Health post: Challenges of scope

This past week I met with two women, Sireesha and Vyoma, of Access Health International, an organization that works to provide quality, affordable healthcare in India and other countries around the world. Both Sireesha and Vyoma are based in Bangalore but travel for their work with Access Health, so I was glad for the opportunity to ask them about what factors in India (as opposed to other countries) influence the adoption of medical technology.

First, we talked about the attitude towards health in India in general. Sireesha said that, in her experience, there is no concept of an annual physical check-up – except for those who have private health insurance. Only 17% of the population has health insurance, so that is a small number, but it’s growing as more people are provided insurance by their companies in employment packages (http://www.thehindu.com/news/national/only-17-have-health-insurance-cover/article6713952.ece; however, most people I’ve talked to seem to think the number is closer to 7%). Overall, though, preventive promotive care is not something that really happens in India. Sireesha’s example was that unless there’s a wound in your foot and it’s not healing, you won’t go to the doctor and learn about your diabetes. Since many medical devices are for preventive care and/or self-management of a condition, these devices won’t easily succeed in such a market.

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These photos are unrelated to the meeting with Access Health, but I took them walking around Bangalore. This is a Hard Rock Café in a beautiful old “Tract and Book Society” building!

The most important factor in India that determines whether or not someone accepts a medical device, though, is purchasing power. Sireesha and Vyoma are two of many people here to tell me that cost is first and foremost what influences peoples’ attitudes towards medical technology. Beyond cost, we talked about who might use medical technology and why. The main health issues in India are NCDs (non-communicable diseases) such as diabetes and hypertension, which would require devices like glucometers and blood pressure monitors.

Sireesha and Vyoma suggested that elderly people would be more likely to use medical devices, as they are the ones with chronic illnesses that have progressed further and therefore have a greater need for devices. I’ve heard the opposite from everyone else, so I thought this was an interesting view. Most people have told me that elderly people would not want to use medical devices, either to save money for their children or due to a lack of comfort with technology in general.

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Bangalore has lots of green streets like this.

Sireesha mentioned that the availability of traditional medicines (Ayurveda, homeopathy, and so on) takes some of the market share away from medical devices. Lack of awareness of medical devices is not the only reason besides cost that someone might choose against using a medical device. If people see the technology as too complicated or prone to glitching, they might prefer traditional medications, which don’t have batteries that die or readings that fluctuate.

What I found most valuable about our meeting, however, was that we also discussed the challenges with my project and my approach – mainly the need to normalize my experiences so that I can compare the countries. My project topic, which is already so broad, is complicated by the fact that it has to morph with each country I visit. How can I make sense of all my meetings at the end? How can I put them all into a framework so that these meetings don’t each disappear into one-off experiences? Obviously, I can’t see everything everywhere I go, so each meeting does have to be its own little unique example. Can I make generalizations based on these individual meetings? In addition, I have a time constraint: I only have a matter of months each in these countries with multifaceted histories, cultures, and populations, so I can only see various slivers of each country in this limited time. But maybe taking out the factor of time – seeing each country at a snapshot in time – simplifies the normalization problem.

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There’s lots of fun architecture in Bangalore, and I quite liked this example. Also, check out all the motorbikes – the best way to get around the Bangalore traffic!

The other issue is bias. Everyone I meet speaks from their own individual experience, which is biased based on where they’re from and what they’ve seen. Many of the people I talk to are quick to point out that “this is just my perspective and I don’t know for sure” (which is how I feel all the time). Then their perspective gets filtered through my own when I write about my meetings, meaning that I’m adding my own subconscious bias to each experience. Vyoma called a problem of “counter factors,” which I thought was a really cool way to put it. I’m trying to understand and collect these factors for acceptance, but as I do that, I have to be careful to consider the “counter factors” – the biases – that work against my complete and objective understanding of what influences someone to use a medical device.

