The journey from a scientific finding to a binding national policy is never linear, never clean, and almost never fast. India’s record on this journey is mixed. Two recent episodes — the e-cigarette ban and the national snakebite programme — reveal both what the country’s health research establishment can do and what, in practice, it still cannot.
In September 2019, the Government of India promulgated an ordinance banning the production, import, export, transport, sale, distribution, storage, and advertisement of electronic nicotine delivery systems — e-cigarettes and related devices — throughout the country. The move was rapid by any standard of public health governance. It followed directly from a white paper published in May of the same year by the Indian Council of Medical Research, a document that synthesised available global evidence on the health risks of ENDS products and arrived at an unambiguous regulatory recommendation: prohibit them. The government acted within four months.
In March 2024, nearly five years later, the Ministry of Health and Family Welfare launched a National Action Plan for Prevention and Control of Snakebite Envenoming — NAPSE — setting a target of halving snakebite deaths in India by 2030. This too was anchored in ICMR evidence: a white paper, a multi-site national task force study on incidence and burden, implementation research on health system responses. In November 2024, snakebite envenomation was made a notifiable disease for the first time. In 2025, the Supreme Court of India took cognisance of the snakebite crisis and sought responses from the Centre and states on antivenom access and treatment availability.
The two cases are instructive in what they share and in where they diverge. Both illustrate ICMR’s capacity to generate the kind of multi-institutional, evidence-synthesising output that can move a policy debate to a conclusion. They also illustrate, with different degrees of discomfort, the gap between a national plan and its operational execution — and the question of whether the systems that produce evidence are adequately connected to the systems that must implement the resulting policies.
The ENDS Case
The ICMR white paper on Electronic Nicotine Delivery Systems, published in the Indian Journal of Medical Research in May 2019, was a document of deliberate scientific conservatism. Its conclusion — that ENDS products have a net negative impact on public health — rested on evidence of nicotine addiction, DNA damage, carcinogenic effects, respiratory and cardiovascular harm, neurological risks, and adverse foetal outcomes. Crucially, it rejected the harm-reduction argument: that e-cigarettes might help established smokers quit combustible tobacco. The paper found that evidence for smoking cessation benefit was not firmly established, while evidence for youth initiation risk — ENDS use by minors was found to double the likelihood of subsequently using combustible tobacco — was considered sufficient for a precautionary policy response.
The scientific consensus since then has continued to evolve, and not in a direction that allows for simple conclusions. Several health authorities in Europe and North America have taken a harm-reduction position that regards vaping as substantially less harmful than combustible tobacco for established adult smokers, while acknowledging the youth initiation risk that ICMR’s paper highlighted. India’s statutory ban — still in force — has not eliminated demand; the Indian e-cigarette market was estimated at approximately US$2.2 billion in 2024 and is projected to approach US$3.4 billion by 2033, with consumption having migrated substantially toward illicit and unregulated channels. That migration carries its own health risks: unregulated products are not subject to the quality controls that even a lightly regulated legal market would impose.
This is not to argue that ICMR’s 2019 recommendation was wrong. The precautionary principle — particularly in the context of a country with over 250 million tobacco users and documented youth uptake of ENDS — has defensible justification. It is to observe that the translation from evidence to national law, in this case, was unusually rapid, and that the subsequent evolution of the evidence base has not prompted a corresponding policy review. The question of whether India’s ENDS ban is still the optimal public health posture in 2026 — given what is now known about relative risk, illicit market dynamics, and cessation efficacy — is a question that ICMR’s evidence capacity is uniquely placed to revisit. There is, as yet, no public indication that such a review is underway.
“ENDS or e-cigarettes have documented adverse effects on humans including DNA damage; carcinogenic, cellular, molecular and immunological toxicity; respiratory, cardiovascular and neurological disorders; and adverse impact on foetal development and pregnancy.”
ICMR White Paper on Electronic Nicotine Delivery Systems, 2019
Snakebite: When the Evidence Exists but the System Cannot Deliver
The snakebite story sits on a different axis of policy failure. Here, the problem is not that the evidence arrived too fast and produced an inflexible policy. The problem is that the evidence has been accumulating for years, the policy framework is now in place, and the implementation — the part that requires not a white paper but a supply chain, a trained health worker, a quality-assured vial of antivenom at a rural primary health centre — is where the system struggles most visibly.
India accounts for nearly half the world’s estimated snakebite deaths. The exact burden is contested: a 2025 community-based cross-sectional study published in Nature Communications found mortality rates considerably lower than projections from the Registrar General of India’s Million Death Study, with significant variation across biospheres. What the data does confirm, regardless of which mortality estimate is accepted, is that the deaths are concentrated in rural communities with poor healthcare access, and that a substantial proportion occur before the victim reaches a medical facility. Delays in seeking formal care — compounded by reliance on traditional healers, distance from hospitals, and poor awareness of snakebite as a medical emergency — are the dominant determinants of fatal outcomes, not the absence of an effective antivenom. Effective polyvalent antivenoms exist. Getting them to the right facility, in the right condition, at the right time, is the unsolved problem.
