SPAN March/April 2020

MARCH/APRIL 2020 Rs. 20

Innovations in

Health Care

DNA of Diseases Smart Cancer Screening Promoting Health Through Digital Tools

Project ECHO, started by Albuquerque-based Dr. Sanjeev Arora, combines technology, mentoring and medical expertise to increase health care access for underserved communities in India.

ECHO of Good Health

SWONGPIRIYAPORN/iStock/Getty Images

Above right: Dr. Matthew Bouchonville (left), an endocrinologist at the University of New Mexico who is part of Project ECHO, listens to a case presentation by Dr. Ninad Shet (on screen) of La Casa Family Health Center in Roswell, New Mexico. On the left screen are primary care clinicians connected to the teleclinic from across the state.

Right: Dr. Sanjeev Arora (right) receives an honorary doctorate from President Ram Nath Kovind at the foundation and convocation ceremony of the Institute of Liver and Biliary Sciences in New Delhi.

Courtesy Endocrine News magazine

f you live in a big city, qualified doctors of nearly every specialty are often easy to find.

But what if you live in a rural community? The specialists you need could be thousands of kilometers away.

This is precisely the sort of problem that Project ECHO (Extension for Community Healthcare Outcomes) was created to address. It is an innovative and multifaceted model that increases health care access for underserved communities.

Project ECHO began in 2003 when Dr. Sanjeev Arora, a liver disease specialist from Albuquerque, New Mexico, decided to confront a disturbing reality: Thousands of patients in his home state were unable to get treatment for hepatitis C simply because specialists were hardly accessible from where they lived.

To combat the problem, Dr. Arora created a free educational model to mentor local health care providers to treat the disease themselves, anywhere in New Mexico, guided and supported by specialists like himself. Dr. Arora’s goals were bigger, though. “We knew if we could treat something complicated like hepatitis C...in rural areas, we would have a model that could

Courtesy ECHO India

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By MICHAEL GALLANT

March/April 2020

V O LU M E L X I N U M B E R 2

Expert hub team

Patients reached with specialty knowledge and expertise

Courtesy UE LifeSciences

ECHO supports community-based primary care teams

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ECHO of Good Health

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Tech for Health

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Collaborations in Health Care

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Device for Early Detection

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A Coil-Shaped Cure

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Promoting Health Through Digital Tools

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Health Buddy

Jonas Salk’s Citadel of Science

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Smart Foot Treatment

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Smart Cancer Screening

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DNA of Diseases

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Selecting the Nominees

20 Editor in Chief Conrad W. Turner

Reviewing Editor Karl M. Adam

Editor Deepanjali Kakati Associate Editor Suparna Mukherji Hindi Editor Giriraj Agarwal Urdu Editor Syed Sulaiman Akhtar Copy Editor Shah Md. Tahsin Usmani

Art Director/ Production Chief Hemant Bhatnagar Deputy Art Directors / Production Assistants Qasim Raza, Shah Faisal Khan

Courtesy Adarsh Natarajan

TeleECHO Clinic

CONTENTS

Courtesy Kayla Huemer

ECHO vs. Telemedicine TM

Screenshot courtesy www.echoindia.in

https://span.state.gov

36 Front cover: FulbrightNehru Student Researcher Hannah Lider (left) tests a patient’s hemoglobin level using needle-less technology, in Rajasthan.

Photograph courtesy Hannah Lider.

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treat all kinds of complex diseases in developing countries,” he said in a 2013 TEDx Talk.

To begin with, Project ECHO set up 21 “centers of excellence” across New Mexico, each run by a local health care provider, and all tasked with the mission of treating hepatitis C everywhere in the state.

Treating a disease, however, is far more complicated than following a list of instructions. Dr. Arora had to find a way to train local health care providers so they could quickly gain the specialized knowledge that he had attained through years of study and practice. The answer? Case-based learning.

Project ECHO began enabling hands-on mentorship through technology. Local health care providers in even the most remote areas are connected via weekly web-based calls and virtual meetings with specialist teams. The teams advise their local partners on how to best treat individual patients.

The Project ECHO model is not traditional telemedicine, in which a specialist assumes

SARA MOTA

Above left: The National Institute of Mental Health and Neuro Sciences (NIMHANS) in Bengaluru. The Virtual Knowledge Network NIMHANS ECHO program has trained over 4,000 health care professionals.

Left: King George’s Medical University in Lucknow, which operates as a hub for ECHO India.

Below: Dr. Sanjeev Arora, who began Project ECHO in 2003 in New Mexico.

Project ECHO-India

www.echoindia.in

TEDx

https://bit.ly/2TqBzxs

Screenshots courtesy https://echo.unm.edu/

University, Lucknow, and National Health Mission, Maharashtra, already operating as ECHO hubs, a pilot program to train accredited social health activist (ASHA) workers is currently being run in collaboration with Community Empowerment Lab and National Health Mission, Uttar Pradesh. The aim is to replicate such hubs in all states.

One of the components of the Ayushman Bharat Yojana is to provide comprehensive primary health care, with an expanded range of 12 services available at the Health and Wellness Centres. To implement these, a midlevel health care provider will be placed at each center located at the sub-center level.

The National Health Systems Resource Centre has partnered with ECHO India for joint training and capacity building of these health care providers.

A cascade model of knowledge sharing will be built for continuous capacity building of health care providers at all levels, including specialists, doctors, paramedical professionals, mid-level health care providers and frontline workers. Government of India’s Ministry of Health and Family Welfare has released a mandate to conduct ECHO programs by all states for training and capacity building.

Speaking at an orientation program for doctors and health care professionals in 2017, Dr. Colonel (Retd.) Kumud Rai, chairman of

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care of a patient, but is telementoring, a guided practice model where the participating clinician retains the responsibility of managing the patients.

In India, the first ECHO clinic began in 2010, as a collaboration between the National AIDS Control Organization and Maulana Azad Medical College on managing HIV/AIDS patients. Since then, the programs have worked on addiction and substance use disorders, mental health, tuberculosis, hepatitis C, liver diseases, cancer screening and prevention, and more. All ECHO programs in the country fall under ECHO India, a nonprofit trust registered in 2008, which works toward replicating the ECHO model in the areas of health care, education and environmental security.

Today, ECHO India has grown to include hubs in 10 states and has signed a Memorandum of Understanding with the Government of India’s Ministry of Health and Family Welfare.

In 2018, ECHO India entered a partnership with the National Health Systems Resource Centre, as a Capacity Building Implementor under the Ayushman Bharat Yojana. The goal is to set up 153,000 Health and Wellness Centres across the country, and ECHO India would support capacity building of staff at these centres. With King George’s Medical

Above: Project ECHO enables hands-on mentorship of local health care providers through web-based calls and virtual meetings with specialist teams.

The teams advise local partners on how to best treat individual patients.

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Photographs courtesy ECHO India

Above and above right: Through video conferencing, ECHO India allows specialists to assist and guide local health care providers.

Top: ECHO India runs immersion training programs for organizations on how to replicate the project’s practices and successes in their own communities.

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ECHO India, said, “The Indian health care environment provides a one-of-a-kind opportunity for the adoption of the ECHO model. The need for specialty care in India, especially in rural settings, is substantial and growing. System-wide integration of Project ECHO offers a solution that can benefit the entire population.”

Many prominent health care institutes in India have partnered with ECHO India. There are 26 active hubs, including the Mumbaibased Tata Memorial Centre, which has launched programs to connect hospitals from the nation-wide National Cancer Grid using the Project ECHO platform. At the National Institute of Mental Health and Neuro Sciences (NIMHANS), the Virtual Knowledge Network NIMHANS ECHO program has completed 22 programs and is currently running eight more

for participants across the country and abroad.

This program has trained over 4,000 health care professionals, and works with the state governments of Bihar, Chhattisgarh and Karnataka.

The ECHO model has also been adopted in the field of education, by Ambience Public School in New Delhi. The ECHO Teacher Mentorship Program works on improving the skill-sets of teachers and ensuring that they are constantly mentored. After successfully completing seven ECHO programs, with focus on English, mathematics, early literacy, science and mindfulness, among others, the second hub was launched at Ambience Public School, Gurugram. The Ambience Preventive Health and Wellness ECHO is a unique program that focuses on helping teachers, parents and counselors identify early signs of

STATEMENT FORM IV

The following is a statement of ownership and other particulars about SPAN magazine as required under Section 19D(b) of the Press & Registration of Books Act, 1867, and under Rule 8 of the Registration of Newspaper (Central) Rules, 1956.

