008), Patna (2008), Jodhpur (2008), Indore (2009) and Mandi (2009). Some IITs were established with financial assistance and technical expertise from UNESCO, Germany, the United States, Japan and the Soviet Union.
Each IIT is an autonomous university, linked to the others through a common IIT Council, which oversees their administration. They have a common admission process for undergraduate admissions, using the Joint Entrance Examination (popularly known as IIT-JEE) to select around 8,000 undergraduate candidates a year. Postgraduate admissions are done on the basis of the national competitive examinations called GATE, JMET, JAM and CEED. About 15,500 undergraduate and 12,000 graduate students study in the IITs, in addition to several hundred research scholars. The alumni of the IITs have become top-ranking scientists, technologists, managers, and entrepreneurs globally. The IITs, especially the ones with long history, have won consistent ratings among the top technological institutions of the world. In more ways than one, the IITs have become global institutions and brands of India, attracting the best students and teachers in India.
In contrast, higher medical education in India has largely been introverted, partly due to the institutional constraints and partly due to the reluctance of advanced economies to open up to foreign doctors. Neither has it been promoted as an educational mission of national importance by the Central government as it did in the case of IITs. There are only a few national medical institutions such as AIIMS, Delhi and JIPMER, Puducherry, which are centrally sponsored. Most other medical institutions are State sponsored or private sponsored and have won reputation as teaching hospitals. If the concept of IITs as institutes of national importance has paid off, an analogous concept in medical education as a mission of national importance should be equally relevant and feasible. By extending the scope of IITs to include medical education, potentially the 5 decade experience and institutional structure of the IITs can be effectively leveraged for medical education.
The other logical treatise relates to the role of science and engineering in the field of medicine. From diagnostics to surgery, and from pharmaceuticals to human organs technology plays a major role as never before. The body scanning and blood analysis equipment and processes are getting advanced each year with more sophisticated imaging systems, informatics and predictive capability. As the sciences of human genetics and genetic engineering become more advanced the ability to predict likely disease incidence and therapeutic efficacy would only increase in future. At the other end of the spectrum, minimally invasive surgical methods, utilizing robotics and laser surgery on one hand and regenerative medicine including transfused and auto stem cell therapies would substitute the classic surgical scalpel. In more senses than one, future physicians and surgeons need to be expert biologists, physicists, chemists, engineers and technologists, all rolled into one. This indeed is a tough call and requires a highly communicative, collaborative and networked community of scientists and technologists.
By letting the current graduate studies in sciences, engineering and medicine consolidate as at present but establishing a new paradigm of post-graduate and research studies in life science technologies, the IITs can certainly make biology and technology work for medicine. The challenge is, therefore, not merely one of teaching medicine in the IITs; it is one of defining a whole new stream of life sciences technology. This would involve understanding the human body better through deployment of engineering tools, individualizing diagnosis and therapeutics through deployment of genetics, potentiating pharmaceuticals through newer molecular moieties, more patient-friendly and more efficacious delivery systems, moving surgery into an almost non-invasive technological tool, and regenerating the human body through its own immune and cellular therapeutics. IITs can certainly create these new life science technological substrates through higher education and research. Respecting that human beings can never arrogate themselves to create or modify life which is God’s great creation, some of the potential life cycle technological theorems are hypothesized below.
Modeling the human body and mind
Cellular technologies. Engineering aims to reduce the abstract to precise, visualize the hidden and optimize performance. From mathematical equations to heuristic algorithms, and from simulation to fuzzy logic multiple engineering approaches are available to model systems. Biological and medical sciences have so far used in vitro and in vivo animal models to understand how human body gets affected by disease and how it is cured by medicines. This modeling continues the principal theme of medical development despite the knowledge that exists that animal modeling does not simulate, replicate or predict human modeling. If the fundamental building block of human body, or for that matter any living organism, the “cell” is understood better the science of life and living becomes stronger. Considering that the human body is made of trillions of cells as building blocks, with different types of cells conducting different tasks, modeling, engineering and optimizing cellular behavior is the fundamental challenge as well as opportunity for newer life science technologies.
NIGA models. Engineering has moved from designing and manufacturing machines operated by human beings to designing, manufacturing and operating human-like machines, the humanoids. Science has moved from explaining the laws of physics, chemistry and biology to cloning and creating biological organisms leveraging the laws that have been discovered and defined. Yet, what propels cells to do what they do has not been understood yet. The nutrition-immunity-growth-aging (NIGA) model (the author’s unique acronym) has not been understood either as an individual model or collective system. Energy is essential for growth; yet it is not understood at what points of time, and in which manners, energy supply to, and consumption by, the human body become optimal or sub-optimal. Relating cell growth and death to alternative models of nutrition and energy would be an essential component of life science technologies. IITs, having mastered mechanical, electrical, electronics and computer engineering domains can apply these principles to establish and validate customized NIGA models at cellular levels.
Networking solutions. The human body is an impossibly complex electro-mechanical, neuron-capillary network with multiple biological pumps and filters that maintain the body and mind in harmony with themselves and in dynamic equilibrium with an often hostile environment. Principles of engineering can be utilized to model these interactions. For example, failure of venous pumps in legs causes accumulation of blood in capillaries and swelling of either peripheral or deep veins. Engineering rather than medical solutions to correct the pumping abnormalities are perhaps called for. Mapping of brain exteriors as well as interiors in neurologically challenged persons, and reviving of neural networks in brains of strokes-incapacitated patients is yet another area where electrical engineering could offer relevant solutions.
