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Emergency medical system makes strides in India

Is boon for nation with few hospital ERs

The call center in Andhra Pradesh's capital city, Hyderabad. The call center in Andhra Pradesh's capital city, Hyderabad. (Noah Seelam for the Boston Globe)
By Neil Munshi
Globe Correspondent / March 29, 2009
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HYDERABAD, India - Siren wailing, the ambulance drove into the lane-less, chaotic traffic toward a bus accident. Cars, motorcycles, three-wheeled taxis, and big candy-colored trucks zipped and swerved into its path.

"Call 108" stickers were plastered on the side of some of the vehicles, part of a marketing campaign to promote India's nascent emergency medical system and its version of 911.

While the unyielding traffic shows the innovation hasn't gained complete acceptance, the four-year-old service has brought major improvements to a country where there are few hospitals equipped with emergency rooms, let alone modern ambulances with heart defibrillators and ventilators.

"Indians didn't have access to a number like this before, or to ambulances within 20 kilometers," said Venkat Changavalli, chief executive of the Emergency Management and Research Institute, which runs the free emergency medical service.

Its success has drawn a team of Harvard School of Public Health researchers to India to evaluate the service and whether it could be adopted in other countries.

The service harnesses the vast citizenry's ready access to mobile phones - 370 million people in nine of India's 29 states can now call 1-0-8 - and the country's call center expertise to quickly dispatch ambulances dispersed around the participating states.

They respond to more than 10,000 emergencies a day, and the institute provided data showing that 73 percent of its urban ambulances reached the patient within 15 minutes, while 68 percent of rural ambulances reach patients within 25 minutes. While this is not up to US standards, it is a remarkable response rate for India, given its generally poor roads, Harvard team leader Marc Mitchell said in an e-mail. "Indeed this . . . is certainly a model for the rest of the developing world," he wrote.

Some private hospitals provide paid ambulances, but Changavalli said his service provides free transportation to the hospital of the patient's choice, prehospital care by trained EMTs, and follow-up 48 hours later.

In a call center in the state of Andhra Pradesh, 250 workers sat among a honeycomb of octagonal cubicles one recent day, answering emergency calls from all over the southeastern state.

Praneeth Pulukkuveetil looked like your typical Indian call center worker: a 20-something staring at a couple of computer screens. He spoke into his headset with the clipped, rapid cadence of an auctioneer - like all the workers, he is fluent in Hindi, English, and Andhra Pradesh's vernacular, Telugu. He dispatched ambulances to both the far reaches of rural India and the heart of its teeming cities.

"I walked through the call centers, and was very impressed - that this was a very well thought out, top notch approach . . . because they cover the whole state with one call center," Thomas Bossert, director of Harvard's International Health Systems Program, said during a recent trip to India.

The service has done a good job overcoming India's wide gaps in wealth and uneven distribution of public health resources, said members of the Harvard team, which is funded by a British international development agency. Of the service's 3.7 million annual users, about 80 percent have come from lower castes, they said.

The government is providing 95 percent of the service's $120 million total funding this year, and that has drawn a lawsuit from a group called Transparency in Contracts. Shaffi Mather, a lawyer representing the group and also the founder of an ambulance service that serves Mumbai and state of Kerala, said the Emergency Management and Research Institute has gotten contracts to cover eight states without competitive bidding or proper transparency.

Changavalli said these states invited the institute to run their ambulance services because of its track record in Andhra Pradesh. "This is healthcare - you go to the doctor who delivers results," he said.

Some also criticize the service for stopping at the hospital door. In a country that effectively lacks emergency rooms, stabilizing patients and getting them to the hospital faster isn't enough, said Dr. Ram Rao, medical director of private CARE Hospital in Hyderabad.

The institute is working toward enhancing emergency rooms, but first it is training doctors in emergency treatment, beginning in Andhra Pradesh and Assam, Changavalli said.

He plans to double the service's fleet to 4,000 ambulances within six months, he said, and is hoping to cover the entire country with 10,000 ambulances on the road by next year.

Some of the ambulances are state-of-the-art, some are basic, but all have been "Indianized" - with long, heavy ropes to retrieve victims from deep wells, antivenom for various types of snakebites, and a long bench to accommodate the extended family that always joins the patient.

The recent bus accident in Hyderabad was typical of the traffic challenges the service faces, where ambulances don't yet get the respect they do in the United States.

Balakrishna Uppada, an emergency medical technician trainee, used the ambulance's public address system to pierce the incessant honking and politely prod drivers to give way - with little success.

When the ambulance finally reached the scene 20 minutes after receiving the call, police waved it forward past a crowd of onlookers.

The EMTs rushed out, only to find that the three victims had already been transported to the hospital in autorickshaws - little three-wheeled taxis.

"In urban areas . . . they recognize that it's quicker for them to take an auto and pay a little bit to go to a hospital than to wait for the ambulance," said Bossert, the Harvard professor. "What they don't realize is that the ambulance can give you a lot of services right away, and they have paramedics trained that can help save people's lives during that critical period from home to the hospital."

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