Top: Since its founding, ECHO India has grown to include an impressive array of field experts, staff and community members.

Above: Dr. Sunil Anand, executive director of ECHO India, speaks about the project’s work in the country at a recent immersion event.

Above right: Dr. Colonel (Retd.) Kumud Rai, chairman of ECHO India, at an orientation and immersion event.

various health issues in children. The participants are mentored by doctors from institutes like the All India Institute of Medical Sciences, Max Super Specialty and NIMHANS. Regardless of the community served or disease treated, Project ECHO’s goals remain the same: To make quality, comprehensive health care available for even the most rural and underserved communities in India, the United States and beyond. “We want to demonopolize knowledge,” said Dr. Arora in his TEDx Talk.

“Typically, knowledge is trapped in the head of super-specialists like me. We want to share it freely with our primary care colleagues. We want to improve access to quality health care and reduce disparities.”

Michael Gallant is the founder and chief executive officer of Gallant Music. He lives in New York City.

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MARCH/APRIL 2020 7

Courtesy Dr. Preetha Rajaraman

Collaborations in

Health

By SUPARNA MUKHERJI

U.S. Health Attache to India Dr. Preetha

Rajaraman

talks about U.S.-India partnerships on health innovations to address some of the biggest health-related challenges of today’s world.

LIUZISHAN/iStock/Getty Images

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s the U.S. Health Attaché to India and Regional Representative to South Asia for the U.S. Department of Health and Human Services (HHS), Dr. Preetha Rajaraman coordinates, monitors and represents the work of all HHS agencies in India, including the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and the U.S. Food and Drug Administration (FDA).

Dr. Rajaraman was trained as a cancer and molecular epidemiologist and worked for many years as a researcher in this field. Her current job involves a much wider perspective and represents the entire regional

8 MARCH/APRIL 2020

U.S. portfolio in health and biomedical research, spanning health policy, communicable and non-communicable diseases, health safety and security, and research and innovation. “This required transitioning from knowing an awful lot about a few topics to having to know at least a little bit about a huge array of topics,” says Dr. Rajaraman. “It has been an exciting change, and an incredible opportunity to be working on building the health and science relationship with India at a time when there is so much potential for growth.”

Excerpts from an interview with Dr. Rajaraman.

MONICA TIWARI/International Vaccine Access Center

Care Above: A baby receives a dose of ROTAVAC at Assam Medical College, Dibrugarh. Early research leading to the development of this vaccine against Rotavirus was supported by the Indo-U.S. Vaccine Action Program.

You joined Reed College, Oregon, to major in literature–theater. What made you switch to biology and then environmental health at the University of Washington?

I have always loved biology, but before I came to college, I didn’t think of myself as particularly talented at the hard sciences underpinning many of the advanced biomedical fields. A handful of dynamic college professors changed that perception. With the right mentors, I found that science was both easy and fun—a realization that played a big role in my change of study and career.

I’m a big fan of the liberal arts education

that allows such dramatic switches and encourages interdisciplinary thought. And, in fact, I find my early training in literature and drama quite helpful in my current role!

In your opinion, what are some of the biggest health concerns for India right now?

Like many countries in the region, India currently faces a double burden of diseases— a high burden of infectious diseases as well as a growing amount of non-communicable diseases like cardiovascular disease, cancer and mental health problems.

Some priority areas for HHS in the region are global health security, which includes

To share articles go to https://span.state.gov MARCH/APRIL 2020 9

improving the prevention, detection and response to infectious diseases; biomedical research and innovation; digital health; and identifying practical ways to increase access to safe, effective, affordable and life-saving medicines around the world.

In what ways do you think U.S. experts, especially those at the U.S. Department of Health and Human Services, can help India overcome these challenges?

U.S. scientists and policy makers, including those within the HHS agencies, have unique expertise and skills to share with our Indian counterparts and we, in turn, can learn from these collaborations. Through grant funding,

Photographs by BONNIE CARLSON, USAID/India

SATISH KUMAR/CDC Global/Courtesy Flickr

Below: Dr. James J. Sejvar, a neuro-epidemiologist from the U.S. Centers for Disease Control and Prevention, examines an Acute Encephalitis Syndrome patient in Muzaffarpur, Bihar.

Bottom: Funded by the U.S. Agency for International Development (USAID), the Gene Xpert project helps diagnose tuberculosis in children, including multi-drug-resistant strains, in India.

Bottom right: USAID is working to accelerate the urban tuberculosis control agenda in India, through technology and innovation.

Biomedical innovation is one of the most vibrant areas of U.S.-India health cooperation.

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technical assistance, capacity building, and policy engagement, we have been working to find joint solutions to pressing health problems for India, the United States and other countries around the world.

Could you please share some examples of U.S.-India collaborations on health innovations?

Biomedical innovation is one of the most vibrant areas of U.S.-India health cooperation.

For example, the Indo-U.S. Vaccine Action Program, led by the U.S. NIH and India’s Department of Biotechnology (DBT), is considered a model bilateral initiative. Its success is reflected in the indigenous development of ROTAVAC, a vaccine that can prevent infection with Rotavirus, a common childhood diarrheal disease. Rollout of this vaccine is expected to save millions of lives in India, and globally. The Vaccine Action Program continues to support vaccine research for diseases like malaria, dengue and tuberculosis.

Another urgent global health problem is antimicrobial resistance (AMR), or the ability of germs to develop resistance to the drugs designed to kill them. The number of resistant infections is growing worldwide. These infections are harder to treat, leading to longer hospital stays, higher medical costs to individuals and societies, and often death.

Many U.S. agencies, including HHS (Office of the Assistant Secretary for Preparedness and Response, CDC, NIH and FDA) and the U.S. Agency for International Development (USAID) are working closely with Indian partners to tackle the problem from various perspectives, including strengthening hospital infection control, building surveillance systems for antimicrobial-resistant infections, supporting scientists and innovators working toward AMR solutions, and funding the development of critically needed new antimicrobials.

Scientists from the United States and India also conduct joint research on vision, HIV/AIDS, tuberculosis, malaria, emerging infectious diseases, and chronic diseases like diabetes, cardiovascular disease and cancer, vision, mental health and environmental health, including on air pollution and its health impacts. To strengthen research capacity, U.S. agencies, including NIH and CDC, host hundreds of scientists from India and organize several training workshops and exchanges each year.

RAKESH MALHOTRA

What role can technology play in boosting global health diplomacy?

Technology plays a vital role in global health diplomacy, which ultimately hinges on defining and finding joint solutions to key unresolved challenges in health. India recently introduced the Ayushman Bharat health care program, which aims to provide expanded primary care through 150,000 Health and Wellness Centres (HWCs) across the country and, simultaneously, provide health insurance coverage to over 500 million Indians. In the United States, the government has identified health insurance reform, drug pricing and value-based care as key priorities for health care.

Although these programs are being rolled out in vastly different settings, we share the same goals of providing our citizens affordable, high-quality solutions. Many of these are derived from biomedical research and innovation, including drugs, vaccines, diagnostics and devices.

Which medical technology or area of research seems to be most promising to you?

Dr. Francis S. Collins, director of the NIH, recently identified 10 particularly promising opportunities for biomedical innovation over the next 10 years. These include fields like single-cell analysis, which could provide key

Courtesy Dr. Preetha Rajaraman

HHS

www.hhs.gov

NIH

www.nih.gov

CDC

www.cdc.gov insights into autoimmune diseases and cancer; regenerative medicine; cancer immunotherapy; the development of new vaccines; gene editing to cure diseases; precision medicine; and mapping of the brain.

What are some of the key concerns for facilitating relationships between the U.S. and Indian governments?

While the opportunities for biomedical innovation are immense, it is critical to simultaneously create an enabling ecosystem to ensure the maximum diffusion of these innovations. This can be done by ensuring sufficient and sustainable funding for research; deploying big data and digital health along with infrastructure and policies that support data sharing; ensuring efficient regulatory approvals; and investing in building a skilled scientific and health workforce.

Do you have any message for our readers studying or working in the field of health and medical technology?