On top of that, there’s bias that results from the way I travel on the Watson, mainly that I tend to stay in urban areas. First of all, it’s easiest to find housing in urban areas; if I have a family friend offering a place to stay in a country, chances are they live in one of the bigger cities of that country, and if I’m looking for an Airbnb or a guesthouse, I’m looking for one in a city. Many of the companies I research have offices in cities. For safety reasons, I stay in cities. And finally, I stay in urban areas just because that’s what I know about a country in advance – its cities – and I’m ignorant of its rural areas (and how to get there and stay there). Of course, this means that I miss out on a big part of the experience, and my meetings tend to be biased towards the urban upper class, and an even more elite minority of that group – the English speakers. In Sweden and Qatar, where I saw most of the population by traveling to Stockholm, Gothenburg, Malmö, and Doha, this wasn’t a problem. However, most of India’s population lives in rural areas. So my experience here to date has definitely been skewed.

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A lot of the flyovers have colorful murals on the supporting pillars.

One reason I wanted to spend more time in India and Japan compared to the other countries I’m visiting on the Watson is to explore the differences in urban and rural areas. So far in India, I’ve mostly been staying in Mumbai and Bangalore, two of the most urban and cosmopolitan cities in the country (so, not at all representative of India, not that any one place here would be representative of the whole country – Vyoma mentioned that I could do my entire Watson in India, and it would still be like visiting a bunch of different countries). Still, the urban vs. rural conversation has come up far more in my meetings in India than it ever did in Sweden or Qatar, either by my prompting or that of my project interviewees. That’s good, but I am also hoping to plan some sort of field visit to a rural area for the project to understand these issues first-hand. It will be tough to plan and get approval, but of course it would be a hugely valuable experience, so hopefully I can work something out.

Anyway, as I continue having meetings, it’s good to keep this in mind so that I think of each meeting as a part of the framework, a piece of the puzzle, rather than an isolated experience.

Is the project your life, or is your life the project?

I’ve been boasting to all my friends, especially my local Indian friends, that I have a stomach of steel. I’ve been drinking heavily filtered tap water since my arrival in India (along with bottled water as well) and eating Indian food nearly every day. After a couple weeks, I tried all the craziest street food including pani puri, which involves spiced water and ungloved hands.

And to my surprise, I still felt great! Well, you can see where this is going…fast forward a month to this Monday, when I was packing up from a weekend trip in Goa to fly back to Bangalore (Goa is a really pretty state in India known for its beaches). Just before the bumpy hour long drive to the airport, I started feeling nauseated, and that was the beginning to a tough day of travel.

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Goa was beautiful though.

I managed to throw up twice on a 50-minute flight, and I had to cancel a project meeting I had scheduled for that evening. I got to the guest house where I’m staying and Skyped my parents from the bed, sliding further into zombie-ness over the course of the call. The saddest part of all of this is the food that made me sick: a few bites of fruit salad! It’s true that people warned me against raw fruits and veggies, but I suppose I thought a fruit salad at a hotel restaurant would be okay since I’ve survived some serious street food.

I couldn’t afford to reschedule any more meetings, as the week was pretty booked and I probably won’t come back to Bangalore. So I had to get better, and while I did bring medicine for an upset stomach on the Watson with me, I left it in Mumbai for this short trip along with other things I haven’t needed much (of course).

I made it through Tuesday’s meetings and then found my way to a medicine shop. I walked up to the counter, scanning the wide array of products displayed in the floor-to-ceiling cabinets. It was definitely a counter service place, so I told the man behind the counter that I had a stomachache and a headache (probably from not eating or drinking much due to the stomach issue).

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My super stealthy shot of the counter. This is one of the smaller pharmacy stores in Bangalore, though Mumbai has more of the tiny packed ones.

I think I expected some conversation about options. Instead, the man at the counter swiftly placed two boxes on the counter, removed a set of ten pills from each, and said “67 rupees.” (That’s just under $1).

“Umm…okay. Can I see the boxes?” He shrugged as I picked up the decidedly minimalist boxes that merely listed generic medicine names that I didn’t recognize. After 20 seconds of this, the man basically told me I wouldn’t learn anything from the boxes. So I gave him 67 rupees, took the pills in a small brown paper bag, and walked away.

