Our College awards the President’s Medal each year to mark outstanding work by one of our Members or Fellows. The recipient for 2019’s President’s Medal was Balram Bhargava, Professor of Cardiology at All India Institute of Medical Sciences and was featured in the latest edition of our membership magazine “voice”. The feature is below and College Members can read the full magazine by logging into their online dashboard account.
To celebrate this success, Professor Bhargava was invited to deliver a lecture at the College in February 2020 about his programme of ‘Frugal Innovation’, and how others can learn from India’s achievements in this area. This novel concept aims to design affordable medical innovations to improve health in low income countries.
Introducing Professor Bhargava’s presentation, College President Professor Jackie Taylor acknowledged the huge contribution made by our members across the world in developing and delivering healthcare. “We are, of course a global community which shares the same challenges, the increasing needs and complexity of patients, finite resources, workforce challenges and concerns about the health and wellbeing of our workforce” she said. “These things unite us, and we are tied together with our purpose of ensuring the very best health care for patients. Professor Bhargava epitomises the qualities of dedication, professionalism, integrity and leadership that we hoped to recognise with this award.”
Dr Rajan Madhok, the College’s Honorary Treasurer and former colleague of Professor Bhargava, delivered the citation, declaring that “our College isn’t just a building on St Vincent Street. It is so much more. It has an ideological goal. It’s a group of dedicated clinicians determined to create new and better treatment standards for patients of all backgrounds. It is appropriate that the recipient of this medal be someone who embodies this vision.”
Professor Bhargava’s links to Glasgow were also highlighted by Dr Madhok. “Balram was awarded no less than nine awards for academic excellence, including the award for best all round student for 1979 and 1980. He worked for a year as a registrar in Stobhill Hospital. The late Stewart Hillis was your mentor, and I recalled he said of you, “he’s nae dafty”.”
It was following his time living and working in Glasgow, while working at the Royal Brompton Hospital in London, that he began the transition into the field of innovation, developing the design for a low cost platinum-iridium coil as a coronary stent. This was his first success in developing medical devices to be cheaper and more widely available to patients in low and middle income countries.
“It isn’t just this unquestionable academic prowess or innovations in the field of cardiology or public health which has brought you to the attention of our College once again” concluded Dr Madhok, “it has been your determination to bring your work to those most in need. Put simply, there are people alive today who would not have been so if it had not been for his work and philosophy.”
Addressing the assembled Fellows, Members, former colleagues and staff, Professor Bhargava welcomed this opportunity to return to the city of Glasgow. “It is indeed a pleasure and a joy to come back to Glasgow and to come back to the College. This College has contributed immensely to medicine in the world for several centuries, and that contribution is immeasurable. When I think Glasgow, I think of the training that I got here under the tutelage of the late Stewart Hillis, on how to be a good doctor, a good human being and a good family person – that has helped me tremendously throughout my career.”
He went on to set out the progress that India has made in the 70 years since gaining its independence from the UK, and discussed his work at the School of International Biodesign before giving some examples of “frugal innovations” which are now in the development process.
Professor Bhargava set out his view that the progress that India has made over the past few decades has been underrecognised. “When I’ve talked about India and I ask my audience about what has India done well, they say India has done well in IT and mobile technology. And they stop there. I ask again, what else can they can think of? Then someone would get up and say, India has done well in IT, mobile and cricket! What they don’t talk about is our progress in space, with nuclear technology or the Green Revolution.”
“I grew up in an Indian generation when food grains were being supplied from Australia and the United States. We were asked to miss a meal by the Prime Minister at that time, Chidambaram Subramaniam. Now, thanks to our Green Revolution India is supplying grain to countries across the world.”
According to the Professor, the one area where India’s progress has been under-valued is in the field of medicine.
“India is now the world’s largest exporter of generic drugs, while we also treat around four million medical tourists who visit India to get excellent treatment at low cost.
“My cardiology outpatients clinic treats about 3.5 million patients a year. It is a government-run facility with about 3,000 beds, and we operate at a cost of one dollar per day. At the same time, have the same level of infection rates as any similar facility across the world. This was one of the reasons that our hospital featured in a cover story in Newsweek magazine on the medical meccas of the world.”
This work doesn’t diminish the challenges that India’s healthcare system faces, especially given that on the country’s own estimates it has around 40 million people who fall below the poverty line.
The proportion of Indian GDP spent on healthcare also ranks behind other countries. For example, Canada spends about 11% of its GDP in health, and the UK invests 9%. In India, only 4% of total GDP is spent on health, with government expenditure making up only 1% of this.
“Because of this,” says Professor Bhargava, “our mind set is frugal. Providing high quality healthcare at low cost is at the forefront of our thinking.”
That’s why he believes that there are two key challenges facing Indian healthcare: providing universal health coverage and the provision of high quality emergency medicine.
This is one of the areas where the College could play a part. “I would like to hold discussions between Indian representatives and this College, on how we can develop our emergency medicine systems in India. I can think of no better example than the United Kingdom as far as the provision of emergency medicine is concerned.”
