Medicine, in the way it is practised and administered in India will change because the world is changing. Significantly. Eric Topol, in a recent article titled “How to Change Medicine” said “New tools in medicine can reboot the future of health care, making it more precise, consumer driven and truly preventive“. This, interestingly, mirrors the trends in technology as also those in many consumer facing industries.

Before we look at the ramifications these new technological developments have for India lets get an overview of the current medical scenario and the milestone discoveries/advances that will change medical practice and administrative protocols worldwide. Perhaps, forever…

The Theatres of Change:

1. Genome Mapping: The Discovery of our Unique Individual Genetic “Bar Codes”

Patients EVERYWHERE including India are prescribed drugs that they:

1. Do not respond to or
2. Respond to only at markedly different dosages than what is normatively prescribed

Some common examples of the same are cited by Eric Topol in his book. 3 of these are mentioned below.

• Patients who have a stent placed in their heart are routinely prescribed a drug called Plavix even though at least 30% of such patients do not have the normal genetic capability of metabolising Clopidogrel, the main ingredient in this drug AND need triple the normal dosage Or an alternate drug to bypass the glitch in their metabolic pathway. These aspects are rarely taken into account!

• The story repeats itself with Metformin: a first line drug for Type 2 ( non immune mediated) diabetes mellitus. At least 20% patients that receive this drug register NO response to it at all.

• Statins are widely prescribed to treat high cholesterol levels and prevent heart attacks or strokes. The largest clinical trials of common statins viz Lipitor, Crestor, have demonstrated only One Out Of Hundred people taking the drug would actually benefit and avert a heart attack. Yet 90% people continue to pop this pill even though it doesn’t help them at all beyond lowering cholesterol levels: they remain as susceptible as before to risk of heart attack/stroke.

These are just three examples. There are innumerable others. Each of these medications, and the numbers are shockingly large, are part of the current medical system where one size fits all.

The good news? ALL THIS WILL CHANGE. AND SOONER THAN WE CAN IMAGINE. Profound inefficiency, needless prescriptions, fiscal waste, imprecise determining of whom may/may not benefit from a treatment or test will stop. Because we now have new tools to effect this change: the ability to define each individual in “high definition” at the biological, physiological, anatomical level. Tools that reconfirm our belief that each individual is unique even as they enable us to leverage this knowledge to improve medicine, customise it to target not generic but biologic “individual” maladies.

This magic tool is Genome Mapping. The 6 billion bases that comprise our genome, we’ve discovered, represent ONLY ONE PART of our “omics” which comprise other omics like our full set of proteins, metabolites, the resident bacterial flora in our gut/skin/other tissues, the packaging and side chains of our DNA. Thus even identical twins, we’ve discovered, do not have the same epigenomes and biogenomes even though their DNA might be identical!

This individual “bar code” inscribed on our bodies helps make medicines and treatment much more precise and helps ensure more successful outcomes. Lets take a few instances: a drug like Carbamazepine (Tegretol) can have devastating side effects like a virulent, fatal auto immune skin reaction called Stevens-Johnson syndrome. But only 1 person in a 1000 having a particular gene variant will manifest this fatal effect. Shockingly while this test in routine for anyone prescribed this drug in Taiwan, no such screening is done for anyone given the same drug in the U.S or In India. Each time any American or Indian pops this drug he/she is, in effect, playing Russian roulette. That grim scenario is avoidable because easy availability of genome mapping tests affords the tantalising possibility of our being able to map the genetic basis of all serious side effects.This would have three salutary fallouts

• Drastic reduction of prescription errors

• Immediate identification of patient most likely to benefit from a given drug making precise customised targeting and treatment possible

• Knowing a person’s susceptibility to diverse ailments through gene mapping would enable people to take preemptive measures, initiate therapies, effect lifestyle changes to both rectify/control a potential debilitating condition or worse: a fatality, before its too late

Now here would this help alleviate human misery more than in the treatment of diverse cancers. Cancer therapy will not be based on general diagnosis any more. Sequencing of “tumour DNA” and what is termed “germline DNA” would help us determine the driver mutations that are propagating the cancer. Medication, then, would be directed to eliminate that root cause of cancer because we now know definitively its not the “type” of cancer we need to treat but the type of “mutation” thats causing it. An example: a mutation in the gene such as BRAF maybe responsible for malignant melanoma in some patients but is responsible for thyroid cancer in other individuals!