I couldn’t believe how cheap and easy it was to get the pills. Of course, as soon as I had wifi, I Googled the generic medicines and found myself on some of the same websites that I had visited when looking for companies to interview for my project. I suddenly understood the need for all the websites here that help you look up individual generic medicines and find the best price and uses and so on. In the US, I never Google my medicines. I either get a prescription from my doctor and take that without question, or I go to a store like Walgreens and go to the aisle labeled “headache” and pick a brand I know, or the stores’ generic version of that brand, or read a few labels.

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The pills were more labeled than the boxes they came in, which was helpful.

Going on the internet for that information makes the process so much more complicated; one site said that the stomachache medicine I got was for menstrual cramps (no), and another said the headache and stomachache pills might react with each other (but most sites said they wouldn’t). Anyway, I found out that the headache tablets were basically Tylenol, so I took one. The stomachache tablet medicine was something I hadn’t had before, so I waited a bit, felt better on my own, and decided to forgo the medicine.

And now I’m all better – back to the stomach of steel. Phew! (Though I will probably avoid fruit salad for a while).

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Health post: Cochlear implants

Back in Mumbai, I visited Cochlear Limited, the biggest producer of cochlear implants in the world. Cochlear implants are small medical devices for the deaf or severely hard of hearing, and they replace/bypass the damaged cochlea (the inner ear). Two-thirds of the cochlear implants in the world are made by Cochlear. Unlike a regular hearing aid, cochlear implants include a surgically inserted device, which requires a single surgery as well as an external piece that sits over the skin on the skull and contains a microphone and sound processor. The microphone picks up the sounds in the environment, the sound processor processes them, and then the device transmits the information to the implant. The external and internal parts connect via electromagnetic induction (the magnet is strong enough to hold through skin).

My contact at Cochlear, who did not want to be named, told me that while of course the implant itself is hidden, there’s a social stigma against the external part of the hearing aid. In the United States, Europe, and Australia, the mindset he’s observed is that “a hearing person is a normal person” – but not in India. Also, in comparison to the other health issues, he said that cochlear implants are the lowest priority of health here.

My contact said that the stigma here partially results from the fact that Indians are always focused on what others are doing. (I have definitely noticed this stereotype! I don’t get stares just because I’m a white woman; everyone seems to stare at each other no matter what.) So if you have a hearing aid or some other visual oddity, it could prompt your friends, relatives, and coworkers to point it out and ask questions. “What is that? Are you alright? How bad is your hearing?” and so on. Best to avoid it altogether, in that case. Of course, this is all per the stereotype and a large generalization, though it differs from the generalization about the United States that it’s considered rude to stare. I do think it’s true that most people might look and then glance away quickly, adopting a studied ignorance of the device (which could also perpetuate a stigma, but that’s a different discussion).

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On the left, you can see an older model of the cochlear external piece, which has 3 separate parts to the microphone, processor, and transmitter. It comes in neutral colors but there is an array of caps in bright colors and prints to modify the over-the-ear part. (Far to the right is the newer Kanso 3-in-one device).

At Cochlear, the internal implant is the same size for everyone, while the external processor is a different size depending on the model. In response to the consumer feedback research done by Cochlear’s R&D team, they’ve developed different color caps for the processor in case people want to decorate it – they’re trying to make it into a cool gadget like any other wearable (such as how Fitbit sells wristbands in all colors). But they have had trouble selling these caps in India, as they’ve observed that no one wants to advertise that they have a hearing issue. Instead, most people go without any aid and try to manage without telling anyone, as I mentioned. Cochlear is always working to avoid this stigma, so they developed Kanso, a subtler hearing aid, in response to stigma in general, in India and around the world. Kanso, which means “simple” in Japanese according to Google Translate, has no wires and no parts that sit on the ear (unlike Cochlear’s previous models), hiding instead on the back of the head in neutral colors to match hair. It was launched 2 months ago, so it’s hard to tell how successful it’s been so far.

