SIEMENS

The bus arrived on time today. Once a month, remote areas in Tamil Nadu, India’s southernmost state, are visited by a doctor’s office on wheels operated by the Christian Medical College (CMC) in the city of Vellore. Crowds of people flock from surrounding villages to consult their doctors or have blood samples taken. On these occasions the “ASHAs” make their appearance too. ASHAs, or Accredited Social Healthcare Activists, are women who volunteer to provide health education in villages, collect the residents’ health data, and support pregnant women before and after they give birth.

The process of using ASHAs and bringing doctors to villages in medical buses originated with the “National Rural Health Mission 2005–2012” initiative, which was launched by the Indian government in 2005. The program was intended to improve healthcare for rural populations. The Indian subcontinent suffers not only from a severe shortage of physicians — there is a deficit of about 600,000 doctors Tracking Illnesses in India countrywide — but also from a large gap between the urban and rural populations regarding the availability of health care. For every 100,000 residents, there were about 4.48 hospitals in urban areas and 0.77 in rural areas in 2005. What’s more, in 2010 there were six times as many physicians in cities as in the countryside, where about 70 percent of all Indians live.

Prior to this health care initiative, many Indians in the countryside had hardly any contact with modern Western medicine. Instead, they relied on traditional treatments known by the acronym AYUSH — Ayurveda, yoga, Unani (an Arabic counterpart of Ayurveda), Siddha (southern Indian naturopathy), and homeopathy — which are practiced by AYUSH doctors trained at universities. The ASHAs now act as links between villagers and the doctors in hospitals. Since a primary goal of the initiative is to lower the child mortality rate, only women are used as ASHAs. ASHAs go from house to house at regular intervals and inquire about illnesses and the health of pregnant women. Today, they still record all the information they obtain in a book. However, a paper-based system of this kind may be incompatible with the information storage media used at hospitals, which in some cases already maintain electronic patient records. ASHAs also have to carefully protect their notes from damage.

Mobile Healthcare. Three years ago, Dhandapany Raghavan, who heads Siemens Healthcare in India, had the idea of letting ASHAs record medical data via cell phones. “We soon realized that we need a competent and experienced partner for this, and we’re proud to be working with the Christian Medical College,” says Dr. Zubin Varghese of Siemens Corporate Technology (CT) in the Indian city of Bangalore. CMC has been active in this part of India for over 50 years and is very familiar with local conditions. The college has helped Siemens CT to develop a pilot project called the “Community Health Information System” (CHIS), which has already been tested in some villages. “During the first test phase, ASHAs tried out the cell phones,” says Prof. George Kuryan, head of the Community Health Department at CMC in Vellore. “They’re very excited about using them and the possibilities offered by the new technology.” After the testing phase, 83 villages with a total population of about 100,000 people are expected to take part in the CHIS project.

An ASHA starts her work by downloading villagers’ up-to-date demographic data, including some health information from a hospital server, to her smartphone. This tells her what she should look out for when examining particular villagers. Later, after she has recorded all the data from a village, she transfers it via the mobile communications network to the hospital server, or she can upload the data to a laptop the doctors have brought with them in the bus. “In both cases, doctors first have to check that the data is correct before it’s stored on the server. This is for quality control,” says Varghese. The data transferred to the server is included directly in patient records and undergoes statistical analysis. All the software used in the process, from the cell phone to the laptop, was developed by Siemens Corporate Technology.

One of the ASHAs’ focus areas is on supporting women during pregnancy, preparing for birth, and providing postnatal and postpartum care. Most women in India give birth at home, usually under poor hygienic conditions. According to the World Health Organization, 37 of every 1,000 Indian newborns died within the first four weeks of life in 2008. By comparison, Germany had a mortality rate of three in 1,000 newborns that year. After a delivery, an ASHA therefore records data such as the baby’s weight and heart rate. If an emergency occurs, she can call a doctor on her cell phone. Siemens CT India also hopes to provide better support to doctors by developing inexpensive medical devices that are usable by trained laypersons, such as the ASHAs, provide reliable results, and are robust enough to operate dependably in adverse conditions. The top priority in this regard is to provide support for pregnant women. The device currently at the most advanced stage of development is the Fetal Heart Rate Monitor (see Pictures of the Future, Fall 2010, Catching Up, and Emerging Markets: Amazing Growth Ahead), a sort of stethoscope that automatically measures and displays the heart rate of an unborn child. Production of this device will soon begin at a Siemens plant in Goa. After the test phase of the project has been completed, the ASHAs in 83 villages in Tamil Nadu will be equipped with cell phones and, later on, with Fetal Heart Rate Monitors.

In the case of premature births, it is also common to monitor not just the heart and respiratory rates but also blood oxygenation. With this in mind, CT India is developing a portable device for ASHAs that measures respiration and a pulse oximeter, which uses sensors to measure the oxygen saturation of arterial blood after the skin is exposed to infrared light.

Technology for Emerging Economies. Increasingly, the typical diseases of modern civilization are spreading in India. For instance, there are already over 40 million diabetics on the subcontinent, and each year about two million people suffer a heart attack. Indian authorities estimate that by 2020 over seven million Indians will die of chronic illnesses each year. The reasons for this include population growth as well as the country’s rising prosperity. CT developments are therefore also focusing on simple devices for investigating cardiovascular illnesses, such as mobile ECG devices. Also in planning are easy-to-use systems for remote patient monitoring. “These devices we’re developing are tailored to the needs of emerging countries like India,” says Varghese. “Since we need a great quantity of devices for our large population, we have to supply them at the lowest possible price. These devices also have to be as easy as possible to use and they must be virtually maintenance-free.”

Another challenge faced by Indian society is infectious diseases. India accounts for a fifth of the world’s cases of tuberculosis — and a large proportion of these occur in rural areas. The biggest problem in this context is contaminated water, which is also partly to blame for the high child mortality rate: Every day, over 1,000 children in India die of diarrheal illnesses. ASHAs therefore keep a record of all cases of diarrhea in their villages. Using analytical software, CT researchers can evaluate the database of its project partner in the hospital and pinpoint those villages in which cases of diarrhea occur very frequently. Now that tests have been completed, the first mobile water treatment systems from Siemens Water Technology will soon be delivered to those villages most affected by diarrheal illnesses.

For Dr. Varghese it is already clear that the CHIS project is a successful model that can be carried over to other Indian states and to other countries. In its next phase, the project could be extended to a million people in the neighboring state of Andhra Pradesh. But as Varghese knows, there is still a long way to go before that happens.

Annapurna Verma, has just finished transferring her data from a cell phone to a laptop. She and her fellow ASHAs are done with their examinations for the day, and the bus starts moving again.