Anaemia : some facts and an innovative idea

        Anaemia is one of the major public health problems worldwide (acc. to World Health Organization). When we hear this, the first thing that comes to our mind is - what is anaemia ? We hear this term almost daily that someone known to us has anaemia. We advice them to take iron tablets, iron tonics, nutritious foods etc. Now let's discuss some facts about anaemia in short. Anaemia - is low haemoglobin level in the blood. This haemoglobin is present in our red blood cells. Each haemoglobin molecule is composed of a 'haem' portion with a globin chain(protein). Iron is an integral part of this 'haem'. Other factors that help in haemoglobin synthesis are vitamin B12 and folic acid. Vitamin C is also important, as it increases iron absorption from diet in the body. Haemoglobin carries oxygen from the lungs to rest of the body and to the tissues, where oxygen is utilised for various metabolic processes that provide energy and are necessary for our well-being. Our body can utilise the oxygen that we get from atmosphere, only when it is transported by haemoglobin to target tissues. Now if haemoglobin level is low, then oxygen carrying capacity of blood will decrease. The tissues will suffer from low oxygen availability, and the problems due to anaemia will arise.

The etiology for anaemia in India :

• Inadequate nutrition - some of the causes are low socio-economic status; dietary patterns [diet consisting of - (a) foods having low level of micro- and macro-nutrients e.g. cow's milk, which is a poor source of iron or, (b) foods inhibiting the absorption of these, e.g. tea inhibits iron absorption if taken with or immediately after meals]; gender discrimination  (like female family members eating only after male members have finished their meals and in many cases, eating leftovers, also girl child getting less nutritious food than her brothers) and ignorance.
• Inadequate dietary intake during adolescence, pregnancy and lactation (when nutritional demand of body is increased).
• Chronic blood loss and chronic diseases (worm infestation, malaria and other infectious disease, hemorrhoids, inflammatory bowel disease, cancer, chronic kidney disease). 

           Most important cause of anaemia in India is inadequate nutrition. It is a vicious cycle, once there is an anaemic lady, anaemia will progress as she will be pregnant and after that her children will also suffer.

   
        Anaemia is a major health problem for adults as well as children, affecting 55 percent of women  and 24 percent of men. The prevalence of anaemia for ever-married women has increased from 52 percent in NFHS-2 to 56 percent in NFHS-3. Pregnant women are much more likely than nonpregnant women to be moderately to severely anaemic. The prevalence of anaemia among children aged 6-35 months has increased from 74 percent in NFHS-2 to 79 percent in NFHS-3. This increase is largely due to a sharp increase in anaemia among young children in rural areas (source-NATIONAL FAMILY HEALTH SURVEY(NFHS-3)2005–06 INDIA VOLUME I, Available from: http://www.measuredhs.com/pubs/pdf/FRIND3/FRIND3-Vol1%5BOct-17-2008%5D.pdf, accessed on July 18,2013).

       Anaemia leads to increased fatigue, lethargy, palpitation, irritability, weakness, susceptibility to infections. During pregnancy, when the energy requirement of body is increased, anaemia leads to decreased work capacity and increased fatigabilty. Anaemia has serious consequences on health of foetus like poor development, low birth weight, preterm delivery and increased perinatal mortality. Children born to anaemic mothers are also at risk of developing anaemia in infancy. In young children, anaemia results in developmental (motor, linguistic and social-personal) delay, increased risk of infectious diseases than non-anaemic children.
 

        Pregnant mothers with moderate to severe anaemia cannot tolerate blood loss during or after delivery, and unfortunately die more early than a non-anaemic pregnant mother. In the city hospitals, when we get referred cases of APH (Antepartum haemorrhage) and PPH (Postpartum haemorrhage) from health centres in periphery in shock state, and sometimes we cannot save the pregnant mother's life in spite of all our efforts, it really hurts a lot. It feels so so bad when we think that we could save her if she had been diagnosed and treated during her pregnancy for anaemia. Simple measures like eating some nutritious food, green leafy vegetables(which are easily available in rural areas), iron supplementation and a little bit of care can save a pregnant mother and her baby's lives. Government of India has a programme where iron and folic acid tablets are given to all pregnant mothers, whereas those with anaemia need double dose of this tablet. For diagnosing anaemia and also for monitoring if the patient is responding to treatment, it's necessary to periodically check the haemoglobin level. But how to do that with such limited health facilities in rural areas?

           These problems are easily preventable, if anaemia is diagnosed early. In urban areas, health facilities are easily available and accessible, doctor to patient ratio is high, there are government hospitals, medical college and hospitals, lots of private hospitals and numerous diagnostic centres, where early diagnosis and treatment of diseases is very much possible. But in rural areas, incidence of anaemia is higher, mostly because of low education level in women, poor socio-economic status and low health awareness. Diagnosis is important than treatment. In rural areas, with limited health facility, few health centres, low doctor:patient ratio, and very few centres with diagnostic facility, it becomes a great challenge to diagnose anaemia. Also the long distance of health centres, poor transport system, some misbehaving group-D staffs, long waiting time for simply getting a date for the investigation, and finally another long wait for getting the report of the investigation, repeatedly going to health centre simply for doing one test are some of the discouraging factors. People do not opt for investigations, also because of their daily wage loss due to absence from work on the days they have to go to health centre. And most of them cannot afford private diagnostic centres. So they are not interested to check their haemoglobin levels at all. Here comes a great challenge for testing the blood for haemoglobin level. Now what to do next ? 