I asked about the factors that would influence someone to accept or reject a cochlear implant device (ie, my “big question”). One of the main factors was age; many of the cochlear implants are bought by parents for their young children. Older people, however, will prefer to buy a $1000-2000 hearing aid over a $12,000 cochlear implant, even if the latter is the only device that will really give them hearing. After a certain age, they decide that it’s not worth it to spend that much money on hearing (money that could go to their children or grandchildren, for example), or they’re used to living without hearing, or they’ve really internalized the stigma.

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These are models of the internal part: the cochlear implant itself. This gets surgically inserted and never needs to be replaced. (If you look really closely, you can see a spiral shape at the end of some of the wires, and that’s what fits into the snail-shaped cochlear.

In addition to age and general stigma, Cochlear has noticed other barriers to acceptance of cochlear implants in India. One is a fear of surgery. I have heard this now from multiple people here in India, both project contacts and friends; most people would prefer to find a solution that does not involve anything invasive or surgical. Another barrier Cochlear mentioned is the desire to try traditional healing methods instead, such as working with babas and godfathers, which is somewhat common in the rural areas. Cochlear is especially concerned with tackling these barriers when it comes to children, who need auditory input before age 3 if they are to develop language skills properly.

I thought it was interesting that Cochlear’s R&D happens in Australia and the US, which means that when it comes to creating new products, most of their feedback comes from wealthy countries. This came up when I asked if Cochlear India was developing anything specifically for India that it wasn’t creating for its other markets. Though Cochlear sells all its products in all markets, they do try to erase the stigma in India with awareness campaigns. One way they advertise the need for cochlear implants is via the Cochlear India Facebook page. They also try to encourage people with a celebrity “hearing ambassador,” Brett Lee, a well-known cricket star in India who promotes Cochlear’s implants (http://www.cochlear.com/wps/wcm/connect/au/home/connect/cochlear-hearing-ambassador).

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The new Kanso device, which comes in neutral colors to hide under the hair. It sits back on the head, magnetically connecting to the implant.

As a global company, Cochlear has offices in many countries, including Sweden, India, Singapore, and Japan. That’s four of my six Watson countries! (If I haven’t mentioned it yet, I decided a couple months ago to add Singapore as a Watson country, and I’ll spend two weeks there between India and Japan). Anyway, I wish I had known about Cochlear earlier so that I could have met their team in Sweden. Still, it will be good to meet them in Singapore and Japan. It’s quite hard to compare and contrast the countries I visit – even though I’m obviously doing the same project in each, they are all so different. I think it will provide a good point of comparison to see the same company in 3 of the different countries.

I’m particularly looking forward to meeting with Cochlear in Japan. My contact was telling me that Japan is a difficult market for Cochlear because the deaf culture is so strong there. That is, there is so much respect for the deaf and pride among that community that it is almost insulting to suggest that deafness is a disability that should be corrected. So Cochlear is finding it hard to break into that culture and sell cochlear implants. India is a difficult market too, but for completely the opposite reason! (Of course, this is a sweeping generalization that I can’t back with numbers, but it’s an interesting idea that I’ll look out for when I arrive in Japan.)

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I was pretty impressed by Cochlear’s display packaging!

Lastly, a fun note for the engineers: I asked about the digital signal processing code on Cochlear’s sound processor. I learned about Cochlear’s SmartSound iQ sound processing system, which is designed to dynamically identify the type of sound in the surrounding environment (conversation, wind, music, etc.) before processing. The algorithms on the chip include a background noise reduction algorithm and a new wind noise reduction algorithm as well. For more details, check out http://pronews.cochlearamericas.com/cochlear-tech-talk-smartsound-iq/.

Bangalore / Bengaluru

It’s decided: if I ever move to India, I’m living in Bengaluru (“Bengaluru” is the official post-colonial name, but used just as much as Bangalore – much like Mumbai and Bombay). I arrived here a couple days ago for my project. Bangalore is known as the “Silicon Valley” of India, housing many startups and technology parks.