Another far reaching intervention of genetic sciences is in the field of Pediatrics. There are 1139 recessive genetic disorders which account for 20% of the malformations that account for infant mortality. Current genomic knowledge has helped us screen for 570 of these genetic disorders and seriously reduce incidence of diseases like TAY and SACHS and Cystic Fibrosis. Digitising infant genetic data has helped reduce infant mortality, provide recourse, redressal, treatment, even preemption at the foetal stage.

Finally the foreknowledge that genome sequencing bestows would help us avert, preempt, treat, even nip in the bud serious late onset diseases like hypertension, heart disease, many cancers, asthma, diabetes, brain disorders like Alzheimer’s. These diseases usually manifest themselves in our forties or fifties. Genetic foreknowledge would help us leverage this fifty year window/lead time advantage to mitigate the possibility of occurrence or the severity of the disease foretold. It would also enable us to make the lifestyle rectifications that would help prevent damage .

Thus medical focus would shift from Treatment/Cure to Prevention. Treatment strategies would be informed by knowledge of unique individual genetic behaviours, causality, proclivity, rather than generic assumptions that result in the shooting blind, one-size-fits-all variety of treatment protocols that harm rather than help patients.

Implications For India

At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals. The World Health Organization believes that one in 10 hospital admissions leads to an adverse event and one in 300 admissions in death. The risk of health care-associated infection in some developing countries is as much as 20 times higher than in developed countries. In India every statistic for any given lacunae viz mismatched drugs, genetically antipathic drugs administration resulting in fatalities, is magnified manifold given the sheer numbers of people that populate the second most populated landmass in the world.

Cancer is a major public health concern in India and has become one of the 10 leading causes of death in the country. The burden of cancer is expected to further increase due to increase in life expectancy, demographic transitions and the effects of tobacco. The savings in terms of hospitalisation fee, incremental gains in terms of lives saved, would be tremendous should we concentrate on precise, targeted, effective therapies rather than shooting blind at unknown enemies as we are wont to do in our battle with cancer.

Similarly infant mortality rates in India are unacceptably high viz 47 per 1000. And the actual figure is suspected to be much higher camouflaged as it is by massive underreporting and deliberate listing of “cause of death” under misleading heads like septicaemia or organ failure. This sorry state of affairs could be remedied significantly, many precious lives saved with early genetic mapping, diagnoses, treatment.

Likewise chronic killer diseases would be tamed, survival rates would soar, avoidable patient discomfort/hospitalisation would be averted should we learn to capitalise on the foreknowledge advantage and the lead time it affords us. Great news for the millions of Indians afflicted with cardiac trouble, blood sugar, sleep apnea, hypertension, asthma, Alzheimer’s.

Can genome mapping be the answer to India’s growing healthcare crisis? What are the implications for pharma companies, hospitals and doctors if we move from the current illness focused practices to promoting wellness instead?

2. Remote  Physiologic Monitoring

Biosensors external or implanted within the body are sophisticated, miniaturised mini computers than can monitor sleep apnea, blood glucose/ pulse/ oxygen levels, glaucoma through monitoring eye pressure, heart arrhythmia, early cardiac episode warning signs, asthmatic symptoms, blood pressure, body temperature when we are awake, asleep, working or resting. They can sound red alerts way before any symptoms appear. Such data proves invaluable in detection, diagnosis, tweaking of therapies and determining the effect of diet, exercise, emotional, physical peaks and troughs that manifest in symptoms which have the potential to turn acute, even fatal.

Such data that matches information yields obtained with ICU level monitoring and care (with the attendant dislocation and great emotional, physical, psychological cost to patients not to mention steep hospitalization costs) would render hospitalization redundant except in cases of acute distress, criticality. The many savings on various fronts including a considerable easing of the pressure on already overworked, understaffed, health services can hardly be emphasised.

Information generated by personal use medical gadgets may well be likened to the CHK ENGINE signs flashed in computerised cars which give early warnings of impending trouble, mechanical shutdowns.

Implications for India

Delhi’s “Yusuf Sarai” is the epicentre of the Delhi/NCR medicines and medical gadget trade. A small dipstick research yielded some startling facts:

1. A slew of personal care oriented medical gadgets have been introduced in the market in the last three years, which, in the long term, have the potential to radically change the way we look at diagnosis, treatment and dispersal of medical care to patients.

