Change Agents: ECHO travels, taking specialist doctors to places where there are none

The ECHO team at the India headquarters in Delhi watches Dr Prabhat Kumar Chand from NIHMANS conduct his weekly clinic on screen from Bengaluru.

IT IS 2 pm. Dr Prabhat Kumar Chand, a specialist dealing with substance-use disorders at the National Institute of Mental Health and Neuroscience (NIMHANS) in Bengaluru, speaks into the microphone: “Thought, Impulse and Cannabis — that is the topic of discussion today. Let’s begin.”

His audience of 15 community healthcare providers is spread far and wide, from Kabul in Afghanistan to Idukki in Kerala, and Dr Chand realises it’s important that his message breaks down those distances and reaches the last patient possible.

This is one of India’s 15 clinics under ECHO (Extension for Community Healthcare Outcomes), a concept of weekly or fortnightly virtual clinics that use teleconferencing to bridge the gap in healthcare resources by using the best specialists to reach out to underserved areas. But unlike telemedicine, ECHO clinics do not provide care directly to patients. Instead, they equip primary healthcare clinicians — doctors, nurses and other health workers — in remote areas with the knowledge and support to manage complex cases. Essentially, it brings specialist care and knowledge to areas where there is none.

At the Virtual Knowledge Network Centre on the NIMHANS campus, Dr Chand has moved on to questions. “Which receptor is responsible for cannabis-induced behavioural or psychological symptom?” he asks. Among the first to respond is a doctor from Kabul, followed by answers from Bhilai in Chhattisgarh, Sivasagar in Assam, Idukki in Kerala and Ghaziabad in Uttar Pradesh. A detailed discussion follows.

“These virtual clinics help provide excellent specialty care to patients in their own communities. It the best tool to bridge the huge treatment gap in mental health in India,” says Dr Chand after the meeting. He adds that he and his team have managed to reach out to over 700 healthcare professionals since NIMHANS became part of the ECHO project in 2014.

Project ECHO began in 2003 in New Mexico when Dr Sanjeev Arora, a liver disease specialist in Albuquerque, US, realised that there were thousands of people in the state of New Mexico with Hepatitis C but with no access to treatment because there were no specialists where they lived. It’s then that Dr Arora began ECHO, bringing together local clinicians and specialists through weekly virtual clinics.

India’s first ECHO clinic began in 2008 as a collaboration between the National Aids Control Organisation (NACO) and Maulana Azad Medical College (MAMC) on managing HIV AIDS patients. Since then, ECHO clinics in the country have tackled addiction and substance use disorders, mental health, tuberculosis, hepatitis C, liver diseases, cancer screening and prevention, among others.

Many of the best healthcare institutes in the country are part of the ECHO bandwagon. The Tata Memorial Centre, a premier institute for treatment and research on cancer, has launched an ambitious plan to connect 86 hospitals using the ECHO platform. The session started on December 16 last year and is held twice a week. “We call it the ‘hub and spoke’ model. The hub is the hospital or centre of expertise and spokes are the healthcare practitioners in rural and underserved areas,” says Dr Sunil Anand, executive director of the project.

Less than 200 km away from NIMHANS is the tribal village of Gumballi with a population of just under 16,000 people. The village has one primary health centre (PHC) where community health workers offer immunisation and other basic healthcare needs. However, over the last one year, thanks to an ECHO clinic thousands of kilometres away, the health workers of Gumballi have been delivering a specialised service: screening of cancer at the village level. The Institute of Cytology and Preventive Oncology (ICPO), the research wing of the Indian Council of Medical Research (ICMR) in Delhi, has been training healthcare workers of Gumballi to conduct cancer screening.

Dr Anand says that when the project began there in 2015, ICPO staff visited the village and provided four days of intensive training in cancer detection to PHC workers. “Subsequently, every fortnight, through the virtual ECHO clinic, we discuss patient cases. If someone in the village is screened positive for the disease, they are treated at the Kidwai Memorial Institute of Oncology in Bengaluru,” he says, adding that 11,342 people in Gumballi have been screened.