As we move into a new era of global biomedical innovation in science and technology, the United States remains committed to bringing knowledge and resources to our shared agenda of protecting lives and enhancing the health and well-being of people around the world. We hope that you will join us on this exciting journey of discovery.

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Above: U.S. Ambassador to India Kenneth I. Juster (second from right) at the launch event of the U.S. Agency for International Development’s initiative designed to galvanize India’s corporate sector in the fight against tuberculosis.

Right: Dr. Preetha Rajaraman speaks at a panel discussion, titled “Creating Healthy Lives—The Future of Medical Innovation,” held at the launch of the Global Innovation Index 2019, in New Delhi.

U.S. FDA

www.fda.gov

DBT

http://dbtindia.gov.in

MARCH/APRIL 2020 11

A Coil-

KEVIN FRAYER © AP Images

RAJESH KUMAR SINGH © AP Images

Cure

12 MARCH/APRIL 2020

Far left: X-ray results of a patient suspected to have tuberculosis (TB).

Left: TB patients must visit clinics to take their medication, every single day, for six months.

This acts as a huge deterrent for patients, especially those in rural areas.

SVETAZI/iStock/Getty Images

-Shaped

By MICHAEL GALLANT

Researchers in the United States and India collaborate to create an innovative device to help treat tuberculosis.

D

Photographs courtesy Malvika Verma, Feyisope Eweje, John A F Salama and Jonathan B. Miller

angerous and highly contagious, tuberculosis (TB) has plagued humanity for thousands of years. Although tests and treatments exist to fight TB, it continues to kill hundreds of thousands of people in India, and over one million around the world, each year.

India has “the highest burden of TB disease in the world,” says Dr. Upasna Agarwal, head of the Department of Internal Medicine at the National Institute of Tuberculosis and Respiratory Diseases in New Delhi. “It is a major public health problem in the country, with a huge economic impact, in terms of treatment, care costs, as well as lost wages.”

TB is caused by bacteria that most often infect the lungs, but can attack any part of the body like the kidney, spine and brain. It causes patients to suffer bloody coughs, fevers, night sweats and other debilitating symptoms.

Above left: The innovative tuberculosis treatment device, created by a team of American and Indian experts, including Dr. Malvika Verma (center).

Left: A representative prototype of the device inside a stomach model.

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The device may be small, but its implications are huge. If patients use this new treatment, they will have to visit clinics only once a month, instead of once a day.

Treatment obstacles The roots of India’s TB problems are widespread and complex.

“As Sir William Osler’s prophetic words, ‘Tuberculosis is a social disease with a medical aspect,’ imply, its elimination is a challenge.

There are many social determinants like poverty, overcrowding and social stigma associated with the disease which need to be addressed,” says Dr. Nandini Sharma, director professor at Maulana Azad Medical College in New Delhi.

TB is also becoming increasingly resistant to medicines usually used to treat it, says Dr. Agarwal. With about 40 percent of India’s population infected with the bacteria but not experiencing any symptoms, TB can become freshly active and contagious any time, triggered by factors like a weakened immune system.

One of the most daunting obstacles to treating TB, though, has to do with its most common cure. To deal with the disease, patients in India are currently required to “come to a clinic daily and have a health care worker watch them take pills,” says Dr. Malvika Verma, who studied TB at the Massachusetts Institute of Technology (MIT).

Patients must visit the clinics and take their medication, every single day, for six months before they are free of the disease. It’s a regimen that Dr. Verma describes as a huge burden for patients and health care systems, especially for TB cases in rural areas. As a result, roughly half of TB patients fail to complete their course of treatment, she adds.

Courtesy Jonathan Miller

Left: Dr. Malvika Verma who, as a student at MIT, helped develop the tuberculosis treatment device.

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Courtesy Malvika Verma and Karan Vishwanath

Right and below right: The coiled wire device, threaded with beads of antibiotics that release slowly inside a tuberculosis patient’s stomach over the course of a month.

willingness to treat TB with a device embedded in the stomach.

The team is actively testing the device for safety and effectiveness, and studying how best to bring it to patients across India. “We anticipate initial trials to begin in the next five years,” says Dr. Verma.

Although much work awaits before patients can directly derive the benefits, the research team sees great potential in its invention. The procedure would not only help patients around the world stick with their treatment plans, describes Dr. Agarwal, but also drastically improve patient outcomes, reduce the disease’s resistance to antibiotic drugs, and more.

MIT

www.mit.edu

NITRD

www.nitrd.nic.in

Maulana Azad Medical College

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This obstacle to treating TB has sparked a medical innovation that could make treatment easier for patients and health care providers alike.

The invention is a small, thin piece of metal wire strung with pills of anti-TB medicine.

Inserted through a patient’s nose, the wire travels to the stomach. The body’s internal warmth causes it to curl up into a coil shape, which prevents the device from passing into the intestines and out of the body. Once successfully inserted inside the stomach, the coil slowly releases the drugs at a regular rate for up to four weeks.

The device may be small, but its implications are huge. If patients use this new treatment, they will have to visit clinics only once a month, instead of once a day. They will, thus, be much more likely to finish a course of treatment and become fully cured, says Dr. Verma.

The device’s creation began several years ago at MIT when Dr. Verma, then a graduate student, collaborated with university professors Robert Langer and Giovanni Traverso to investigate ways to treat TB that didn’t involve daily pills and clinic visits. As their research progressed and the coil-shaped device began to take form, their team grew to include other TB experts from the United States and India, including Dr. Sharma and Dr. Agarwal.

“This is a totally new way of looking at TB treatment,” says Dr. Agarwal. During the research in India, she continues, the team was pleasantly surprised by the number of patients and health care providers who expressed

Courtesy Jonathan Miller

Innovative engineering

www.mamc.ac.in

Michael Gallant is the founder and chief executive officer of Gallant Music. He lives in New York City.

MARCH/APRIL 2020 15

Promoting Health

By PAROMITA PAIN

E

USAID-funded Project Samvad communicates best practices related to health and nutrition through videos and other digital tools.

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ffective and timely communication is one of the key requirements for success of public health programs. It plays an important role in informing, influencing and motivating audiences about health issues. Building on this approach, Project Samvad uses the power of messaging and dialogue to change social behaviors related to family planning, maternal and child health, and nutrition in rural communities in India. The United States Agency for International Development (USAID)-funded project, implemented by Digital Green in six states, uses how-to videos to communicate its messages. Digital Green is a development organization with offices in India, the United States and Ethiopia.

Project Samvad demonstrates good health and nutrition practices through locally relevant videos created with the help of community members. Trained health workers

screen these videos to groups of 15 to 20 villagers using battery-operated projectors.

Project Samvad taps into existing public and private outreach channels to target both women and men, especially those of reproductive age. It partners with state-level counterparts of the National Health Mission, the National Nutrition Mission, the Ministry of Women and Child Development, and the National Rural Livelihood Mission. It has also collaborated with other organizations, like Centre for Youth and Social Development and Gram Vaani, to complement the video-based approach with radio and interactive voice response system (IVRS) messages. Samvad Mobile Vaani, for instance, offers a combination of drama, testimonials and infotainment directed to change behaviors and prompt action. It also offers a two-way communication platform in which listeners

Photographs courtesy Digital Green

Through Digital Tools

Top right: Health workers screen Project Samvad videos for community members.

Above center: The health workers are trained to use projectors to screen the videos.

Above, above right and right: Project Samvad disseminates information on maternal and child health and family planning practices, along with health and nutrition issues.

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The partnership with USAID and state government departments helped us double the number of people we had initially planned to reach.

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Photographs courtesy Digital Green

Far left: Ritika Pandey at the National Workshop on the Role of Technology in Improving Health, Nutrition, and Family Planning Outcomes, in New Delhi, which brought together key stakeholders to share their experience with Project Samvad.

Left: Project Samvad’s content is created by and for the community members.

Above: Project Samvad demonstrates good health and nutrition practices.

women, this is also a social event, where they can hang out with their friends and peers.”

The viewers generally have very positive reactions. “A video on family planning had a man who was shown to be very caring toward his pregnant wife,” she says. “Many women requested that this be shown to their husbands as well, since they would like them to be just as warm.” More than half of all viewers have adopted at least one healthy practice, with three to four practices being the average.

Project Samvad’s government partners have also observed increased attendance in VHSNDs and immunization days since the project began.