2. The range of gadgets available over the counter today consists of Home Dialysis machines (Fresnius/Braun), Insulin monitors (Johnson & Johnson) BiPap autoSv sleep therapy systems by Respironics and Resmed to monitor conditions like Sleep Apnea, ECG/Pulse Rate meters, Watches with GPS/GPRS connectivity geared to be 24/7 monitors for fall detection,and for 17 different health parameters such as pulse, blood pressure and blood sugar for analysis and pre emptive medical help.

The table below outlines top selling brands from 6 leading Yusuf Sarai Outlets among them 2 distributors

The logical extrapolations that lead us to the conclusion that this is a significant trend with far reaching implications. Empowered, informed, enabled metropolitan Indians are looking for authorship, autonomy, drivers seats in co managing their disease in consultation with doctors from whom they are demanding individual specific, appropriate, customised treatment.

Rajendra Sadhu, 39, a US citizen and IT professional who had to relocate to Hyderabad in December 2009 after nine years of working with Verizon Wireless to look after his ailing parents intuited precisely such a need and vaccum in the market and proceeded to adddress it. In March 2010 he decided to work on the Vesag watch device for which he applied for Indian and international patents. By December 2010 he unveiled a prototype at the Mobile Health DSummit in Washington DC. The product was launched in Feb 2011 in India through the 110 strong Hetero Pharmacies chain in Hyderabad. Over four months he sold (before stopping sales while negotiations are ongoing with a major corporate for sales across the country) 150 Vesag watches, 39 pulse oximeters, 39 ECG monitors and 33 BP monitors. By March 2011 his invention was rated the best among top ten health products of the year by the Connected magazine in the USA. A subsequent article in the magazine about the product titled “The Watch that Watches you Back” garnered yet more favourable media attention. It was subsequently voted Cool Product of the Year by the Intel magazine in the US.

The internet is Sadhu’s preferred sales and communication tool because it is cheap and effective. He’s negotiating now with a major corporate to market his idea and his product across India. Especially in the rural hinterland where he feels it answers a critical medical need.

The Plan? Simple.

Rural Medical Monitoring Centre to be run by the classic erstwhile PCO booth person who buys a complete VESAG medical monitoring kit for Rs 20,000. Each medical check up would cost Rs 50, Rs 3 from which would go to the entity running the software processing centre. “Over 400 checkups the Rural Med Centre operator would have recovered his equipment cost” says Sadhu.

The Advantage?

His data is immediately flashed to the nearest hospital/treating doctor so appropriate timely medical care can be provided and emergencies preempted.

On the Anvil?

An intercity connectivity network that would enable a villager in Raipur to send his medical details to the specialist in Bhopal or Indore or Delhi for immediate evaluation and advise.

Basic health care in India is a privilege not a right. Private hospitals dot the urban Indian landscape. Conversely the state of health service delivery in smaller cities is largely still with government run medical establishments which were set up several years back. Most of these have limited infrastructure and are largely understaffed. Universal access to essentials like women and child health, water, sanitation, immunisation is a large focus area for the government. Traditional structure of medicine will need huge investments to make this a reality. Can democratization of medicine provide universal healthcare access? Are new models of healthcare the answer, which actively use both technology and make information transparent to the consumer ?

3. Appropiate  Safe Medical Imaging

A significant 2% of the cancers reported in the United States are thought to originate from indiscriminately prescribed nuclear scans, CT scans which expose patients to 40 SMV level radiation which is the equivalent of deadly ionizing radiation from 2000 chest x rays. Despite which in 2010 , 80 million CT scans were made in the US and the number is growing at 10% annually.

Similarly MRI’s and ECG’s are routinely prescribed. There is gross overuse of these gadgets: in the US 20 million ECG’s are performed every year and 50% of these are known to be totally unnecessary.

Today some doctors have taken to using nifty miniature, hand held, high resolution ultrasound devices that can be incorporated into the physical examination visit. Many confess to not having used a stethoscope for two years because with one handy transducer they can hear the heart, see each of its four chambers, their size, the heart itself, the sac around it, muscle function, the status of the valves… all in the space of a minute. This gives occasion to the doctor to review examination results together with the patient in real time: an impossibility if the patient has been shunted to another ultra sound cabin. The transducer, of course, renders the formal ultra sound examination totally redundant. This useful device, capable of transmitting high resolution images, is of invaluable help to paramedics who can transmit high resolution data on a patients vitals to trauma teams from the ambulance itself long before the patient reaches the hospital where cardiologists, radiologists are waiting: ready, alert, forewarned with appropriate treatment strategy in place.

