Health post: Remote monitoring for villager patients

These past few days I’ve been staying at the Amritapuri Ashram in Kerala, India (3 hours from any airport). For some months, I’ve been planning this visit with Amrita University, which has a few different campuses across India and includes Schools of Biotechnology, Medicine (including a university hospital), and Engineering. Amrita University is doing a lot of interesting research in medical devices, especially at their campuses in Kochi and Amritapuri, so it’s been exciting to connect with them for my project. I’ve met with some faculty members at Amritapuri to talk about their research here, and this evening I’ll head up to the Kochi campus for more meetings.

As I mentioned, I’m staying in an ashram, which is a communal living area (like a monastery) often centered around a spiritual leader. I had never stayed in any religious community before, and I had no idea that my accommodation here would be a room at an ashram, as my contacts at the university set it up on their end. Apparently this ashram is famous for being one of India’s few female-founded ashrams. The ashram’s leader is a woman named Mata Amritanandamayi Devi, though she is known as “Amma,” meaning “mother” in many Indian languages. I learned that Amma is not only the spiritual master of this ashram, but also the founder of Amrita University, which started at the Amritapuri campus (just across the bridge from the ashram) and has expanded into the multi-campus university it is today. Once I realized that all of Amrita University exists solely because of Amma, it made sense that I was staying in her ashram (also, practically, it’s the closest residential complex to the rest of campus. However, I was embarrassed that first day to be staying at the ashram having never heard of Amma, whom so many people were there to see!).

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There are no pictures or recording devices allowed inside the ashram (without special permission, anyway), so here is a view of the ashram complex from across the river. This is the bridge I’ve been crossing every day to get from where I’m staying (the buildings) to the campus buildings.

It’s been a fascinating experience – honestly, I never understood how one person could have so many devotees, let alone devotees who travel from all over the world just to be in that person’s presence for days, months, or even years at a time. But all types of people come here to Amritapuri to be with Amma, and some devotees live in the ashram permanently.

My first meeting here was with Dr. Maneesha Ramesh, the Director of the Amrita Centre for Wireless Networks and Applications (AWNA). Her faculty office is actually in the ashram complex, so I met her there the evening after I arrived. As part of her work with the center, Dr. Maneesha is working on a real-time patient monitoring system for patients in remote villages. The full system includes wireless devices to capture vital signs (we mainly discussed a wireless ECG device to monitor cardiac patients), all connected via Bluetooth to a central interface. This type of system helps post-op patients save the money they would have spent from staying in the ICU after an operation, which gets very expensive. Also, it can be used to keep an eye on people in remote areas who for many reasons have little to no healthcare access.

I asked what she’s observed as the reaction to such gadgets in India. She said that it depends on their income category: low, middle, or high. She said that people like gadgets in India, and “of course” the high income population is ready to spend money on health. However, the business is really with the middle income population, as they comprise a greater number than the high income population. The low income population can’t afford to lose a day’s worth of wages to get care, and they might not be aware of all their options if they are in remote areas. So even if they would have a positive reaction to such devices, they often are not in a position to use them.

Thus to get the low income population to engage with their health and use the aforementioned monitoring system, it’s key that the sensors be wearable. Since these people can’t afford to lose a day’s worth of wages, they don’t have time to lie down somewhere and get all their vital signs measured, especially if they have to travel to that place. So, Amrita University needed to develop monitoring sensors that could function well while being worn by people as they go about their days and do manual work. Dr. Maneesha’s team had to work on algorithms to remove the added noise in the ECG signals that resulted from patients moving around while their wearables recorded data.

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The campus buildings here are beautiful! This one houses the Office of International Programs, with whom I’ve been communicating to set this all up.

Most of my project in India so far has focused on acceptance of medical devices in urban areas, so I was eager to learn more about mattered for the success of a device in a rural setting. Dr. Maneesha said that when it comes to rural areas, medical technology mostly stays in a primary healthcare center (a primary healthcare center will be the first point of care for a villager, and one center might serve a couple nearby villages). So to get people in a village to accept a medical device, you have to go through these centers and get some advocate in the community – perhaps a community health worker (CHW) working at the center. Again, NGOs that work within these villages can help find the right person to be that advocate; and once one person starts using the device, there is acceptance throughout the village.