“I shied away from taking the IFA tablets (iron supplements) fearing the side effects would hamper my abilities to take care of my household chores,” says a beneficiary from Chhattisgarh, on the Digital Green website.

“At a video dissemination, the Mitanin Trainer noticed I had swollen feet and enquired if I had been taking the IFA tablets. She showed us a video about the importance of taking these tablets and how to tackle the side effects. This convinced me and I started taking the tablets and also shared my example with other pregnant women in my village.”

Project Samvad

www.digitalgreen.org/ samvad

USAID

www.usaid.gov/india

Digital Green

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can share their opinions and messages.

Started in 2015, Project Samvad has reached 600,000 rural women directly and 1.9 million family and community members indirectly across the six states of Bihar, Jharkhand, Odisha, Chhattisgarh, Uttarakhand and Assam. “The partnership with USAID and state government departments helped us double the number of people we had initially planned to reach,” says Ritika Pandey, project director, Samvad at Digital Green.

As part of the project, community-level health workers, like accredited social health activist (ASHA) workers and facilitators, are trained to produce videos in local languages.

“The ASHA workers are closely connected with communities, and know about different health- and nutrition-related behaviors, as well as barriers and triggers that influence their behavior and uptake,” says Pandey. “They also help mobilize audiences to come and watch the films.” This collaboration is extremely important.

“In Digital Green’s agriculture-related videos, a demonstration of a technique works because outcomes like better crop yields and healthier crops are tangible results that can be seen,” says Pandey. “But health- and nutritionrelated behaviors are more complex.” There are myths and preset approaches that must be addressed. “Besides, the role of community influencers and members of the family, like mothers-in-law and husbands, are very critical,” she adds. “We make sure we factor in all these issues.”

Project Samvad also trains frontline workers to use projectors and disseminate videos among women. “The videos are usually 10 to 12 minutes long. They are paused at strategic points for discussions around the topics,” says Pandey. An attendance record of all those who participated is maintained to assess how many people have viewed them.

The videos, which dramatize best practices related to specific behaviors, are promoted in existing community groups in anganwadis or rural child care centers, couple counseling sessions, self-help groups, mothers’ groups, as well as on Village Health Sanitation and Nutrition Days (VHSND), which address health and nutrition concerns.

People are extremely open to the topics covered in the videos. “Since the community is deeply involved in the process, from story boarding to scripting, even men do not have a problem that their family members come to watch these videos,” says Pandey. “For the

www.digitalgreen.org

Paromita Pain is an assistant professor of Global Media Studies at the University of Nevada, Reno.

MARCH/APRIL 2020 19

ALEXRATHS/iStock/Getty Images

Fulbright-Nehru Student Researcher Kayla Huemer's project focused on developing a lowcost solution to identify patients at highest risk of developing

diabetic foot ulcers.

Smart

Foot Treatment

A

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By MEGAN MCDREW

Fulbright-Nehru Student Research Program https://bit.ly/2V9HTMo

University of WisconsinMadison https://www.wisc.edu 20 MARCH/APRIL 2020

s the prevalence of diabetes increases rapidly across the world, complications like diabetic foot ulcers are expected to rise as well. Unmanaged diabetes can cause nerve death in the extremities, leading to a loss of pain sensation and an unbalanced gait, which may lead to pressure ulcers on patients’ feet.

Without proper treatment, these ulcers could become infected and eventually necessitate amputations. Untreated diabetic foot ulcers are one of the leading causes of non-traumatic amputations worldwide. This is a particular point of concern in India, which is home to the second-largest number of adults with diabetes worldwide, according to the latest data from the International Diabetes Federation.

Fulbright-Nehru Student Researcher Kayla Huemer’s project in 2018-19 focused on developing a low-cost solution to identify patients at highest risk of developing foot ulcers. She came across thermal patterns in the feet of the diabetes patients she was working with, and began assessing the use of thermal imaging to predict ulcer development.

She hopes this information will enable health care workers to initiate treatment sooner, to prevent the ulcers from ever happening.

Huemer’s interest in medical devices goes back several years. She had dreamed of

becoming a medical doctor until she took an engineering course at the end of her freshman year of college and realized it was the innovation of medicine that interested her more than anything else. “I enrolled in biomedical engineering and became very passionate about the projects I collaborated on with doctors,” she says. “I’d sit down and talk with these doctors, sometimes for hours on end, to understand the ideas they had for novel medical devices. I’d then get to put my engineering skills to work—designing circuits, embedding sensors, writing primitive phone applications. It’s always a privilege to work with doctors because I get to bring their ideas for better medicine to life.”

In 2016, Huemer traveled to India under the S.N. Bose Scholars Program for a research internship at the Indian Institute of Science in Bengaluru. This student exchange program between institutions in India and the United States is a partnership between the Indo-U.S. Science and Technology Forum, the Government of India’s Department of Science and Technology, and others.

In Bengaluru, Huemer worked on wearable technology meant to improve therapy of diabetic foot ulcers. After developing the device that summer, Huemer applied for a

Photographs courtesy Kayla Huemer

It’s always a privilege to work with doctors because I get to bring their ideas for better medicine to life.

Above: Kayla Huemer presents her work on diabetic foot ulcers to doctors from across India, who were part of a weeklong course at Christian Medical College (CMC) Vellore.

Above center: Huemer with a group of children with disabilities at a children’s home she would visit often during her Fulbright-Nehru Fellowship in India.

Top: Huemer with members of the department of bioengineering at CMC Vellore.

Fulbright Research Fellowship, outlining the need for such a device in the context of the wide prevalence of diabetes in India. “After graduation, I had no other desire than to continue working in low-income settings on health care issues,” she says. “To this day, receiving a Fulbright Fellowship to work on this issue that I’m passionate about was the single most affirming moment in my career as a young biomedical engineer.”

For nine months, starting August 2018, Huemer worked with a team at Christian Medical College Vellore to create a wearable technology to aid in the therapy of diabetic foot ulcers. The device would map the pressure in the feet of patients with ulcers, allowing doctors to understand how they should alleviate the pressure to allow the wounds to heal. However, while observing patients coming to the clinic, Huemer realized that many arrived past the point of any help.

Their infections were too deep to treat and gave doctors no choice but to amputate. She felt that instead of developing a device to help

patients heal, she needed to focus on preventing the ulcers in the first place, especially in low-resource settings.

Searching for a different solution, Huemer noticed during her time in the clinic that just prior to ulceration, a patient’s foot would have slight inflammation and be warm in the preulceration area. This led to a new idea—to focus on temperature—prompting her to take hundreds of thermal images of the patients’ feet. “I’m now working with this data back in the U.S., as an affiliate researcher at the University of Wisconsin-Madison, to identify pre-ulceration warning signs in the thermal scans. I’ve brought six new students onto the project and, as of now, four of the students are set to return to India to continue the work next summer.” The students hope to travel on the Research Internships in Science and Engineering (RISE), S.N. Bose and other funding opportunities for international research.

Looking back at her time in India, Huemer says, “I absolutely love it. India truly feels like a home and I miss the people whenever I’m away. The color of the culture, and the diversity of the people in language, food and customs makes it a country of such contrasts!

It’s humbling to get to work on unmet health care needs and India specifically has my heart. I see so much growth in the coming decades for health care within the country and I desire to dedicate my career to bringing to light the issues it’s facing.”

Megan McDrew, based in Monterey, California, is a professor of sociology at the University of California, Santa Cruz, and the University of California, Merced.

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DNA of Di D

By PAROMITA PAIN

D

iabetes is a major health concern in India, and the number of people being diagnosed with it is growing every year. Nearly 50.9 million people suffer from the disease in the country, according to the Diabetes Foundation of India, and by 2025, this is likely to go up to 80 million. According to the Texas Heart Institute, obesity is the leading risk factor for type 2 diabetes. Further, “High blood pressure (or hypertension) is twice as likely to strike a person with diabetes than a person without diabetes. Left untreated, high blood pressure can lead to heart disease and stroke,” according to Johns Hopkins Medicine. All these factors worried Surbhit Johri, a dualdegree graduate in biology and electrical engineering from Birla Institute of Technology and Science, Pilani (BITS Pilani). “Obesity, diabetes and hypertension have a strong genetic component, and are today considered ‘lifestyle’ diseases,” he says. “What this means is that with early detection and lifestyle

changes, they can be managed and, in some cases, avoided.” His company, GnomikX, cofounded with others from BITS, is a health care start-up that works to simplify the identification of these diseases and ensure early intervention and treatment.