Implications for India

In the last 2 decades despite state of the art medical care being offerred by corporate owned private hospitals in most metros in the country patient dissatisfaction with the quality and most importantly the cost of medical treatment remains extremely high. Our research suggests that in the last 20 years, the GP or the Family Doctor stands marginalised from being cornerstone of medical practice to mere fringe player. Because of this consumers are gravitating to high cost delivery centres, specialist visits, excessive testing and needless medication. The progressive growth of India’s 35 billion dollar healthcare industry can be seen in the rise of the number of diagnostic laboratories. There are over 12,000 hospitals and 15,000 diagnostic laboratories in India. Many patients look to new tests as the answer to their health care problems: it also is a primary driver of health care cost increases. According to the Indian Journal of Basic & Applied Medical Research, diagnostic tests and screening strategies are not absolute and when applied in low prevalence situations, produce false positive results leading to further testing or unnecessary medication.

A growing number of corporations are also willing to provide high end health care benefits to their employees. This is leading to some dramatic changes–over burdening of the large hospitals, excessive testing of executives who may be perfectly healthy and a rise in healthcare costs. Sometimes, this is also leading to needless over medication and over treatment.

How will the Indian medical system react to a reduction in needless testing? What changes will the gadgets bring to an environment that is invested in a practice that promotes testing over substantive clinical diagnosis? More importantly what kind of customer education is required to change expectations that have today started equating testing with treatment?

4. The Personal Electronic Health Record

The emergence of the patient rather than hospital based electronic health record that encapsulates every cumulative bit of medical data on the patient on one platform which could be as tiny as a personal cell phone or laptop. Details about imaging, radiation exposure from medical testing, genomics, pharmogenomic oddities, physiologic monitoring information would be on tap here, available at the touch of a button to both patient and his/her doctor of choice.

The positive fallout: the patient finds himself in a democratic set up, in a relationship of both autonomy and equality with the medical establishment where the treatment was sought. These records would also ensure huge fall in prescription error margins, ensure adoption of appropriate treatment protocols, protect patient from indiscriminate radiation exposure not to mention unnecessary expense/exhaustion from gratuitous testing.

Implications for India

It is precisely this need for information, autonomy, empowerment thats driving individuals to research their disease, self monitor, acquire and retain and present their own data and case and research and demand appropriate medical treatments from doctors as also question their expensive test/obfuscate/deflect/render opaque treatment protocols.

Our research of over 300 patients in 2012 Delhi found that when patients are dissatisfied with doctor recommendations they start on a Search for Cure trajectory. Shopping for cures across doctors, alternative therapies such as yoga, reiki, ayurveda, homeopathy and more. This is an important signifier of the pro active, participative, informed, questioning patient. This is likely to be a stronger trend once the personal medical record is available to all.

5. Hyper-Connected Information Highway

We live in historic times. There’s never been a technology other than human observation that has been so pervasively employed all over the world.

Our world is increasingly connected: 85% people all over the planet have access to a mobile signal. Six billion people inhabit Planet Earth. 3 billion of them own a telephone. There’s been a remarkable hybridisation of a maturing internet and mobile phones which has facilitated a unique technological convergence. Today a mobile platform includes texting, email, telephone gps, camera, multi media, 24/7 internet access.

Phones are enabled, equipped to work as stethoscopes, health monitoring and medical alert/ information transmitters. Video conferencing, skype interfaces are revolutionising the way we meet, transact, operate, analyse/resolve situations/make decisions in real time across countries and time zones.

More communication, connectivity through phones, internet, social media networks is making for immediacy, instant access and increasing redundancy for intermediates. An advantage publishing, music, movie, consumer industries are making adroit use of. And the health sector is awakening to the use and employment of all over the world.

Implications For India

The statistics are revealing:
1. The mobile subscription user base in in Jan 2012 was 903 million and is expected to breach the 1 billion mark anytime now. The user base is predicted to be over 1.5 billion by 2016.