When I first arrived, however, I wasn’t happy. I tried to go to the National Gallery of Modern Art, which has a 20 entrance fee (~30 cents) for Indian nationals and a 500 entrance fee (~$7.50) for foreigners. This isn’t so unusual – there’s often a difference for sites in India, but not such a steep one! I raised my eyebrows at the man at the ticket counter, who told me that the new wing is closed that week. So I left. I’m not paying $7.50 to see only the old wing of a modern art museum!

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The “Vidhana Soudha” government building.

So I went to a café to work, only their wifi was out, and none of their outlets were working; there was some issue with the power despite the lights and coffee machines working perfectly. I had trouble finding wifi all day, actually, due to various similar issues and invalid passwords at “free wifi”-labeled cafés (this wouldn’t really fly in Mumbai. Also, the wifi at my Airbnb wasn’t working when I arrived). Okay, fine. I ordered a coffee and wrote a letter instead, and I went to the post office to mail it.

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View from the steps of the post office, which is situated in a big, green park.

There was a bit of a language barrier at the post office, but I made it clear that I wanted to mail a letter to the U.S. Apparently this only cost me 25 (under a dollar). Hm. I asked a second person, who basically said “Yeah, just put the stamp on and put it in the box outside,” so I licked the back of the stamp and placed it on the envelope. He gave me a horrified, disgusted look, shaking his head and saying “glue!” Of course, I walked outside the office to see a tray of glue and a paintbrush for applying the glue to stamps sitting on a table by the post box. So I felt pretty bad about that.

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The tip of the Vidhana Soudha as seen from Cubbon Park.

Feeling upset and embarrassed – and slightly defeated, I suppose – I sat outside the steps of the post office for a while to gather my thoughts. I was thinking “Why on earth did I come to Bangalore, if it will just be like Mumbai without any of my friends?” I’ve made some great friends in Mumbai, and while the city can be super chaotic and challenging, having friends there makes it all okay.

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The state library building in Cubbon Park.

Of course, I needed to give Bangalore more of a chance, and I started to love it that evening and the next day (yesterday). The city is far greener than Mumbai, with more shade and a cooler climate. Coupled with the fact that it’s more pedestrian friendly, Bangalore is a great city to walk around in, and that is my favorite thing! I’ve already walked around here and taken more pictures in two days than I did in my first week in Mumbai (to be fair, I make more of an effort to get to know a place when I have less time there).

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A fun mural on Church Street.

One of the friends I made in Mumbai lives here, so we got dinner that first night, and I remembered that I do have friends in Bangalore, which makes all the difference. (Also, he confirmed that there is no way my 40-cent letter to the US will make it there. “90% chance it gets sent to the dustbin,” he said). Well, you live and learn!

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It’s hard to see, but I love the rainbow-painted columns down the road under this flyover.

Bangalore is known for being the city with the worst traffic in all of India, which I experienced a bit when I spent 1.5 hours in an Uber on my way to my first project meeting here (the person I was meeting was luckily very kind about the fact that I was almost 20 minutes late, which I hate to be). Also, the bus into the city from the airport takes just as long as the flight from Mumbai! So thank goodness it’s easier to walk around here – and in terms of the kind of city I would want to live in, I already feel just as comfortable here after two days than I felt in Mumbai after four weeks, if not more!

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A glimpse of a military base I walked past.
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I really love this building! It’s another government office – it seems like all the fun old-fashioned architecture in Bangalore is reserved for the government buildings.