Testing and counseling GnomikX offers saliva-based genetic tests to help people know their risk of acquiring diabetes, hypertension or obesity. Saliva collection kits, ordered online, come with simple instructions to spit in a tube. The tube is then collected by a delivery partner and shipped to GnomikX’s laboratories. These labs are certified by the National Accreditation Board for Testing and Calibration Laboratories (NABL) and use state-of-the-art technologies to extract, process and analyze DNA from saliva. After the kits are tested, customers are sent easy-tounderstand reports that explain the Courtesy GnomikX

Nexus-trained GnomikX provides saliva-based genetic testing, and counseling, for prevention and management of lifestyle disorders like diabetes, hypertension and obesity.

Raja Shukla (from left), Aditya Chauhan, Surbhit Johri and Attya Omer of team GnomikX.

22 MARCH/APRIL 2020

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UNDEFINED/iStock/Getty Images

iseases

Courtesy Facebook.com/SurbhitJohri

possibilities of them suffering from obesity, diabetes or hypertension. “It’s not enough to just tell people how prone they may be to obesity and hypertension,” says Johri. “It’s important to explain the steps they need to take to stay healthy.” So GnomikX also offers online video sessions with nutritionists, genetic experts and physical trainers to help customers bring about the required behavioral or lifestyle changes. This combination of testing and counseling costs about Rs. 3,000.

Johri spent a summer interning at the Massachusetts Institute of Technology (MIT) under the Khorana Scholar Exchange Program, which is supported by the Government of India’s Department of Biotechnology, the IndoU.S. Science and Technology Forum and WINStep Forward. “At MIT, much of my work revolved around stem cell-based research, where I was trying to model genetic switches

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GnomikX

www.gnomikx.com

Nexus Incubator http://startupnexus.in

MIT

www.mit.edu 24 MARCH/APRIL 2020

to create drugs to cure lymphomas,” he says.

There, he met Attya Omer, a researcher who immediately recognized the potential of helping people make healthy shifts by understanding risks through DNA examination.

Eager to be a part of something that works for positive change, Omer was among the earliest members of the team at GnomikX. Motivated by his own family members, whom he saw battling obesity and hypertension, Johri wanted to use his knowledge and training in molecular biology and combine genetics to help people adopt a preventative lifestyle. Many of his family members were GnomikX’s earliest customers.

The team was also part of the Nexus Incubator start-up hub at American Center New Delhi, which provides training on sharper business pitches and propositions before a product is marketed and connects selected teams to mentor and venture capitalist networks.

Not just genetics

Screenshot courtesy gnomikx.com

It’s not enough to just tell people how prone they may be to obesity and hypertension. It’s important to explain the steps they need to take to stay healthy.

Left: Surbhit Johri at Nexus Incubator’s graduation ceremony for start-ups, at American Center New Delhi.

Below left: GnomikX’s saliva collection kit for genetic testing for diseases.

Johri and his team aim to ensure that customers not only get reports about genetic risks, but also receive advice about precise and actionable changes to improve health and wellbeing. “When we first launched, we thought we are just biologists and worked on improving our saliva tests,” says Johri. “But when we realized that customers found so much more value in the interactions with the nutritionists and trainers, we immediately amped up our efforts in these areas.”

GnomikX is heavily customer-focused. Their feedback is extremely important and, as Johri says, this often helps examine the product from new angles. The founders also consider GnomikX to be part of the wellness space, with genetics forming an important component.

They would, therefore, like to build a database of health and lifestyle choices that can be used for research to further the understanding of health concerns and preventive measures. “We want to help people live a preventative lifestyle and genetic testing is one of the ways we are doing this,” says Johri. “We want to find more effective ways to help people adopt the recommendations provided.”

Paromita Pain is an assistant professor of Global Media Studies at the University of Nevada, Reno.

Tech for

Health Courtesy Buddha Burman

By JASON CHIANG

BoomNBuzz provides skill development and health screening services in a simple and easy way.

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Photographs © Getty Images

Nexus Incubator-trained BoomNBuzz’s portable, renewable energy-powered health platform provides diagnosis and health screening in rural India.

We will train locals to become health educators and tech support resources.

I

ndia’s large population poses a challenge for the country’s health care system, complicated further by the fact that about 70 percent of its 1.3 billion people live in rural areas, where it is much harder to access care as compared to urban areas. According to the Central Bureau of Health Intelligence, for instance, as of 2017, while 84 percent of India’s government hospitals are in rural areas, these hold only 39 percent of the total government beds. Social tech entrepreneur Buddha Burman witnessed these rural health struggles firsthand, having grown up in the Leh-Ladakh region. He decided to found BoomNBuzz in 2018, with the goal of providing affordable technology solutions and health and skill development training to the underserved population.

The New Delhi-based start-up has created a portable technology-enabled health platform, equipped to provide primary health care and screen chronic conditions. This renewable energy-powered device can create digital popup health centers in hard-to-reach areas, without the need for grid electricity, Internet or expensive infrastructure. The major components of the health care platform and application include the renewable energy-powered CozBoz, a device that delivers health awareness and educational content in an audiovisual format.

CozBoz-Buddy creates a network for the medical diagnostic data to travel to and from villages where mobile data networks don’t exist or are very erratic. The CozBoz-Buddy ecosystem also powers Mera Checkup, a tech platform which provides access to low-cost health assessment, diagnosis and health monitoring. BoomNBuzz has received training at the Nexus Incubator start-up hub at the American Center New Delhi.

Excerpts from an interview with Burman.

Could you tell us a bit about BoomNBuzz?

At BoomNBuzz, we develop innovative and affordable technology solutions for the underserved population. Our solutions help create education and health care centers on the fly, in hard-to-reach areas. We provide skill training and health screening services in a simple and easy way.

What problems drew you to the education and health sectors and why did you feel technology could help?

Education and health are interlinked, and illiteracy has a direct impact on human health.

For example, many people are not able to read the instructions on a medicine bottle. Or the

26 MARCH/APRIL 2020

diagnose conditions, develop treatment plans, create efficiencies in medical research and clinical trials, and make operations more efficient to handle. Telepresence will be used more effectively with the penetration of 5G Internet. This will help doctors examine and treat patients efficiently in rural areas.

Wearable tech, like ECG monitors that can detect atrial fibrillation and send reports to your doctor, blood pressure monitors, self-adhesive biosensor patches that track your temperature, heart rate and more, will help in the detection and prevention of chronic conditions. With 3D printing, now a doctor can replicate patientspecific organs to help prepare for procedures. 3D printing makes it easier to cost-effectively develop comfortable prosthetic limbs and other organs.

What were some of your biggest takeaways from working with the Nexus Incubator?

The mentoring and support provided by the Nexus team was one of the biggest takeaways of the incubation program. We are continually seeking support and advice from Nexus. The program actually saved a lot of our precious time by proving the right direction for commercialization and helping BoomNBuzz pivot business models several times until we hit the right product or market fit.

We learned that it is very important to map and highlight other key players in the ecosystem and understand their contributions. The mapping exercise helped us to understand potential partners or competition. We learned the need to be clear and confident in our values to customers and stakeholders, and deliver on it!

Also, going out and meeting the customers and stakeholders was one of the best parts of the program. We learned a lot from the customers, vendors, mentors and industry experts.

BoomNBuzz

http://boomnbuzz.com

Nexus Incubator http://startupnexus.in

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consequences can be widespread, for example, as people are less likely to know facts about AIDS, malaria and other infectious diseases. It means that they will be less likely to know about prevention and support services, and how to use lifesaving medicines and other treatments impacting their day-to-day life.

Today, it is less about access to technology and more about participation. Participation includes the quality of engagement and what people are doing with the technology that they have access to. This, along with our experience in the rural areas that we visited, motivated us to start thinking about something that could bridge the digital divide.

What does your vision for a virtual education/health care system entail?

We have designed our system for emergency and crisis situations, keeping in mind that there might be no grid power, no Internet, no trained people, and we would want to get reports and updates over the Internet. Our solution is affordable, portable, easy to set up, solarpowered, online and offline, with a focus on health and skill development. Keeping our solution modular will help us scale fast, with wide scope for improvement over time. Features can be changed easily due to its plug-and-play approach. Also, we will train locals to become health educators and tech support resources.

