Healthcare Innovation during the Pandemic Opportunities and Challenges

Introduction

On Friday May 21, we had a very insightful session by Anu Acharya, CEO and founder of Map my Genome. A distinguished alumnus of IIT Kharagpur, Ms Acharya spoke on “Healthcare innovations during the pandemic.” The session was ably moderated by our R Prasad and Sudhakar Rao.

Brief history of Map my Genome

Ms Acharya returned from the US in 2000. The human genome was getting sequenced those days. Thanks to collaboration and multiple groups working on this important project, the sequencing was competed, resulting in a reference genome. The project which began on October 1, 1990, finished in April 2003. For the first time, we had the complete genetic blueprint for building a human being

Note: For those, interested in Biology, DNA molecules are made of two twisting, paired strands. Each strand is made of four chemical units, called nucleotide bases. The bases are adenine (A), thymine (T), guanine (G) and cytosine (C). Bases on opposite strands pair specifically; an A always pairs with a T, and a C always with a G. The human genome contains approximately 3.2 billion of these base pairs, which reside in the 23 pairs of chromosomes within the nucleus of our cells. Each chromosome contains hundreds to thousands of genes, which carry the instructions for making proteins. Each of the estimated 30,000 genes in the human genome makes an average of three proteins.

Ms Acharya sensed an opportunity to develop software for genomics from India. Being a Physicist by training, she had to immerse himself in the subject to understand what it was all about. She built a team in India and a smaller team in the US. Along with building capabilities, she also acquired companies in the US, Germany and the Netherlands. Her company soon emerged as a leading genomics software services provider.

When genome sequencing was first done, it was affordable only to the very rich people. Gradually the prices started to fall. Meanwhile, the concept of personalized medicine was taking off. Sensing an opportunity in the Direct-to-consumer space, Ms Acharya launched a new product called Genomepatri in 2013. Genome Patri is a DNA based preventive health assessment product. Using a painless, simple saliva-based test it scans our DNA for variations providing insights into how we are built, right down to the molecular level. We can get an assessment of our traits, drug response profile, nutritional needs and predisposition to over 100 conditions.

During the Q &A session, Ms Acharya explained that building the Genomepatri business posed various challenges. There was not enough data going around. The right price had to be worked out so that it was attractive to customers and profitable for the company. There was a lack of awareness of genome mapping as most Indians with their fatalistic mindset thought there was no urgency and they could deal with a problem when it occurred.

Financial prudence based on past experience had taught Ms Acharya not to splash money on a nationwide ad campaign. So, the company wisely focused on the influencers and the medical professionals to spread the word around. The awareness spread gradually in an organic manner. The team also started working closely with hospitals and corporates.

The company also did not invest heavily in inhouse equipment to begin with. Form past experience, they knew that equipment can become obsolete quickly. The operations were kept lean. Heavy capital investments were made only when the demand grew. The company focused on efficiency and quality. With their scientific background, the team built the business in a sustainable way instead of trying to be opportunistic.

Ms Acharya’s philosophy is that money must be borrowed not to establish the proof of concept but to scale up the business. As she put it, funding is a double-edged sword. Debt means the need to service. Equity implies pressure to generate revenue growth. So, one should be careful while taking funds in a new business.

Awareness of the kind of work which Ms Acharya and her team do, has increased during the pandemic. If we (and the doctors) know our drug response profile and predisposition to various conditions, the treatment would be that much more effective.

The coronavirus has some 30,000 base pairs. It is the spike in the structure that gives the virus its unique properties. It is based on the spike that treatments and vaccines are being developed. Once the virus enters the body, it begins to replicate. Sometimes, the replication is not correct, leading to mutations. It is because of the mutations that we have seen new waves of infection. Essentially mutations are ways for the virus to evolve and prolong its ability to infect people. Mutations happen through missense, insertion and deletion.

While the names of the variants may sound confusing, the naming principle is simple. Consider the amino acids: N (Asparagine), K (Lysine), D (Aspartic acid), G (Glycine) and P (Proline). E484K represents an UK variant. It means change in the 484th position from E to K. An Indian variant N440K means change in the 440th position from N to K.

Innovations in testing

The RTPCR test initially cost Rs 6000-8000.The necessary ingredients had to be imported. Thanks to the pandemic, the global supply chains were broken. Indigenous efforts got a boost from the government and costs came down substantially. Then other ways were developed like antibody tests. With the emergence of different kinds of tests and different types of equipment and reagents, costs fell to one tenths of the level at the start of the pandemic.

(As Sudhakar mentioned during the Q&A session, one of the recent innovations is CoviSelf, developed by MyLab Discovery Solutions, a Pune-based company. It uses a rapid antigen test, in which a nasal swab sample is tested for the virus and gives results within 15 minutes. Taking the test takes hardly two minutes. This testing kit costs only Rs 250.)

Note: PCR tests are used to directly screen for the presence of viral RNA. These tests can tell whether or not someone has the virus very early on in their illness. We also have CRISPR. (CRISPR is an acronym for clustered regularly interspaced short palindromic repeats. It is a family of DNA sequences found in the genomes of some organisms such as bacteria.) Corona virus is an RNA virus and this method can detect the virus without conversion into DNA, which is what PCR does. Then we have the LAMP tests. LAMP or Loop-mediated Isothermal Amplification provides a highly specific, low cost, fast and portable test. An antibody test tells us who has been infected and who should be immune to the virus.

