Inaccessibility and cost cripple efforts to treat sickle cell disease

People from marginalised tribal communities, face a battle even to access basic healthcare and diagnostics. They also face an underresourced health system, inadequate information, and high expenditure. Treatments like CRISP cost $23 million and bone mar

disparities it makes apparent.

The U.S. Food and Drug Administration recently approved two gene therapies, Casgevy and Lyfgenia, to treat SCD in people ages 12 and older. Casgevy, developed by Vertex Pharmaceuticals and CRISPR Therapeutics and also approved in the U.K., is the first CRISPRbased therapy to have received regulatory approval in the U.S. Lyfgenia, manufactured by Bluebird Bio, doesn’t use CRISPR but depends on a viral vector to change blood stemcells.

Both treatments entail collecting a patient’s blood stemcells, modifying them, and administering highdose chemotherapy to destroy the damaged cells in the bone marrow. The modified cells are then infused into the patient through a hematopoietic stem cell transplant. The treatments are expected to take up to a year and require several hospital visits. Victoria Gray, a patient in her mid30s from the U.S., was the first recipient of Casgevy in clinical trials. Having been free of SCD symptoms and pain for a few years, she is now seen as a symbol of hope for new therapies.

CRISPR’s inventors have won a Nobel Prize and it is celebrated as a revolutionary innovation, but its treatment cost of $2–3 million keeps it out of reach of most of those affected in countries where SCD is endemic. While researchers and policymakers are considering potential alternatives to improve access in low and middleincome countries, such hightech therapies require advanced care in wellresourced hospitals, too, bringing with it challenges of availability, affordability, and quality — which disproportionately affect the poor and marginalised. It raises pressing questions about equity, access, and justice in the use of gene therapies.

CRISPR in India

In India, CRISPR’s possible medical applications also pose ethical and legal quandaries. The National Guidelines for Stem Cell Research 2017 prohibit the commercialisation of stem cell therapies and allow the use of stem cells only for clinical trials, except for BMT for SCD. Geneediting stem cells is allowed only for invitro studies. The Guidelines also encourage (but don’t mandate) the sharing of financial benefits resulting from the commercialisation of stem cell products with the donor or community.

Further, the National Guidelines for Gene Therapy Product Development and

Clinical Trials 2019 provide guidelines for the development and clinical trials of gene therapies for inherited genetic disorders. India has approved a fiveyear project to develop CRISPR for sickle cell anaemia. Under its Sickle Cell Anaemia Mission, the Council of Scientific and Industrial Research is developing geneediting therapies for SCD. Around ₹34 crore has been allocated for this mission over 20202023. It is reportedly in the preclinical stage, with clinical trials awaited.

However, the Guidelines need a stronger health inequity and discrimination perspective, addressing issues such as equitable opportunities for underserved populations to safely participate in clinical trials, and whether and how this therapy will be made available to those populations in future.

Adopting and promoting advanced therapies like CRISPR in India require a comprehensive approach that accounts for inequities and disparities in the country’s overall healthcare access framework. While such advances in curative treatments are encouraging, our concerns are primarily focused on the importance of equity and access throughout the lifecycle of research, development, and implementation of gene therapies.

The development of therapeutic technologies occurs at a pace and level that renders it unavailable to the same constituencies most affected by the disease. The wait for the products of geneediting to trickle down to the margins is long and often in vain. We suggest investment in expensive therapeutic technologies need to be preceded by focused efforts to first make basic treatment available — such as an uninterrupted supply of hydroxyurea — to those direly in need of treatment.

Deliberations on regulatory frameworks also need to be expanded from closed scientific circles to the larger public. Policies on the development of such technologies need to receive inputs from civil society and patients’ advocacy groups to be able to develop frameworks for ethically responsible research. The need of the hour is an approach that focuses on integrating these multiple issues of access to diagnostics, drugs, health information and community support. It is only then that children like Suraj will be able to live a healthy life in the long term.

(Sarojini Nadimpally, Gargi Mishra, and Keertana K. Tella work on public health, bio and reproductive technologies, human rights and gender.)

Sickle cell disease is an inherited haemoglobin disorder in which red blood cells become crescent or sickleshaped. These RBCs are rigid and impair circulation, often leading to anaemia, organ damage, severe and episodic pain, and premature death

JANICE HANEY CARR/AP A colorised microscope image made available by the Sickle Cell Foundation of Georgia via the U.S. Centers for Disease Control and Prevention shows a sickle cell, left, and normal red blood cells of a patient with sickle cell anaemia, 2009.

FILE PHOTO The Sickle Cell Team from JSS College in Mysuru performing a skit on sickle cell awareness at Chamarajanagar.