NAPSE, the national action plan launched in March 2024, is explicit about this. The plan identifies inadequate ASV availability at primary healthcare facilities, inconsistent product quality, insufficient training of frontline health workers in snakebite recognition and management, inefficient emergency referral systems, and limited community awareness as the core challenges. Regional venom centres are proposed to address venom variation across geographies — an important recognition that the current ‘Big Four’ species paradigm, under which Indian polyvalent ASV is manufactured to target four canonical snake species, is scientifically insufficient for a country whose venom profiles vary substantially across its ecosystems. A 2025 paper in Transactions of the Royal Society of Tropical Medicine and Hygiene has argued formally that India must expand its antivenom approach beyond the Big Four framework.
Implementation, a year into NAPSE, has been uneven. Published assessments note limited multi-sectoral engagement in the programme’s early phase, wide variation in state-level capacity, and logistical barriers in reaching remote populations. These are not surprising findings — they are the normal friction of implementing a complex health programme across a country of India’s scale and administrative diversity. But they underscore a structural reality that ICMR’s evidence capacity alone cannot address: the gap between a national action plan and its district-level operationalisation is not primarily a research problem. It is a governance, supply chain, and health-system-strengthening problem that requires the active participation of state governments, the procurement machinery of the health ministry, and the pharmaceutical manufacturers who produce ASV under conditions of limited commercial incentive.
The Evidence-to-Procurement Gap
What the ENDS case and the snakebite case share, beneath their obvious differences, is a structural gap between evidence generation and operational delivery. ICMR is well-designed to produce the former. The white paper process — convening multi-institutional expert groups, synthesising global and domestic evidence, producing a consensus document that can withstand scientific and regulatory scrutiny — is something the council does with genuine competence. The ICMR-National Task Force model, applied to snakebite as to several other priority areas, has produced research that has informed national policy at the highest levels. That is a genuine achievement.
Where the system is less well-designed is in the connective tissue between the recommendation and the supply chain. The snakebite crisis is, at its operational core, partly a procurement and logistics problem: quality-assured ASV must be manufactured, stored under appropriate conditions, distributed to facilities that may lack cold-chain infrastructure, and administered by health workers who understand how to use it. The ENDS case, in a different register, raises a comparable question: when a policy recommendation leads to a statutory ban, and when the evidence subsequently evolves, what institutional mechanism exists to ensure that the policy is reviewed in light of new evidence rather than simply entrenched by precedent?
These questions point to dimensions of the health research-to-policy system that ICMR’s current reform agenda — the IRIS metrics, the MedTech Mitra pipeline, the Biopharma SHAKTI infrastructure — is not directly addressing. They concern not what India’s research institutions can discover, but how what they discover is absorbed and maintained by the systems that govern public health. The Central Procurement Cell that manages ICMR’s own supply needs sits at one end of this problem. The health ministry’s procurement and distribution machinery sits at the other. And between them lies the terrain where evidence, however robust, can fail to produce the outcome it was designed to achieve.
“Ensuring consistent access to quality anti-snake venom in rural and remote areas remains a logistical challenge. Implementation remains inconsistent across states, often overlooking regional venom variations and specific population characteristics.”
PMC / Tropical Medicine and Infectious Disease, 2025
The Institutional Roles That Rarely Get Named
Inside ICMR headquarters, the gap between evidence and operational delivery is not invisible. There are scientists whose careers sit precisely at this junction — who have both generated evidence that shaped national policy and administered the institutional machinery that determines whether that policy can be executed. That combination is rarer than it should be in India’s health research establishment, and the fact that it exists at all is worth examining.
The ICMR white paper on ENDS and the national task force research programme on snakebite share a common thread: each required not just scientific synthesis but institutional coordination across disciplines, regulatory bodies, and government ministries. The scientists who led that coordination work quietly at the intersection of research, administration, and policy — roles that receive far less institutional recognition than the published paper, but without which the published paper would have no consequence. In an era when ICMR’s leadership is explicitly trying to create a metric system that rewards exactly this kind of translational and implementation-oriented work through the Publication Equivalent framework, the question of whether the institution’s culture can be changed to match its stated incentives is one of the most consequential questions in Indian health research governance.
The evidence machine is running. The policy pipeline is being rebuilt. The procurement architecture — including the centralised procurement operations that serve ICMR’s own research infrastructure — is the least visible but most operationally significant part of the system. Whether the three are adequately aligned is the question that the ambitious plans of 2026 have yet to answer.