Diagnostic solutions. Clearly, major strides have been taken in developing diagnostic equipment which produce highly granulated images of the human body based on computer aided, magnetic resonance aided, and positive emission aided scanning devices. While the current equipment are minimally invasive and much faster compared to the earlier generation equipment, the continued use of radiation and radiological contrasting agents bring in risks of invasive analysis and discomfort. It is necessary to work on continued engineering solutions which not only sharpen the imaging capabilities but also correlate with clinical outcomes in auto diagnosis as well as in feedback correction model.
Robotic solutions. The use of robots for surgery has indeed been a game changer. Large incisions have now given way to key-hole surgeries. Use of robots in surgery can go a step further as new technologies enable slender, flexible arms to navigate through the contoured internals of the human body. While so far robots have provided better magnification and manipulative skills in one to one relationship with surgeons, it is possible to envisage a future whereby more than one robot could be pressed into service to perform multiple tasks simultaneously. It is also possible to envisage miniaturized robots and nano robots which can actually be placed in the internal body systems for more precise nature of body responses during the surgical processes.
Materials solutions. From creation of synthetic organs to development of artificial blood, engineering can play a major role. Discovery and development of more bio-compatible materials together with in situ design and manufacture of required human parts could lead to better outcomes, especially in orthopaedic, cardiac and cosmetic surgeries. Materials which minimize blood loss, suturing systems which promote rapid self-healing, carriers and excipients that enable better bioavailability for pharmaceuticals are all within the realms of engineering possibility.
Pharmaceutical solutions. IITs have a great track record in the sciences of chemistry and physics. Chemistry is traditionally focused on engineering kinetics and dynamics in a machine system rather than on kinetics and dynamics of molecules in a human system. Yes, these two key disciplines, can be supplemented to develop powerhouses of new chemical entities and new drug delivery systems. With the addition of newer disciplines of biotechnology and nanotechnology, the IITs are well positioned to drug discovery and drug development activities in both small molecule and large molecules spaces.
Device Solutions. Medical devices are increasingly playing a major role in monitoring patient condition, bedside. The ultimate destination of this quest should be to have a patch which when worn on the patient’s skin can provide a complete readout of all the body parameters. New biochemistry and bio-enzyme technologies would be required which could apply principles of microporosis and generate inputs to a wide range of conditions like salt and electrolyte balances in the body. This, coupled with devices which are capable of programming, feedback and self-regulation could take medicine to an auto-management mode.
IT-enabled Personalized Medicine. The IITs decades ago pioneered computer education. They also have been pioneers in mathematical and stochastic modeling as well as application of statistics and economics. All these capabilities can be applied for developing new frontiers of personalized medicine to eliminate variability in person-to-person therapeutic efficacy. A host of clinical and medical sciences such as pharmaco-genomics, pharmaco-economics, genetic prescription, personalized medicine can be expanded based on application of computer sciences. From simple archiving and analysis of clinical data to complex predictive modeling IITs can harness their computer skills to enable personalized medicine.
The above are only a few illustrative areas indicative of the capability of engineering to redefine higher medical education and research.
Life science technologies – actions for the IITs
Clearly, there are a number of domains and applications where the principles of engineering and physical sciences, including mathematics, when combined with the principles of biological sciences can provide breakthrough solutions for medical needs that are unmet or can be better met. Clearly the current medical schools which have no engineering background are not the campuses to aim for such new developments. On the other hand, given the preponderant use of science and engineering, the IITs could be the campuses where such new life science technologies can be developed.
The route to such development lies in creating centers of excellence, for each of the solution areas that have been discussed in the foregoing in an illustrative manner. For example, there could be centres of excellence for cellular engineering, NCGA modeling, network rejuvenation, diagnostic efficiency, robotic surgery, bio-materials development, pharmaceutical discovery and device optimization. These, and other similar centers, should be bound together by an integrated human life science technology system which understands the engineering of the human body and mind in a holistic manner.
As a fundamental requirement for the new stream of life science technologies, the current distinction between biological sciences oriented curricula and the mathematics oriented curricula (the former leading to medicine and the latter leading to engineering) needs to be done away with. Undergraduate students should be provided with equal grounding in physical sciences and biological sciences to be able to absorb the nuances of medicine and engineering effortlessly.
If the medical education as envisaged herein needs to take root in the IITs, the analytical capabilities need a significant leg-up. More powerful liquid and gas chromatography and mass spectroscopy instruments capable of not only conventional analytical research but also bio-analytical development and detection of entities in the minutest pico and ppq ranges would be required. Similarly, biological laboratories which can develop in vitro cellular models based on genetic sciences will also be required. New genetic engineering equipment such as protein extraction and purification equipment, gene sequences, microarrays will need to be installed. It is likely that upgradation of infrastructure alone would be in the order of one billion dollars for say five IITs together to start with.
Integrated life science technology programs at higher levels of education (post-graduation and research including doctoral and post-doctoral programs) must be flexible to accept entrants via basic bachelor’s degree in engineering or medicine. Establishment of autonomous life science technology centers within the IITs with their own dedicated programs will see a new dream fulfilled in higher education scene in India. Probably with such an effort, India could lead an educational revolution in life science technologies even on a global basis.
Posted by Dr CB Rao on August 16, 2010 (an alumnus of M Tech and Ph D programs of IITM)