Our overall mission is to develop innovative and affordable technology solutions in the field of health and education, which impact the lives of millions of people across the globe. We aim to impact and empower 1,000,000 people by 2022 and contribute to the United Nations Sustainable Development Goals.

What do you see as being the most important emerging health and technology topics in the future?

Artificial intelligence and machine learning offer new and better ways to identify diseases,

Photographs courtesy Buddha Burman

Left and right: BoomNBuzz’s CozBoz device delivers health awareness and educational content in an audiovisual format.

Below left: The portable CozBoz device, which runs on renewable energy, is designed to work in lowresource locations.

Jason Chiang is a freelance writer based in Silver Lake, Los Angeles.

MARCH/APRIL 2020 27

iBreastExam, developed

by Indo-U.S. teams, helps make early detection of breast

cancer

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accessible, affordable and painless.

UE LifeSciences

www.uelifesciences.com

iBreastExam

www.ibreastexam.com

Global Entrepreneurship Summits

www.state.gov/globalentrepreneurship-ssummits

Drexel University

https://drexel.edu/ 28 MARCH/APRIL 2020

Device forEarly

Detection

I

By CANDICE YACONO

Right: Mihir Shah, founder and CEO of UE LifeSciences, which offers iBreastExam, a wireless, handheld device (above left) for early detection of breast cancer.

diagnosed late, with poor prognosis,” says Mihir Shah, founder and chief executive officer of UE LifeSciences. The company, with offices in Philadelphia, Mumbai, Bengaluru, New Delhi and Kuala Lumpur, works on innovations in the field of early detection of breast cancer. Its ultra-portable, wireless, handheld iBreastExam device has helped thousands of women around the world receive crucial information about their health.

The device’s transportability and affordability are critical because survival rates are closely tied to geography, as women in rural areas may not be able to travel to a city to receive a traditional mammogram.

“With basic training, this wireless, battery-powered device enables health workers to detect small lumps in the breast without any pain or radiation, in just a few minutes and at a Photographs courtesy UE LifeSciences

n India, breast cancer is the most common cancer among women, accounting for about 28 percent of new cancer cases in females in 2018, according to the World Health Organization.

The mortality rate for the disease is much higher in India than in many other countries due, in part, to a lack of awareness and education.

Other common barriers to breast cancer treatment and services include the feeling of shame, religious beliefs and inequalities of gender and income. Some women in India wait to seek treatment or decline it altogether. But early detection can be key in preventing breast cancer’s growth. A device developed by teams from the United States and India might hold the key to improving the situation.

“While breast cancer is the most common cancer among women globally, most cases are

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Left: Health care workers are able to operate the iBreastExam device (below left) with basic training, to detect small lumps in the breast, without any pain or radiation, in just a few minutes and at a fraction of the cost of a mammogram.

Photographs courtesy UE LifeSciences

By providing women access to early detection, we can hope to save many lives otherwise being lost to a treatable cancer.

fraction of the cost of a mammogram,” says Shah. “By providing women access to early detection, we can hope to save many lives otherwise being lost to a treatable cancer.”

Feedback received from both patients and health care professionals has been very positive so far. The company has also conducted multiple international clinical studies, with over 7,500 women enrolled.

Shah describes iBreastExam, which provides digital documentation, as a “comfortable, affordable solution; one that doesn’t scare women,” because it is painless and radiation-free. It is an option for those who might be put off by a traditional mammogram.

At the 2017 Global Entrepreneurship Summit in Hyderabad, iBreastExam was selected by NITI Aayog from hundreds of innovations to make a presentation to Prime Minister Narendra Modi and First Daughter and Adviser to the U.S. President Ivanka Trump. “iBreastExam was offered a special feature spotlight, and it was a great experience

for us all.”

The product was developed as a collaboration between teams in the United States and India. “iBreastExam is an IndoU.S. innovation, with its roots in the United States and scale up in India,” says Shah. “We kickstarted the development with Pennsylvania Department of Health’s CURE [Commonwealth Universal Research Enhancement] grant of nearly $1 million, followed by a Digital Health Accelerator grant from the University City Science Center.

Once we had a functional prototype, we transferred the technology to India for clinical validation and production.” The patented tactile sensor technology was invented by the scientists and doctors at Drexel University, Philadelphia. “It was only with this Indo-U.S. team and a whole host of multidisciplinary collaborators that we were able to bring it to scale,” adds Shah.

Many women who learned through the device that they had breast cancer have reached out to the company after receiving treatment, to share their appreciation.

“They want to thank us for saving their life when, in fact, we want to thank them for having the courage to get checked early and taking action promptly,” says Shah. “Early detection of breast cancer starts with a woman’s conviction that breast cancer is not a death sentence.”

Shah and his company have big plans for the future, including a goal to reach 200 million women across India and over one billion women globally. “We’d like iBreastExam to become more and more accessible to women across India,” he says.

“We hope to collaborate with governmental bodies, corporate social responsibility offices, nongovernmental organizations and private health care providers to make this possible. To date, we have done over one million scans.

We hope more people, doctors and health care policy makers take notice of this innovation and put it to good use to make the promise of early detection a reality.”

Candice Yacono is a magazine and newspaper writer based in southern California.

30 MARCH/APRIL 2020

For our 60th anniversary this year, SPAN is reprinting articles from past editions that reflect on issues we are reporting about today. For this edition, focusing on innovations in health care, we are reprinting this article from January 1977.

Jonas Salk's

Citadel of Science

Dr. Jonas Salk, developer of the first safe and effective polio vaccine, shares his vision behind the Salk Institute for Biological Studies, in California.

CHRISTOPHER SPR1NGMANN

H

igh on a bluff overlooking the Pacific Ocean at La Jolla, California, sits a monumental research center—the Salk Institute for Biological Studies. Conceived by architect Louis Kahn, the institute’s massive concrete masonry befits the lofty vision of its founder, Jonas Salk, known the world over as the discoverer of the polio vaccine.

Here, Salk and his colleagues conduct basic research in the life sciences, in such areas as the nature of the cell, the mysteries of the human brain, the process of aging. A common factor running through much of the institute’s work is an investigation of how living cells sense and respond to their environment. This interaction, Salk believes, will eventually explain many pressing medical and scientific problems.

Dr. Salk’s own specialty is molecular biology, the study of the molecular structure and function of human organisms. He was first attracted to this field because he felt that it would provide a fundamental explanation of how diseases start at the level of the individual cell. This approach helped him develop his vaccine against polio, and he believes that it may also produce a chemical vaccine against cancer. Much of the research is guided by Salk’s conviction that the body provides its own most effective defense mechanism. Thus, immunology remains a major area of concentration at the institute.

And it is directed mainly at uncovering the basic riddle of cancer—why a normal cell turns renegade and begins its lethal spread.

In the field of cerebral research, it is now

Dr. Jonas Salk at the Salk Institute for Biological Studies in California.

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Left: The monumental buildings of the Salk Institute, designed by renowned architect Louis Kahn.

Below: An intricate cage of glass tubes formed a piece of equipment that facilitates the study of the brain, particularly its role in regulating the body’s hormone functions.

known that the brain not only controls the body’s nervous system but also plays a direct role in regulating the body’s hormones. It does so by means of its own hormones. Salk scientists have discovered brain hormones that control the thyroid gland and the metabolic processes of diabetes. Still another brain hormone regulates fertility, and institute researchers hope to develop a revolutionary oral contraceptive based on work in this sphere.

If this hope is realized it will be partly because the Salk Institute houses a dazzling array of scientific talent. The staff of about 300 includes some 100 doctors of science and medicine. Visiting specialists from abroad are continually on hand to collaborate on research or to use the superbly equipped laboratories.

And the institute’s group of nonresident

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fellows includes four Nobel laureates— Robert Holley, Gerald Edelman, Renato Dulbecco and Salvador Luria.

Most of the work at La Jolla, however, is conducted by seven resident fellows who have lifetime appointments. Their broadranging program aims at the prevention and cure of specific maladies as well as at improving the general health and well-being of humanity.

Speaking of world health problems, Salk has some interesting comments. He says, “We have come to recognize that poliomyelitis is a byproduct of improvements in living, particularly improvements in sanitation.