Finally, I listened to this song yesterday on the 1+ hourlong drive to my project meeting, and I found that these lyrics really resonated with me: “I try to stop the world from moving so fast / Try to get a grip on where I’m at.” Sometimes, even though the Watson is very free and flexible,  I feel like there’s a lot going on and time is just slipping through my fingers. Part of this is that I’ve been spending (losing) a lot of time in cabs since arriving in Qatar and now India. Back in Sweden, I walked everywhere or took trams, and I posted on the blog every few days, watched movies in the evenings, and saw museums and the like during the day. Somehow, I post on the blog less frequently now, and I also watch far fewer movies, and see fewer sights. And yet time still feels like it’s flying by! How is this possible? I suppose I still spend lots of time on the project – researching companies; calling and emailing companies in an attempt to set up meeting; and having project meetings. In just the past two weeks, I’ve been having project meetings faster than I can write about them! Also, in India, the travel time to and from meetings can get really intense (infrastructure issues). I think I’m also more social in India than I was in Sweden or even in Qatar. Anyway, I don’t like feeling like time is slipping away, so it’s good to get a grip sometimes.

Health post: Starting with startups

This past week, I spoke with a man named Shoibal about the general state of the medtech industry in India. He studied to be a doctor but hasn’t practiced medicine, instead going straight into the pharmaceutical industry – he currently works at an Indian pharmaceutical company here in Mumbai. For a while, he was also a consultant helping healthcare startups and small companies with the projects they wanted to do.

I asked him if the startups and small companies he worked with tended towards a main topic, and he said that most of them focused on smartphone apps that aim to simplify the doctor or the patient experience. There is a need for such apps, he said, because India lacks a universal EMR system (electronic medical records). Often hospitals have no EMR system at all, so patients go to a hospital and get records created on paper. As a result, the patient has no idea what’s in their record, and they might know about parts of their record but not all, and they have a hard time going to different doctors and hospitals. A lot of these companies, therefore, focus on providing electronic data capture for patients so that they can have some control over their records and not worry about forgetting important data. This also gives patients the flexibility to move between cities and share their records with new doctors.

Shoibal mentioned that in addition to EMR-focused apps, companies were working on fitness apps, which provide support and recommendations for maintaining good health – either for an already healthy person or someone with a specific condition. These are apps that are tailored to the user, giving detailed feedback based on input data. I asked Shoibal if these companies had specific target user groups. As I mentioned in my last health post, I think that India’s large and diverse population necessitates the strict definition of intended user populations; no company, especially a start-up, can have a set of offerings wide enough to suit everyone. Shoibal replied that the companies have had to focus on urban populations since they are developing smartphone apps, and the penetration of smartphones in India is mostly in urban areas (though they are slowly spreading into rural areas, and surely the companies ultimately want to widen their focus). Also, the apps are aimed towards educated people, as the uneducated population might not even be literate, said Shoibal.

Finally, there is the issue of language. It’s very difficult to translate an app into multiple different local languages, so most of the companies make apps in English only. Even Welcome Cure, I noticed, had all of its information in English but not in Hindi, let alone any regional languages. So that means that these startups and small companies all have nearly identical target user groups: the educated, English-speaking people living in major cities who own a smartphone. In other words, the 1%. I see a potential for image-based apps here; even if they still require a phone, at least they would work for the uneducated and non-English-speaking members of the population.

I asked if any of the companies were making physical devices rather than just health apps (at the end of the day, I’m an engineer, not a computer scientist). Shoibal said that some were focused on connecting people to devices, but still via smartphone apps. Rather than these startups building and deploying their own glucose monitors, for example, they would have a licensed connection with another company (say a Chinese manufacturer) and sell that company’s device online. Shoibal pointed out that these were two different skill sets, engineering, manufacturing, and quality control vs. app development and IT, and only large companies with enough money keep both under the same roof.

He said that some of the companies that didn’t do apps would maybe do a website, such as Welcome Cure, and have a telephone number, focusing more on having some supportive back-end of people who communicate with the patients. These could be services that ease patient management for doctors, or help patients find the cheapest version of their prescribed medicine, or encourage medication adherence, for example.

Next, I asked one of my favorite big questions: what factors influenced the success of some of these medtech companies over others? Shoibal was ready with two main factors of success, the first of which is funding. Since there are so many tech companies and health startups (and it really does seem like India has a lot), “the ultimate success of these ventures is uncertain.” Even if they have a lot of success in an initial domain, such as childcare, it can be difficult to scale up the company and expand into other domains without a lot of upfront capital in addition to the money the company’s already made.

