A view of people on a pilgrimage to the Kedarnath temple, with the Himalaya in the background, Rudraprayag, Sunday, October 2, 2022. Photo: PTI/Mona Parthsarathi
- The Kedarnath yatra this year has received as many pilgrims who visited the temple in 2019 in just three months. But the number of deaths has been unprecedented as well.
- Nearly 100 people lost their lives, mostly after heart attacks, likely due to low oxygen levels, the low temperature at high altitudes and the physical stress of trekking.
- An early ECG can save lives by pointing to the correct diagnosis, leading to early and proper treatment. So the paucity of ECG machines in rural areas delays life-saving treatment.
- A portable smartphone-based ECG device developed by a startup in Dehradun made a difference in Kedarnath, and could help reduce country-wide mortality due to heart attacks.
Dehradun: The Kedarnath yatra, a part of the Char Dham yatra, recommenced in May this year after a two-year hiatus due to the pandemic. The temple, open this year from May 6 to October 24, received as many pilgrims who visited the temple in 2019 in just three months.
However, the number of deaths has been unprecedented as well. Nearly 100 people lost their lives, mostly after heart attacks, according to the Uttarakhand health department. Low oxygen levels and the low temperature at high altitudes, together with the physical stress of trekking with a probably undiagnosed diseased-heart, could be the reason.
Cardiovascular diseases (heart attack and stroke) are the leading cause of death in India and worldwide. Nearly one in every three deaths in India in 2020 was due to cardiovascular diseases, according to the ‘Report on Medical Certification on Cause of Death’ for 2020.
The demographic most affected is people older than 70 years, although a recent rise in heart-attack mortality among younger people has turned everyone’s attention towards a possibly hidden pandemic of heart disease. The death of singer K.K., at age 53, also highlighted the lack of awareness of the symptoms of a heart attack and lack of access to early care even in tier I cities like Kolkata.
“India will see the most cardiac deaths by 2030,” Dr C.N. Manjunath, a renowned cardiologist in Bengaluru and a Padma Shri recipient, has warned.
As sedentary lifestyles become more common, the size of the population with risk factors for heart diseases is also increasing. These factors – diabetes, hypertension and high cholesterol, among others – are like silent killers. They are often diagnosed for the first time only after the person has been affected enough to become symptomatic.
Preventive strategies like following a healthy and active lifestyle are the way forward to address this public health problem. This said, to save lives, it is also important to identify and treat heart attacks in timely fashion. This is where the lack of good and affordable care in rural India, where most of the country’s people live, emerges as a significant hurdle in reducing heart-attack mortality.
A heart attack is often either confused with acidity or presents with symptoms other than chest pain, like sweating, giddiness and/or breathing difficulty. An early electrocardiogram (ECG) test to diagnose a heart attack can save lives by pointing to the correct diagnosis, leading to early and proper treatment. The paucity of ECG machines in rural areas thus delays the initiation of life-saving treatment.
Primary health centres (PHCs) are the primary point of contact for treatment in rural India. The guidelines for PHCs include ECG machines in the list of “desirable” equipment instead of “essential” equipment, so PHCs treat them as optional. The high cost of a standard ECG machine (typically more than Rs 1 lakh) makes it unaffordable for local clinics – private or public. So it is mostly available in overcrowded secondary and tertiary care centres.
One potential solution is to screen people using remotely operated ECGs. In December 2021, researchers from Gujarat reported that screening high-risk individuals using ECG at PHCs in Ahmedabad was a life-saving as well as a cost-effective exercise. In 2014, researchers in Chandigarh and Mumbai found that ‘tele-ECG’ – in which health workers share the ECG facility with other workers via the internet, over large distances – could improve healthcare coverage in rural areas.
But given the technologies required to realise remote ECG facilities, the idea is still a no-go in rural areas, which have poor internet connectivity, lack of IT infrastructure and low digital literacy.
Yet this is also why ‘Spandan’, a portable smartphone-based ECG device, made a difference in Kedarnath.
After noticing the record number of deaths due to heart-attacks in Kedarnath this year, Sunfox Technologies, a health-tech start-up in Dehradun, worked with the Uttarakhand government to setup a free three-bed screening camp at the starting point of the pilgrimage, near Sonprayag, in July 2022.[footnote]The author declares no vested interests in the company, direct or indirect.[/footnote]
“Our device is able to generate an ECG report without the help of the internet, using a previously tested and proven algorithm,” said Sunfox founder Rajat Jain.
They trained local volunteers to select pilgrims with risk factors for heart disease using a questionnaire. Then they screened them with ‘Spandan’. It works by connecting the ECG leads to a smartphone. Based on the electrical impulses received from the leads, an app on the device generates a report displayed on the smartphone. The abnormal reports are shared over WhatsApp with a cardiologist stationed in Dehradun. People who are found to have abnormal ECG readings are referred to a local physician and advised against continuing the trek on foot.
(Abnormal readings correspond to arrhythmias, ischaemic changes and ongoing infarcts, among others.)
In the first month, Sunfox screened nearly 1,500 people and identified 163 with high blood-pressure or abnormal ECG. Of these individuals, 59 were referred to a local physician and advised to either discontinue the trek or to continue on horses or mules, based on their clinical assessment.
The volunteers also inform the people screened at the camp about the signs and symptoms of a heart attack, so they could seek early care in case they developed symptoms later.
The impact of this camp was soon clear. Sixty-three people had died in May and 48 in June; in July, the month after the camp, the Uttarakhand disaster relief department recorded only three deaths by heart attack. Some people who continued the trek despite being advised against it also returned to the camp later with symptoms of chest pain and breathing difficulties.
“She suddenly complained of feeling unwell soon after we started the trek, and so we rushed her back to the screening camp,” the daughter of an elderly lady reportedly told one volunteer, after the lady had been asked to visit a local physician and not continue the trek on foot.
The camp is proof that timely access to basic care can save lives. ‘Spandan’ is also easy to operate and costs 20x less than a standard ECG machine, so it can be used at local clinics as well as at home. Note however that while the device can confirm, or deny, doubts about having a heart attack, it has a small error rate. So people with the symptoms of a heart attack as well as an abnormal ECG reading on ‘Spandan’ should get a standard 12-lead ECG as soon as possible.
India still struggles to provide accessible care and continues to be severely short on healthcare workers. Remotely operated point-of-care testing devices provide an opportunity to use this scarce competent health workforce effectively. And if we use them well, they can become a meaningful part of India’s efforts to achieve the target of universal health coverage by 2030.
Dr Parth Sharma is a physician, researcher and writer who likes exploring evidence-backed equitable solutions to common public-health problems.