We have to use a device that -

• Would give people in rural areas the opportunity to check their haemoglobin level in their own houses, without going to health centres
• Should be easy to use, with an easy user manual, and no theoretical knowledge of the user is needed
• Should be a simple non-invasive device, easy to attach, easy to read and does not require any other instrument or accessory like needle, electricity etc.

        TEDx Gateway conference Mumbai was held in December'2012. I watched the speakers narrating their riveting stories of innovation on 'The Idea Caravan' at www.ftideacaravan.com. All the ideas they're talking about are excellent, and the cause they have stood for are very much touching. The idea that I liked the most is- ToucHb, a substitute to a $10,000 machine which can be used by the nurses and ASHA workers in rural areas to detect anaemia, by Myshkin Ingawale. I liked his presentation, and here I'm discussing about the idea and the invention in detail. Here is the video showing the demonstration of the device -

                                                                              

                                                                                                              

                                            

 

 

ToucHb
     

          Myshkin Ingawale is co-founder of Biosense Technologies, a Mumbai-based company. ToucHb is the device that they have invented. From the demo in TEDxGateway conference, we can see, it's a simple handheld device, easy to carry in a small bag. 

•  It is easy to handle, does not require electricity, is battery-operated. 
•  It consists of two parts - a probe, that is to be attached to patient's finger, and a small rectangular box with function keys and a display, which shows patient's haemoglobin level. 
•  It is simple to attach to patient's finger, no painful procedure (like finger prick or drawing of blood) is needed. Many people are afraid of finger prick, and resist blood testing, and that is a problem when you have to check haemoglobin repeatedly (as in case of pregnant mothers or anaemic patients under treatment, for monitoring the response to treatment) by conventional methods, so ToucHb has better patient compliance.  
•  They recommend it for ASHA worker's use. According to primary health care system in India, one of the people who work at village level are ASHAs(Accredited social health activists). ASHA is a lady residing in the same village, having minimum class eight education. So in my opinion, this device fulfils all the criteria of a handheld device for field use, and the idea is really very good for use in rural India.  
•  It uses a principle known as photoplethysmography, where light waves are used, and measuring how much of these are scattered and how much are absorbed, calculations are done. It detects blood haemoglobin level, and simultaneously also detects oxygen saturation and pulse rate of the patient. One device measures three important health related parameters. The technology is latest, that is a nice thing about this device.  
•  No special skill is needed to operate ToucHb, but one thing I would like to say - ASHAs should be properly trained how to use it, about the placement of probe, and the direction of the probe. I personally have seen a nurse placing the oxygen saturation probe in reverse direction in an unconscious patient under treatment. She was very afraid when she didn't get any reading, and thought that the patient was dead, on-duty doctor was called immediately, he left other patients and rushed into the ward. He pointed out the mistake, and when he re-positioned it, the patient's oxygen saturation was absolutely normal. In this case, someone was there to rectify the mistake, but in rural areas, health worker has to work alone, and she should be trained about operating the device, assessing the problem when error code is displayed. I do not know whether any error code is displayed in this device, but there should be some technology to automatically detect when something goes wrong, like positioning error, low battery, circuit problem error etc.

                                   And finally, my conclusion about this idea -

    1. This device is an ideal hendheld device which looks very useful. It has to be manufactured in large-scale if we want to use it at mass-level. The general norm in India is one ASHA appointed per 1000 population, if we can provide ToucHb to each and every ASHA in a haemoglobin estimation kit, then only it's purpose would be served completely. Government collaboration is also very much needed for large-scale use, and it should be cheap.

      2. Proper positioning of the patient is one of the problems that health worker has to face while examining the patient in his/her own home, where ample space or proper bed like health center is not always available. In the demo they measure the haemoglobin level of a volunteer, measurement is done while he's sitting. I don't know whether it can be used when the person is standing or lying in supine position, because sometimes ASHA may have to measure haemoglobin level of bed-ridden patients also. From the principle it's using for estimation of haemoglobin, it seems that the positioning of the patient should not matter. If measurement in any position of body is really possible with ToucHb, it would be a great idea.

      3. There should not be much difference in measurement of haemoglobin by ToucHb and by conventional methods. There used to be differences in blood - glucose measurements by conventional methods and by initial glucometers using one drop of blood on test strips. Those devices have improved now, but still in some cases they are not always accurate. Treatment depends on diagnosis, and laboratory diagnosis is done by measuring the parameters. Handheld device may not be as accurate as conventional methods, but the difference in the measurement should be as little as possible. Manufacturers have to keep this in mind.

  Franklin Templeton Investments partnered the TEDxGateway Mumbai in December 2012.