Advancement is not an unmixed blessing. The reduction of illness and death resulting from typhoid, dysentery, diphtheria, smallpox, tuberculosis, yellow fever, malaria and plague

Photographs by CHRISTOPHER SPR1NGMANN

https://www.salk.edu/

Dr. Jonas Salk https://www.ncbi.nlm.ni h.gov/pmc/articles/ PMC6351694/

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Salk Institute for Biological Studies

Above left: A researcher at the Salk Institute looks at a highly magnified human cell.

Left: Chemical changes that occur in the human brain being measured in an effort to understand behavior. Researchers at the institute discovered brain hormones that control the thyroid gland and help regulate fertility.

Far left: A scientist conducts advanced cancer research.

Studying the action of cancer viruses on animal cells, Salk scientists discovered that surface membranes of cells play important roles in the process.

now accentuates problems resulting from the social-economic effects of overpopulation.”

Since mankind at large benefits from the institute’s work, Salk believes firmly that the public should participate in its support. The Salk Institute, therefore, has been set up as a “free standing” body—in effect, a public foundation. Its annual funds come from many sources—grants from the federal government, voluntary health agencies, private corporations, and from contributions to the National Foundation for the March of Dimes

(which millions of Americans support).

The Salk Institute was established in 1963, a time regarded as a turning point in the progress of science. The past century has seen momentous developments in the physical sciences, deepening man’s knowledge of the physical universe and vastly extending his control over natural forces. The next century is expected to see equally momentous advances in the life sciences, implying an extension of control into the realm of living nature.

So in the seclusion of their citadel by the sea, Salk and his associates are striving to understand the basic life processes. And, in doing so, they hope to provide greater wisdom in using the unimaginable power that these sciences are placing within man’s reach.

MARCH/APRIL 2020 33

BESTBRK/iStock/Getty Images

Fulbright-Nehru Student Researcher

Hannah Lider focused on defining the challenges of current hemoglobin measuring devices and designing a data storage bangle for effective antenatal care in India’s rural areas.

Health Buddy

A

nemia is a huge public health concern in India, where a majority of Indians of all ages and both sexes are anemic, according to a research paper published by the Nutrition Foundation of India in 2018. Anemia is a condition in which a person has a lowerthan-normal number of red blood cells or quantity of hemoglobin, which reduces the capacity of the blood to carry oxygen and can lead to a number of health problems.

Low hemoglobin levels lower productivity, cause illness and, at times, even death.

Timely interventions can help both prevent and treat anemia. But such interventions can only be prescribed when health workers are equipped to make accurate and efficient diagnoses.

Hannah Lider, who participated in the Fulbright-Nehru Student Research Program in 2018-19, joined the Women Wellness Initiative team at Barefoot College in

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By NATASA MILAS

Tilonia, Rajasthan, to define the challenges of current hemoglobin measuring devices and design an efficient, low-cost solution suitable for use in rural mobile clinics. “I designed and conducted a comparative analysis of six point-of-care hemoglobin measurement devices to determine suitability for use in remote clinical settings. I also coordinated capacity building for a team of community health workers to perform data collection in nine rural schools,” says Lider.

“Since returning to the U.S., I am conducting data analysis on the results of 1,200 participants and preparing reports of the results in English and Hindi.”

Lider, who graduated from the University of Wisconsin-Madison, with a bachelor’s degree in biomedical engineering and two certificates—in South Asian studies and international engineering—became interested in health care issues in India during the

focused on women’s health before and during pregnancy,” says Lider. “The idea is very similar to the Khushi Baby platform, a wearable necklace pendant which stores a child’s vaccination records. Two colleagues from Barefoot College and I met with the Khushi Baby team at their headquarters in Udaipur to discuss our ideas and how our teams might be able to work collaboratively.”

Lider’s knowledge of Hindi, which she studied at University of Wisconsin-Madison and as a Critical Language Scholarship Program participant in India, greatly facilitated her work. For example, it helped her communicate with the local staff at Barefoot College, many of whom did not speak English proficiently, and members of the medical department, where only two out of the around 20 staff members spoke English. “Being able to speak Hindi was crucial to my being able to form relationships and build trust with my coworkers, fully comprehend observations in the field and interact with patients,” says Lider. “I even used my ability to write in Hindi to document my notes, my findings, write up reports for the local staff to keep and reference. Overall, I probably used Hindi to accomplish 80 percent of my daily tasks while I was completing my Fulbright Fellowship in India.”

Fulbright-Nehru Student Research Program https://bit.ly/39zgxDa

S.N. Bose Scholars Program

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spring of her sophomore year, via an internship supported by the S.N. Bose Scholars Program. This student exchange program between institutions in India and the United States is a partnership between the Indo-U.S. Science and Technology Forum, the Government of India’s Department of Science and Technology, and others.

“I am an engineer trained to innovate, create, design and develop things,” says Lider. After an extensive literature review, along with months of observations, her project became about conducting a comparative analysis of popular hemoglobin measurement devices already being used in rural clinics. “There are so many products already out there in the market that are accessible to rural clinics, like that at Barefoot College,” she adds. “These devices use various detection principles. Some are digital, some are not. Some are more complicated to use than others. Some are costly, some are cheap. Most concerning, though, is that the actual test results of these devices are not consistent with one another.”

Lider was also involved in the Swasthya Sakhi, or “Health Buddy,” project. “This was a project I conceptualized with my Fulbright mentor, Dr. Monalisa Padhee, who is the program head of women’s wellness at Barefoot College. Swasthya Sakhi was our idea of a bangle that women would wear, which stores their health information and medical history. The program would be

https://bit.ly/3bDVukX

University of Wisconsin-Madison www.wisc.edu

Courtesy Dr. Monalisa Padhee

Photographs courtesy Hannah Lider

Natasa Milas is a freelance writer based in New York City.

Above: Hannah Lider worked on Swasthya Sakhi, an app-based platform and wearable data storage bangle, which is embedded with a QR code to identify each patient and provide a physical link to medical records.

Above left: Lider reviews a diagnostic procedure in a pathology lab.

Above right: Lider (second from right), health care workers and teachers conduct a health camp at a school in Rajasthan.

Right: Health care workers learn a new fingerstick technique to collect blood samples, with Lider (left) acting as a patient.

MARCH/APRIL 2020 35

Photographs courtesy Adarsh Natarajan/© Getty Images

Adarsh Natarajan with Aindra Systems’ CervAstra, a suite of three products—Aindra IS (from left), Aindra VisionX and Aindra Astra.

36 MARCH/APRIL 2020

Smart Cancer Screening

By RANJITA BISWAS

Millennium Alliance awardee Aindra Systems’ CervAstra utilizes artificial intelligence to provide smart, fast and affordable screening for cervical cancer.

37

I

One of the most promising and impactful applications of this technology has been in the area of health care to assist with diagnosis, screening and treatment. “This has been highly significant for the health care sector. It is about saving lives using deep learning systems,” says Natarajan, who is regarded as one of the pioneers in using artificial intelligence for health care, specifically in the area of cancer detection.

In the context of cervical cancer in India, he feels that the need of the hour is to “conduct population-based screening to cover all the women in the risk category.”

But this requires a high level of infrastructure and skill set.

Any solution designed for early detection of cervical cancer, according to Natarajan, needs to be simple, affordable and portable so that it can be deployed in any nook and corner of a country. “Technologies like ours [CervAstra] help in releasing the systemic constraints that are the root causes of the lack of good outcomes where populationbased screening is required,” he says.

Before starting Aindra, the team met a lot of clinicians, diagnostic lab owners,

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Photographs courtesy Adarsh Natarajan

Our vision is to democratize access to quality health care with the help of deep technology.

ndia has one of the world’s highest numbers of cervical cancer cases. A 2018 report by GLOBOCAN, an international agency for research on cancer, indicates that in India, cervical cancer is third among new cases of cancer and the fourth biggest cause of deaths from any cancer. However, cervical cancer is curable if detected at an early stage. Thus, an affordable and fastdetecting tool can go a long way in combating the incidences.

CervAstra is one such tool, a point-of-care system that makes screening affordable and accessible to even people in remote and rural areas. It is a product of Aindra Systems, a Bengaluru-based artificial intelligence (AI)driven company, focused on creating pointof-care diagnostic solutions for fatal illnesses.

“We are building a computational pathology platform for all critical illnesses that can be detected using technologies like deep learning,” says company founder Adarsh Natarajan. “The first of such products is CervAstra.”