2. Predicted annual growth rate for the industry? A healthy 26%
Mobile teledensity, a measure of cell phone availability will be 97.4 per 100 people by 2014. That translates into saying everyone except children and the abjectly poor will have a cell phone or access to one.

3. 3G subscriber base is slated to cross 200 million by 2016. Rapid growth expected @106% per annum for services launched in the country as recently as the last quarter of 2010. The Drivers for this incredible growth are:

•  Rural markets: 62% of new subscribers are expected to come from the rural market which is unsurprising considering the saturation levels in the Indian urban markets. Expected Compounded Rural Growth Rate for the mobile phone industry between 20212-2016: a healthy 12%

•  3G handsets: Expect to see 600 million handsets in the Indian market by 2016. Expected annual growth rate: 42% per annum between 2012-2016. Many customers expected to upgrade/migrate form 2G to 3G platforms

•  4G serivces: These will be the next field of bitter price wars that will see Advantage Consumer and further plummeting of telephony expenses

•  MVAS ie Mobile Value Added Services: Subscriber base for these is expected to grow at compound annual rate of 28% and reach 430 million by 2016

4. We have the third largest internet user base at 120 million people. Additionally we have a broad band user base of 13.5 million.
And growing Rapidly.
All these statistics are signifiers of an imminent revolution with far reaching implications for the music, movies, all consumer facing industries BUT most important of all the health care industry.
Mobile Health Services have the potential to change forever.

•  Audio visual medical expertise can be on tap

• Delivery of clinical health data, information can be a click away

• Real time health monitoring with its tremendous positive implications for the Indian situation can be made accessible, easy

• All the personal medical health information being generated by personal bio sensory devices, the net, personal genetic maps included can be easily transferable to our mobiles which in turn can be capable of instantly transmitting this information to the medical centre, monitoring physician/ surgeon/ doctor/ of our choice. A VERY PROBABLE scenario in a country with our kind of mobile penetration, accessibility and above all mobile and internet literacy. And all this within the next decade. Maybe, earlier

• Patients can surf the net to shop for the best doctors with the highest operational success rates/ peer endorsements/ citations in medical journals of repute/ reputation for adherence and upholding of medical ethics

There are huge advantages in our clambering onto the communication revolution bandwagon AFTER most of the “developed” world. Mainly because we enjoy the “Latecomer’s Lead” advantage! Oxymoronic? Not really. Going by the example of our state of the art metro services which rival the best, in fact best the best in the world because we had such a rich skein of previous knowledge resource to draw on. Likewise late entry into the telecom territory affords us the unique opportunity of learning from the mistakes of our predecessors, rectify at the incept, leverage this knowledge base to ensure ease, speed, felicity of dissemination, transfer of information, better and CHEAPER connectivity.

The challenge? To integrate diverse medical devices to operate from one homogeneous platform to make transmission, processing of digital data fast, efficacious, worthwhile.

In Conclusion

• Expensive hospitalisation will be reduced as the fight will no longer be for getting into hospitals but for NOT getting into them. Only the critically ill will seek hospitalisation.

• Dangerous hospital infections (remember the recent NDMA scare?) caused mortality rates will plummet.

• Unnecessary, expensive, gratuitous testing will be contested and countered with personalised, customised data, and new gadgetry that would render such expensive, hazardous testing redundant.

• Medical prescription errors would hugely reduce.

• Nature of patient- doctor interface will change. Emailed data/ videoconferencing would substitute for repeat, exhausting and time consuming OPD visits.

• Alternative medical practice and medical administration protocols will emerge.

Reference

• The Creative Destruction of Medicine- Eric Topol

• 9 steps on How to Change Medicine- Eric Topol

• Medical errors in top 10 killers: WHO

• Medication errors: Malpractice implications & prevention – Dr Arun D Bhatt

• Doctor groups list top overused, misused tests, treatments, and procedures P.J. Skerrett, Senior editor, Harvard Health

• Reinventing Health Care: The Design and Investment of the Millennia – Soren Petersen

• Telecom Data

• Indian Journal of Basic & Applied Medical Research: December 2011: Issue-1, Vol.-1, P. 56-65

• Rs 15, 855cr allocated to fight cancer in 12th Plan

Author

Sunil Mehra is a cultural commentator/columnist who has written extensively on the on issues that impact daily life in the areas of health, fashion, design, art and urban design.