The second main factor of success is that companies have to have a good plan. They need to offer something that is actually valuable to their target group – something that the patients or the doctors need. The plan has to incorporate continuity as well, meaning that the company has to work to keep engaging its users and clients beyond the point of initial interest.

I wondered if Shoibal had any ideas of what new startups should focus on, or if there was some big need that they should address. He said that there was a lot of potential in the patient-doctor relationship – not that there was anything wrong with the relationship, but that both patients and doctors could use more support in terms of adherence, setting up meetings, keeping track of medical records, and so on. The healthcare space is quite “fragmented and disorganized in India,” said Shoibal. “Organizing it through technology really has potential.” With such a large population, it’s difficult to find doctors and the right kind of help, and it’s a big hassle to go to an overcrowded hospital just for a small health issue (I can imagine that this leads to many people avoiding care until their issue gets to be more painful or urgent, which is obviously bad for health). Shoibal also mentioned that there’s potential in rural areas, providing care by translating existing services, apps, and websites into the local languages there.

There’s clearly a large range of health issues in India (due to the large population and high socioeconomic inequality, I would say). Shoibal suggested that Indians might be a little more careless than the rest of the world when it comes to health, but even if they do want to be very careful about health, Indians are exposed to a particularly unhealthy environment. There is high pollution, the presence of environmental and biological pathogens, high levels of stress on the roads (Indian traffic!), and compounding all that, the healthcare delivery system is not well-equipped enough even to deal with normal levels of health issues. There’s a gap between what the people need and the healthcare that is available. Part of it is simply a numbers issue – that there aren’t enough doctors and healthcare professionals in India to accommodate the number of patients. I looked it up, and apparently there are 0.6 physicians per 1000 people in India, as opposed to 3.3 per 1000 people in Sweden, for example (according to Nation Master’s statistics, which has fairly old data). On top of that, the doctors are clustered in urban areas, so people in rural areas have to move whenever they have something more serious than a cold. Shoibal agreed that technology could do a great deal in terms of solving this problem, but only once the infrastructure improves. Right now, there simply isn’t a way to stream images, videos, and medical information out to the rural areas. Also, venture capitalists aren’t so eager to invest in startups that are trying to fix these particular issues. The affordability of the target population in these areas, at least to begin with, is very low (as opposed to the aforementioned 1%), and Shoibal said that many venture capitalists have too-high expectations, preferring to invest in companies with higher, faster returns.

I think, then, if startups are too small and risky, the money and drive to solve these issues will either come from big philanthropic organizations or from the government. Shoibal said that it would be great if the government invested in telemedicine in a big way, but that they’re not focusing on it at the moment (I’ll need to investigate this). They might be focused on technology, or on health, but not yet on both at once. One of the issues they are focused on is the concentration of doctors in urban areas but not in rural.

Shoibal was telling me that most doctors want to live in urban areas because that’s where they can create the life they want. Even though the need for doctors is in rural areas, they will make less money there, have worse infrastructure, have fewer things to do, have fewer options for schools for their children, and fewer options for jobs for their spouse. So even though the government has set up rural health centers, the doctors there are probably low-quality. Even then, Shoibal said that most qualified doctors will only visit the rural health centers a couple days a month, otherwise working at a private practice in an urban area. They do this to maintain a certain lifestyle and make enough money. There’s not much that the government can do in response, as it is better to have a doctor visit a rural health center for 1 day a month rather than not at all. The government could ramp up the incentives offered to these doctors, but that would require tons of money plus bettering the rural areas in multiple ways. Or, the government could try to force doctors to spend all their time in the rural health centers by making it illegal to have a private practice on the side; but then, given the choice, the doctors would all move to the private sector and not work in the public sector at all. Of course, there are some doctors that don’t care about money and really want to work where the need is. But still, the truth is that there aren’t enough doctors in rural areas, and it’s hard for the government to encourage them to move. If the government invested heavily in telemedicine, I think it could help enormously; but the first step would be building the appropriate infrastructure.