Artificial intelligence and machine learning involve the use of computers to mimic the cognitive functions of humans.

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gynecologists and others, which helped to conceptualize, design and develop the computational pathology system. To establish the effectiveness of the system, Aindra worked with a leading oncology hospital, a general hospital, not-for-profit organizations and diagnostic labs.

The screening and detection of cervical cancer, especially in rural India, can be tedious, time-consuming and expensive.

CervAstra simplifies the procedure by putting smarter cancer detection technology at point-of-care centers. Women can visit their local clinics or primary health care centers and get screened with a standard Pap smear. CervAstra is a suite of three products—Aindra IS, Aindra VisionX and Aindra Astra—which work cohesively to obtain quick and accurate test results.

Once a pap sample is collected, it is processed through the Aindra IS automated stainer. The stained sample is then scanned using Aindra VisionX to get an extremely crisp image. The image can either be used for telepathology or be passed through the third system, Aindra Astra, an artificial intelligence platform developed to facilitate

faster and more accurate diagnosis. A report is generated and shared with the woman immediately.

“We covered more than 600 women in a period of six months as part of a pilot rollout.

We are looking to expand this number considerably with the successful conclusion of the pilot rollout,” says Natarajan.

Aindra Systems has received grants from the Millennium Alliance, a consortium of partners including the Government of India, the United States Agency for International Development and others, as well as from the Indo-U.S. Science and Technology Forum, an autonomous bilateral organization jointly funded by the governments of the United States and India.

Aindra Systems is now focusing on creating inroads into the market, says Natarajan. “Our vision is to democratize access to quality health care with the help of deep technology,” he says. “We see a world where machines work along with humans in creating an equitable health care system.”

Ranjita Biswas is a Kolkata-based journalist.

She also translates fiction and writes short stories.

www.aindra.in

IUSSTF www.iusstf.org Far left: Adarsh Natarajan (back, right) with Aindra Systems team members.

Left: CervAstra aims to automate and simplify the procedure of screening and detecting cervical cancer.

Millennium Alliance www.millennium alliance.in

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Aindra

Selecting the Nominees

By CANDICE YACONO

Political parties use primaries and caucuses to choose presidential nominees in the United States.

A

mericans vote for a new president every four years. The U.S. Constitution’s requirements to run for president are relatively simple: An individual must be at least 35 years old, a natural-born citizen, and a U.S. resident for at least 14 years. But to stand out in a sea of possibilities, one of the main differentiators for candidates would be the political party they are affiliated with.

Unlike many other countries, there are only two major political parties in the United States: the Republican Party and the Democratic Party. Although there are other parties, like the Green Party of the United States and the

40 MARCH/APRIL 2020

Libertarian Party, these receive so few votes that they have little sway in national politics.

The race to become the president of the United States is a years-long process involving campaigning, advertising, debating, nomination and election. But one of the most crucial steps along the way is the primary election and caucus process.

Primaries and caucuses are organized in each state and territory for citizens to select their preferred nominee in advance of a general election. Some states only hold primary elections, some hold caucuses and others use a combination of both. While the

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Primaries and caucuses

Top: A voter casts his ballot at the Ala Wai Elementary School cafeteria for the Republican Party of Hawaii Caucus in 2016.

Above: People assemble at a Republican caucus site in Salt Lake City, Utah, in 2016.

Top right: Members of a precinct gathered in a schoolroom raise their hands, signifying a vote, during the Democratic caucus, in Boulder, Colorado, in 2016.

Above right: A 2008 Democratic caucus in Cape Elizabeth, Maine.

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procedures may differ, primaries and caucuses are held between January and June, prior to the general election in November.

Primaries and caucuses differ mainly in how they are funded and operated. State governments typically run primaries, which allows them to set the parameters for factors like who can participate. For example, some states have closed primary contests that only allow registered party members to vote; some follow the open primary model, which allows unaffiliated voters to participate as well.

Caucuses are meetings between registered party members, run by the political parties themselves.

The caucus system started in the early years of America’s political system, in the late 18th century, and has been used in various forms to address a range of political topics. In Iowa, for instance, caucuses not only allow

Mail-in ballots for the presidential primary election, at the Sacramento County Registrar of Voters office in California.

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activists and voters to make a case for their preferred candidate, but also to talk about issues that could be incorporated into the state party platform, said Dennis Goldford, a political science professor with Drake University in Iowa, in an interview to PBS. The caucus system began to be replaced by the primary system at the beginning of the 20th century, with only a few states continuing with caucuses in 2020.

At primary elections, which are similar in format to general elections, voters either fill out secret ballots in polling places or vote by mail for the candidates they believe will best

represent them. Some states hold “open” primaries, which means voters can select candidates from any of the available options, regardless of the party to which they are registered. But in states with “closed” primaries, voters can only select candidates from their own parties. Variations on the open or closed primary processes—semi-open and semi-closed—also exist.

While primary elections are run by state and local governments, caucuses are private events that are directly run by the political parties.

Under the in-person caucus model, groups of voters convene by party, in places like churches and gymnasiums, to discuss, debate and lobby for their candidate of choice before voting. This can take place in the form of a secret ballot or even by voters standing together in groups for a particular candidate, then lobbying others to join them.

In each caucus state, Republicans and Democrats set their own rules, which can vary greatly. In Iowa, for example, the Republican party’s procedure involves registered Republicans gathering on a weeknight at more than 1,000 locations, writing down and submitting their preferred candidate, as well as choosing delegates to send to county conventions. Under the Democratic Party’s procedure, registered party members convene at about the same number of precincts, where they are asked to form groups based on their preferred candidates. Undecided members can also form a group. The number of members in each group is then counted, and typically candidates that receive at least 15 percent of the head count are considered “viable” or eligible to receive delegates. Then there is a 15-minute period, where attendees are given a chance to “realign,” during which members can try to convince others to join their group.

According to this year’s rules, only members of nonviable groups can realign; they can either join an already viable group, or come together to help a nonviable candidate reach the 15 percent threshold. All the candidates who meet the 15 percent cutoff will be awarded delegates based on a formula put together by the Iowa Democratic Party. These delegates will go on to county conventions throughout the state. Later, at Iowa’s statewide conventions, delegates for the Democratic and Republican national conventions are chosen. Both the Democratic and Republican caucuses in Nevada operate in ways similar to Iowa.

Instead, they were selected by delegates at national party conventions in the summer prior to the general presidential election. These conventions still occur, but they are largely symbolic when compared to their prior role.

At the convention, along with selecting their nominees for the president, the parties adopt a set of principles and goals, known as the platform. The presidential nominees also select their running mate for vice president, and the general election process begins.

Candice Yacono is a magazine and newspaper writer based in southern California.

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Caucuses generally have lower turnout than primary elections and tend to favor candidates with the most vocal and engaged backers. Caucuses also pose an access issue for many. Because they require participants to share their vote in public, are held at set times and locations, and can sometimes last for several hours, voters might not be inclined to participate. To that end, states like Washington, Minnesota and Colorado have switched from a caucus model to a presidential nomination primary model for 2020.

Until the mid 1900’s, American citizens did not vote for their presidential nominees.

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Left: People participate in caucuses and primaries (below left) to select their preferred nominee in advance of a general election.

Below: Ballots processed at Multnomah County election headquarters in Portland, Oregon.

Below center: A ballot for the New Hampshire primary is entered into a machine at a polling site.

Bottom: Super Tuesday presidential primary election ballots in Massachusetts. Super Tuesday is the election day early in the presidential primary season when the greatest number of U.S. states hold primary elections and caucuses.

MARCH/APRIL 2020 43

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Registered under RNI-6586/60 Official White House Photographs

by SHEALAH CRAIGHEAD ALEX BRANDON © AP Images

Top: President Donald J. Trump and First Lady Melania Trump at the Taj Mahal in Agra on February 24, 2020.

Above: President Trump and Prime Minister Narendra Modi at Hyderabad House in New Delhi on February 25.

Left: President Trump and Prime Minister Modi during their visit to the home of Mohandas K. Gandhi at Gandhi Ashram in Ahmedabad on February 24.

Below: Prime Minister Modi, President Trump and First Lady Melania Trump arrive for the “Namaste Trump” event at Motera Stadium in Ahmedabad on February 24.