The reasons why a device might work well in one village but fail in another can vary enormously throughout India. Dr. Maneesha told me about one of Amrita University’s devices that used the color red to indicate ‘don’t do this’ or ‘stop,’ like a traffic light. But this community, which incidentally does not have traffic lights, doesn’t have that association. In fact, it’s the opposite: they view red as a positive color and associate it with doing things. So even though they were trained on the device, and learned that red meant stop, they kept using it incorrectly due to spending their whole lives understanding as ‘go.’ This is why it’s so important to understand the community you’re trying to help. Dr. Maneesha brought up the concept of codesign, which I haven’t heard since Sweden (and was happy to hear again, as it’s a very relevant concept for my project!). The idea of codesign is that when you make a new product, you work with the intended end users from the beginning of the design process. You cooperate with them to make sure that, at each stage in the development process, you’re making something that fulfills a need of theirs and is designed with their input, so that at the end of the process they actually want to use the product. Since India is as large and diverse at Europe, Dr. Maneesha said, with important differences even between rural villages, following codesign practices is crucial for the success of a medical device.

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Here is the School of Biotechnology.

I was curious for more details about the villages. Dr. Maneesha said that the needs in a rural Indian village will be completely different from urban areas as well as from other villages. First of all, the prevalent diseases can vary village to village. Second, there are cultural differences (such as the reaction to the color red). In some villages, the women do not leave home, which means it can be very hard to motivate them to go to a hospital, especially if you’re an outsider asking them to break a cultural practice. Amrita University is working with one of Amma’s adopted villages in West Bengal, where they learned that women will refuse to be seen by a doctor if that doctor is male. So they realized that they need to visit villages with a gender-diverse team that included both male and female doctors.

Also, it can be tough to convince someone to see a doctor or go to a hospital if they use traditional medication techniques at home. Dr. Maneesha said it was a goal of theirs to integrate traditional and modern healing practices. Things are getting better in terms of such interdisciplinary development, she said (it’s easy at Amrita University, which has a School of Ayurveda and a School of Biotechnology at different campuses that can communicate with each other). People are now learning about plants all over India – before, Ayurveda in West Bengal would be different from Ayurveda in Kerala, for example, because the plants would be different. Now, with the help of biotechnology, people have a better understanding of the chemical nature of these plants – that is, what compound of a plant contributes to its ayurvedic function – so they can find substitutes across India by looking for the same compound in different plants. “Our goals are to save the ancient knowledge – India has centuries of ancient knowledge that we don’t want to lose – as well as reach all income levels,” said Dr. Maneesha. She pointed out that with one low-cost device, you can reach all income levels even if the usage patterns vary (for example, a wealthy urban person could have one device for themselves, where the same device is shared among many villagers in a poorer rural area).

I asked Dr. Maneesha how the university comes up with new projects – how do the research teams know what problems they should be solving and where the needs are? She said that it’s important to use local NGOs. Amma has “adopted” 101 villages across the country, meaning that she has committed herself to helping them, and it’s helpful to use NGOs in these villages to stay aware of their needs (https://www.amritapuri.org/activity/social/serve). Also, Dr. Maneesha told me that since people come to Amma to pour out their problems, she is a great source of what is needed; Amma triggers the research interests of the university by telling them about the problems she’s been told. Because the “challenge comes from her,” said Dr. Maneesha, “you really want to do it.” Amma is the inspiration for all of the work here, all of which has a social goal of helping others. Since the people at the university are devoted to Amma and like to see the effect of the work they do, they are eager to fix the problems that Amma points out. It was cool to see so many people inspired by one common goal (helping people based on what problems Amma discovers), and it makes sense that having one vision allows for really interdisciplinary solutions.

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