Genome sequencing

There was not much talk about this for almost a year. As variants emerged in the UK, South Africa, Brazil and India, sequencing became important.

Sequencing has enabled the development of vaccines, repurposing of drugs and the identification of new drug targets.

Genetic factors play a big role in case of Covid. For example, a study of the genes will give us a better understanding of how the cytokine storm, which is nothing but a severe immune reaction, happens. Genes involved in cytokine production, regulation and immune response are linked with the cytokine storm.

With Genomepatri, we will have a much better idea of our ability to cope with the virus. It will tell us whether we will have a severe immune reaction to covid. What kind of treatment will work and what will not? We will better understand the implications of comorbidities (Cardiovascular disease, high BP, Type 2 Diabetes, Smoking, compromised immune systems). We will understand which specific drugs will work well and which will not.

Vaccines

Various vaccines have been developed in record time.

• Pfizer and Moderna are mRNA vaccines.
• Covaxin and Sinovac are based on inactivated virus.
• Covishield and Sputnik are adenovirus-based vaccines.
• Zydus (to be launched) is a DNA vaccine.
• Biological E is developing a vaccine based on protein sub unit.

Drugs

Various drugs have been developed/repurposed to treat Covid: Antivirals (Remdisivir), Steroids (Dexamethasone), 2 DG (to reduce oxygen dependence), Monoclinal antibodies, Liposomal Amphotericin (for mucormycosis) and Baricitinib (small molecular inhibitor of kinase molecules)

Other points

• Covid has accelerated digital transformation and various behavioral changes by 5-10 years.
• Teleconsulting has taken off during the pandemic.
• Many apps have been developed to guide people on what to do in case of infections.
• People are realizing the importance of taking care of their health in a more proactive way.
• Corporates are also realizing the importance of proactive healthcare, and spending more on wellness programs.

Q&A

On key emerging trends in healthcare

There is greater awareness of the importance of health. There will be more focus on prevention as opposed to cure.

Consumers will have better access to their health information.

There will be miniaturization of equipment making them more affordable. Small clinics and doctors may become self sufficient when it comes to basic diagnostic tests. With such infrastructure, and supplemented by single use home testing kits, remote consulting will become more effective. Outpatient consulting will be transformed through teleconsulting and low-cost testing.

Engineers, technologists and data scientists will enter healthcare leading to a more interdisciplinary approach around devices, data and treatment. AI based models (already used in radiology) will become popular.

On the need for better communication during the pandemic.

Doctors did rise to the occasion and some of them communicated well on the social media. But there has been a lot of misinformation. The quality of information from the electronic media has been poor. The voice of scientists needs to be amplified. Molecular biologists must simplify the subject and communicate in easy-to-understand ways. Of course, communicating to a population of 1.2 billion is not easy. In some ways, it was easier to communicate to the general public in the good old days when only Doordarshan was viewed.

There is a lot of information on the internet. But someone must filter out the credible information and distribute it. Ms Acharya herself wrote a series of well researched articles on her company’s website and shared them with many doctors. These articles were well received and there were requests for articles on other topics. Just goes to show that our understanding of infectious diseases is still inadequate.

We need more training. This is also validated by the tendency on the part of some doctors to give steroids too early during the treatment.

The industry bodies like NASSCOM, FICCI and CII can play a major role in ensuring effective and reliable communication. We also need jingles and songs to contribute to mass campaigns to reach out to the common man across the country. The right messages must be repeated again and again till they get boring. That is when we know for sure that people have got it!

What should be the government’s priorities in the area of healthcare?

Without saying in as many words, Ms Acharya made it clear that it is not about spending huge amounts of money without any clear purpose. (Recall the govt’s Rs 35,000 crore outlay for health announced in the last union budget.) It is about sending the right signals and building the ecosystem.

The government must enable entrepreneurship. One way to do this is by removing price controls. They may be good in the short run but in the long run may take away the incentives for investment by entrepreneurs.

A strong regulatory framework is also needed.

Much more needs to be done for health insurance. Our country is lagging far behind.

Medical education needs a lot of attention. We need to improve both the quality and quantity of the health professionals being produced. Even as we empower doctors with more tools and equipment, we will also have to train them to be more empathetic to patients. Ultimately, what matters is how comfortable the patients feel.

On the topic of medical education, Ms Acharya had a lot more to say. She mentioned that the pandemic has taken a heavy toll on the healthcare community and posed serious challenges for them. Many aspirants might actually get put off by the profession.

Meanwhile, there is a strong case for revamping medical education. Medical education cannot be imparted just by reading books. Virtual methods of training must be backed by technologies like Augmented Reality to give practical exposure to students.

It is also important to focus on the training of nurses and para medical staff. We need to empower them to handle certain kinds of treatment independently.

On keeping prices low for a market like India

Ms Acharya took the example of RTPCR tests. The prices were initially high in India as there was a heavy dependence on a few global suppliers for the reagents and equipment. Custom duties drove up the prices further. But as global competition increased along with the demand, prices fell down. This might happen with Genomepatri as well. Demand and price are interlinked. High demand can drive down prices and low prices can drive up demand. Of course, demand can be generated with the right moves. The government is enabling the health insurance of poor people. This along with effective messaging about the ROI of preventive health measures can generate demand, bring scale and reduce prices.

A very insightful session from a highly knowledgeable and articulate woman entrepreneur. Thanks to Prasad and Sudhakar for organizing the session. Watch out for these Friday webinars. They are truly insightful.

We thank Dr. Vedpuriswar for bringing out the highlights in the form of this note