Acknowledging the depth of India’s problems, and rising to the organizers’ challenge to be provocative, the Chair of Columbia’s Department of Medicine kicked off the recent Caring for Millions conference by calling for “an industrial revolution” for Indian healthcare.
At the symposium, which was sponsored by the Chazen Institute and The India Business Initiative, Donald W. Landry allowed that such a major overhaul of the country’s health care system would require the national and state governments to spearhead a major initiative. The industrialization of health care, as Landry described it, would combine universal health care, telemedicine, and health care literacy, as well as sweeping reforms in the medical culture and education to create more doctors to treat many more patients. The model would cut costs and drive improvements, extending health care to literally hundreds of millions.
Health care disparities, historically driven by the underserved population, are about to worsen as upper reaches of medical practice become even more rarefied. In India and elsewhere, new capabilities in genetics, biochemistry, and cell biology are leading to a revolutionary approach, so-called “precision medicine.” Rather than a scattershot defense that ravages healthy tissue or triggers unexpected side effects, precision medicine targets specific molecular causes of disease arising from defects or predispositions encoded in the genes. “Diagnostics and therapeutics tailored to the molecular mechanism of disease means we are no longer tracking symptoms or surrogate markers, but the disease itself,” Landry explained.
Also called “personalized medicine,” since each patient receives customized treatment, the approach has implications not only for patient outcomes but also the efficiency and cost of medical practice. Especially in India and other countries still contending with widespread poverty, “disparities will in the short term grow through loss of economies of scale, as only the wealthy will have access to the diagnostics and treatments that involve subpopulations beset by a given illness,” Landry predicted.
Nations Within the Nation
Landry constructed a pyramid to illustrate India’s current demographic disparity. At the top are 60 million people who receive high-quality health care, largely because they are wealthy enough to command it and to travel outside the country if need be. India’s burgeoning middle class of 350 million people has access to fee-for-service health care in principle, but their treatment is in constant jeopardy because India’s medical infrastructure remains inadequate and expensive. Twice that many people — 700 million — remain in abject poverty with little access to health care.
Chief among India’s health care woes is a lack of physicians and other trained medical personnel. Compared to the World Health Organization–recommended minimum ratio of 10 doctors per 10,000 population, India counts only 6.5 (the US manages 24.2), a statistic that plays into India's “developing nation” rank of 135th out of 187 countries rated in the organization's Human Development Index.
It’s not as if India’s government is unaware of the problems, said Landry, who cited the spectacular progress made since India signed on to meet the WHO Millennium Development Goals in 2000. Not all goals were met but data show 58 percent reduction in infant mortality rates, 66 percent reduction in maternal mortality (since 1990), 74 percent measles immunization coverage, and 57 percent reduction in HIV incidence.
Landry also applauded Prime Minister Narendra Mod’'s efforts at modernization of the country’s infrastructure as health care in disguise. He cited the Swachh Bharat campaign, which among other goals targets 100 percent rural sanitation for India by 2019. The new Sustainable Development Goals to eliminate starvation and extreme poverty are essential to India’s aspirations in health care, he noted.
India is looking for solutions for its middle class, but the answers do not lie in the American health care system, Landry warned. “The US system is defective. India should harness the urgency of its health care crisis to leapfrog to where the United States wants to be in terms of pay-for-performance and accountable care organizations.”
But what of the 700 million people at the bottom of the pyramid? For a solution, Landry turned to the industrial model that Henry Ford introduced in the first decades of the 20th century. “In 1900, cars were individually handmade by skilled craftsman, costing perhaps $5,000 each,” he said, noting that fewer than 1,000 cars were sold that year. As the Ford assembly lines harnessed mass production through narrow specialization, though, “the price of a car dropped to $280 and a million cars were sold in 1920.”
Landry’s industrial revolution for Indian health care aims to reorganize general education and medical training to produce a larger number of physicians, but each would operate within a narrow scope of practice. Health care literacy and a public health revolution would provide the foundation for progress, and telemedicine, paid for via universal health care coverage, would bind the new practitioners into an integrated network. Perhaps the most provocative aspect of Landry’s prescription is a reform of the physician culture and practice, which would produce many more doctors to treat far more patients.
Subspecialization within Primary Care
Just as automakers moved from a car built by individual craftsmen to one assembled by a team of specialists, Landry suggests that India implement a novel training program based on subspecialization within primary care. “Historically, medical knowledge within a discipline would grow to become too much for one person to master despite seven to ten years of training – and then new specialties would arise,” he said. He proposed a new paradigm: take primary care as it is now and subdivide it. Instead of many years of training, a much more focused education on the outpatient management of a slice of primary care would rapidly yield a cadre of experts fully capable of diagnosing and treating but who, by virtue of India’s vast needs and enormous population, would be able to focus just on their narrow slice of the primary care population. Telemedicine would integrate these caregivers and connect them to broadly trained primary care physicians and to the usual array of specialists and sub specialists.
Landry realizes that such structural reform “is much easier said than done,” but he also indicated that the state and national governments have the will to move forward.
Concluded Landry: “India is gradually addressing its health care problems, but great disparities and ongoing suffering call for major structural change.”