The professor has high stock in India’s present government, who he believes has put his country on the global map. “We have a large engineering services sector alongside our technology and science industry, and the government has realised the relevance of these sectors. I believe that Indians have a naturally innovative mind set. I do not know whether they are genetically endowed, but I like to think that! We also see more cases than any physician in the world, endowing us with great experience and large amounts of data.”
But despite these advantages, there are two issues which the cardiologist believes is holding the country back – a tendency to wait until our problems reach a critical mass, and a reliance on imports to serve the health service. “When we solve problems, we solve them very elegantly “he states proudly, “cheaper, better, faster than others and in a scalable way.”
“In the area of pharmaceuticals, India has done well, but 80% of the medical devices currently used in India are imported. These are often expensive, so many of our patients cannot afford them.”
It’s for these reasons he started the School of International Biodesign in 2008 with the help of Stanford University and the Indian Institute of Technology in order to “ignite the medical device ecosystem in the country”.
“Our vision for this programme is that it will deliver value conscious innovation, which is underpinned by our deep commitment for serving the underserved. We will always face challenges in this type of work, and you have to work within a range of constraints, but my experience is that by working in an environment like this we can be more innovative.
The philosophy of this work is also key to its success
“More importantly we focus on people, not just shareholders’ wealth and profits. That is why we have this high people value conscious innovation, because the paradigm is social inclusion, that affordability, availability and accessibility. When we talk about innovation from Silicon Valley, then they see innovation as market-led. I won’t invest what I can’t sell. Proof of utility is success. But there is a different view. I call it the Ghandian approach, where innovation provides enough to satisfy every man’s need, but not every man’s greed.”
“In today’s world, I think we have to strike a delicate balance between these two approaches. That is what is what we are trying to do at our centre.”
Building on this philosophy, the institute builds small teams in order to develop and deliver innovative ideas. Teams typically consist of a doctor, two engineers and a designer, and sometimes include an entrepreneur. They put together five or six such teams every year, and encourage them to become immersed in the clinical environment around them. The professor explains: “The team talk to the ward boys, the cleaners, the nurses, the junior doctors, the consultants, and they work out the unmet clinical needs.
“For example, a neurosurgeon might say “I have been operating with forceps which are bent at an angle of 40 degrees, but I’ve always wanted them to be bent at 70 degrees.” This is how we identify the clinical needs.”
Over the course of three months each team can identify up to 500 or 600 unmet medical needs. Then they filter and prioritise their results based on a range of factors, including the competitive landscape, what their individual skills and interests are, and what’s practical and achievable given the available resources. When they’ve narrowed their shortlist down to between eight or ten of their identified needs, they then begin to come up with proposals to solve these challenges.
“This includes IP regulatory research, development of a clinical strategy, then further clinical testing” Professor Bhargava stated. Once the strategy has been finalised, each project looks for funding to bring it to fruition.
“We have had funding from various agencies, including national governments and international agencies, the Gates Foundation, the Grand Challenges Canada and the Pfizer Foundation, not to mention private investment from angel investors and others” the Professor confirmed.
Over the last ten years the Institute has been able to train 125 fellows and several more interns. 41 innovations have been developed to 12 start-up companies, and more than 60 patents have been registered. At the same time, a wide range of technologies have been transferred to industry with several trademarks and design patents. The professor is proud of the progress to date. “Our designs have been approved by the US FDA and by authorities in Singapore and Japan.”
One simple device the Institute has developed is designed to support trauma patients.
“We have about 15 million road traffic accidents in India every year out of which five million are lower limb fractures” the professor explained.” With this sort of injury, patients are stabilised then transported to hospital, before going for x-rays or a CT scan.”
“But in the course of this patient’s journey, they may have to have a splint fitted at the scene then removed by the ambulance team on arrival at the hospital, then hospital staff may put on a Thomas’s knee splint, which will be removed before the CT scan and replaced again afterwards.” This level of mobilisation is not ideal from the patients’ perspective. “So to improve this process we took a cue from our national sport and looked to develop a simple device which looks something like a cricket bat. This is made out of simple cardboard, coated with special plastic, and has velcro tapes to hold it in place. It can be placed on the left leg or the right leg. To make fitting straightforward we’ve added a simple red marker to indicate where the knee has to be. This disposable device can now be used for a mobilisation for up to six hours, and given its simplicity and effectiveness it can be stored in police vans and ambulances so it’s on hand at any critical accidents.
It costs only five dollars, and so this innovation is now being adopted in nine states in the country. It has also featured in The New England Journal of Medicine as one of the major frugal innovations from India.
This is just one example of many new devices developed and adopted by the Institute under Professor Bhargava.
“Overall, these are simple devices” he concludes. “These are simple ideas rather than great ideas, but they have low costs and they are helping large number of patients.”
Finalising his remarks, Professor Bhargava called for greater collaboration between health bodies, facilitated through the College.
“I hope we can build on the discussions we’ve started today, and look to work together to share our knowledge and understanding of this way of working with the college and the NHS here in Scotland and the UK”.