‘You feel omnipresent’: bringing city care to India’s country hospitals

Whenever an ambulance arrived with a critically ill patient, Dr R Mubarak’s heart would sink. His small country hospital in Bagepalli, like most rural government hospitals in India, had no intensive-care unit. Families had to take the patient, who was perhaps on the brink of death, on a two-hour drive to the general hospital in Bengaluru.

“Often the patient came back in the same ambulance, dead. They never made it,” says Mubarak. “I knew I could be signing their death warrant by sending them but I had no choice.”

His hospital sits on flat farming land in eastern Karnataka, a dry belt, where farmers eke out a subsistence living growing peanuts and millet. It is, however, connected by a good highway to Bengaluru.

On a hot, muggy morning, Mubarak and a colleague, Dr GB Sudarshan, are beaming like fathers showing off a newborn as they provide a tour of a brand-new 10-bed intensive-care unit at Bagepalli hospital.

“Never in my dreams did I think we would get an ICU fitted with the latest equipment,” says Mubarak.

Today, the intensive-care unit has five cases of dengue fever; two feverish and dehydrated babies, one of whom, Mahesh Babu, lies listlessly in his mother’s lap; a third baby with pneumonia; and Ansh Hegde, an elderly man suffering from seizures, which makes his food go down his windpipe.

Any one of these cases might have proved fatal without the patients’ quick admission into an ICU. The new unit is the result of a project called 10 Bed ICU, which was conceived by Srikanth Nadhamuni, a technology entrepreneur, to fill a gaping hole in critical care in India’s healthcare system.

The idea came to Nadhamuni during the Covid pandemic. As the second wave scorched a trail across India in 2021, he received frantic calls from friends asking whether he knew of hospitals with ICU beds, because people were dying for lack of available spaces.

This was in the cities but in the countryside, no one had ever seen an ICU.

“I realised with a shock that rural hospitals don’t have an ICU. All they can manage is deliveries and minor surgeries. Critically ill Indians in rural areas have to travel very far from home to the nearest city hospital to get intensive-care treatment,” says Nadhamuni.

In the hilly north-east of India, it can take more than a day on potholed roads to reach a city ICU – too late for patients suffering from strokes, heart attacks, aneurysms, head injuries and a host of other conditions.

Thanks to donations from philanthropists such as Vinod Khosla, with whom he co-founded the startup innovator Khosla Labs, Nadhamuni has raised enough money since 2022 to create more than 200 10-bed units.

Each unit costs about $53,000 (£40,000) and the installations, which come with the necessary electrical and oxygen supply, meet World Health Organization standards.

The scheme is run in collaboration with state governments, which provide the space at hospitals, doctors and nursing staff, as well as medical supplies.

However, as the equipment started being installed, a problem arose as the lack of trained ICU doctors and nurses, increasingly known as “intensivists”, became apparent.

It takes 11 years to qualify as an intensivist and, once qualified, few want to work in remote, rural hospitals.

Nadhamuni’s solution was to deploy a tele-ICU system, connecting the rural hospitals with intensivists at a hub medical college or tertiary hospital via the cloud. The ICU specialists can remotely guide staff in the ICU from a command centre in the hub hospital.

In Bagepalli, Mubarak and Sudarshan are making their rounds, stopping at every bedside and consulting experienced intensivists, Dr Aravind B Guleda and Dr Sathyanarayanan Karunanidhi, who are sitting 60 miles (100km) away in the command centre at Victoria hospital in Bengaluru.

Guleda and Karunanidhi can view the Bagepalli patients from multiple angles through computer screens equipped with high-resolution cameras and live access to their medical details, lab tests and imaging. They provide live-streamed advice on treatment for the nine patients.

For the dengue patients, they recommend constant monitoring of oxygen, platelet and hematocrit [red blood cell] levels to prevent haemorrhagic dengue fever, which can be fatal.

Once Guleda and Karunanidhi are finished at Bagepalli, they turn their attention to another unit, further away at Nanjungud, where a couple have suffered burns after their clothes caught fire while burning dry leaves.

The medics guide the local staff on treating an infection with high-grade antibiotics and monitoring the wife’s falling blood pressure.

Karunanidhi says: “In rural India, people cannot afford the cost of an ambulance or taxi to bring an ill person to the city, nor to lose their daily wages. It is mental agony for them. In this model, the ICU bed is nearer to home and the family can continue working.”

He and Guleda now oversee 55 patients across 10 hospitals. Guleda says: “If the patient has severe burns, head injuries or trauma, then of course they have to be brought here to us. The local staff cannot handle such cases, but at least they can stabilise the patient.”

The project has eased the pressure on overcrowded big city hospitals, with a 70% reduction in transferrals from hospitals with the new units. Dr NN Siri, Karnataka state programme manager, says: “Before, some rural patients ended up crowding city hospitals just for oxygen or for minor infections.”

Local doctors have benefited too, thanks to the daily consultations with specialists.

Mubarak says: “Under their guidance, I inserted a catheter into the thoracic cavity of a patient to remove over three litres of fluid. I had never done it before. If I had delayed the procedure by half an hour, the patient would have died.”

Sudarshan recalls a case in Bagepalli, which he was sure was viral fever. The team in Bengaluru, however, suggested further investigations. These revealed a gall bladder cyst.

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“I’m proud of what I am learning from them,” says Sudarshan.

To date, about 65,000 patients have been treated in the units, and Nadhamuni says the aim is to set one up in every part of the country.

At the Bengaluru command centre, Karunanidhi is winding up his consultation with the Bagepalli doctors before he heads off to attend to his own ICU patients in the hospital.

“Sitting here, you feel omnipresent. Here I am, far away, pulling someone back from the brink of death, someone who never dreamed of getting specialist care,” he says.