India's emergence as a global pharmaceutical powerhouse is entering a transformative new phase, driven by innovation, vaccine leadership, and expanding clinical capabilities, according to Dr Elias Zerhouni, former Director of the US National Institutes of Health (NIH). Speaking to NationPress in Boston on 1 May, Zerhouni said the India-US relationship in healthcare and biotechnology has moved decisively beyond manufacturing into innovation-led collaboration.

From Generics Backbone to Innovation Leader

Zerhouni acknowledged that India continues to dominate in generics and active pharmaceutical ingredients (APIs), describing them as a critical backbone of global drug supply. "India is very strong in chemistry and all the APIs… they come either from India or from China," he said, adding that the country remains "a major source of generic principle drugs."

But he was emphatic that India's pharmaceutical identity has evolved. "We're not just using or working with India as a manufacturing country, but also as an innovative country," he told NationPress, citing the growing global presence of Indian firms. "There's a tremendous amount of exchanges and a presence of now larger and larger Indian companies, Lupin and Sun Pharma, and many others," he said.

Vaccine Manufacturing: A Defining Global Contribution

Zerhouni singled out India's vaccine manufacturing capacity as one of its most consequential global contributions. "Without Indian contributions to the manufacturing of vaccines like the India Serum Institute, it would be very hard to immunise the population around the world," he said. The Serum Institute of India, based in Pune, is the world's largest vaccine manufacturer by volume and played a pivotal role in global COVID-19 immunisation efforts.

He also highlighted India's approach to "frugal innovation" as a structural differentiator — developing solutions that are effective without being prohibitively expensive. "Innovation that doesn't cost such an amount of money that people don't have access to it… I think that's in the culture in India," he said.

Geopolitical Pivot and the China Factor

Zerhouni pointed to a broader geopolitical realignment that is accelerating India's rise. "There's a pivot right now… a lot of people are pivoting outside of China… to India in many ways," he said, citing rising collaboration in medical technology and biomedical research. This comes amid sustained global efforts to diversify pharmaceutical and API supply chains away from China — a trend that intensified after COVID-19 exposed critical dependencies.

He described biotechnology as entering a "multipolar" phase, with India, China, and other nations all contributing meaningfully to innovation. "I don't care where the cure comes from. I want patients to be cured," he said.

Pandemic Lessons and Structural Challenges

Reflecting on COVID-19, Zerhouni said the crisis exposed deep vulnerabilities in global health infrastructure. "We discovered that we were not set up very well for a pandemic situation or a global health emergency," he said. He noted that both India and the US, as large democracies, rely more on private-sector incentives than central planning to address such challenges. "I don't know that there is a grand plan… I think it's the goodwill and the economic incentives that will drive that," he said.

On clinical trials, he acknowledged India is still at an early stage but improving. "Clinical trials are very sensitive… the sites have to be capable," he said, noting that regulatory systems and research culture are evolving. He also recalled bureaucratic delays as a persistent hurdle in NIH collaborations with India, having engaged directly with then Prime Minister Manmohan Singh to address grant approval bottlenecks. "We are democratic, right, but also bureaucratic, both the US and India," he said.

AI's Role and Contrasting Healthcare Priorities

Zerhouni offered a measured assessment of artificial intelligence in pharmaceuticals, saying its impact remains incremental. "It has improved the speed, improved the quality… but it has not really discovered anything that we didn't know," he said. He also drew a sharp contrast between healthcare priorities in the two countries: the US grapples primarily with cost — "people cannot afford the very expensive medications" — while India's focus remains on expanding access to affordable care.

Zerhouni served as the 15th Director of the US NIH from 2 May 2002 to 31 October 2008 under the George W. Bush administration, and was previously executive vice-dean at Johns Hopkins University School of Medicine. He was among the first US presidential science envoys in 2009 and served as a senior fellow at the Bill and Melinda Gates Foundation from 2009 to 2010. As India's pharmaceutical ambitions scale up, the question of whether regulatory and research infrastructure can keep pace with the geopolitical opportunity will be decisive.