01 Sep 2007
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To The Rescue

For the residents of one state in India, a novel 108 emergency response service has been a lifesaver
by Garrett M. Graff

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Life in modern India, despite all of the advances of the last decade, is still barely controlled chaos. On the crowded streets, camels and donkeys mix with handcarts, three-wheeled scooter taxis, massive Tata trucks, luxury cars, and pedestrians. The construction of the gleaming new IT parks that house Western companies happens in conditions that wouldn’t pass an OSHA inspection. Clean drinking water and indoor plumbing are a luxury, and slums line main roads. For many of the country’s 1.1 billion residents, life still exists close to a Hobbesian state of nature: nasty, brutish, and short.

Each day, the chaos that is one sliver of modern India arrives in the form of 13,000 phone calls to the tranquil 37-acre campus of the Emergency Management and Research Institute (EMRI) outside Hyderabad in the southern state of Andhra Pradesh. “Namaste, one zero eight,” the operators answer with a traditional Indian greeting. It’s hard for Western observers to fathom, but EMRI’s 108 service is India’s first coordinated emergency response system, similar to the 911 system in the United States. At least for residents of Andhra Pradesh, where EMRI started two years ago, dialing 108 now means access to immediate help in the event of a medical, police, or fire emergency.

EMRI is the brainchild of Ramalinga Raju (OPM 19, 1993), the founder and chairman of Indian IT and consulting powerhouse Satyam Computer Services. The inspiration for EMRI came from his travels for Satyam, which, with more than 40,000 employees, does business in some 55 countries around the world — many of which have a single emergency number service. In their world travels, Raju and other Satyam executives saw the difference that a coordinated national emergency response system could make and realized that Satyam’s project management skills and technical ability could be brought to bear on the problem back at home. “Rather than expecting the government to take the initiative, we could establish certain services in a few cities so that the citizens would come to appreciate the difference that it could make,” Raju explains. “Eventually, we could partner with the government and other institutions” to expand the service.

Like any good businessman, Raju saw in emergency care an untapped market. The need was clear enough: Every day some 200,000 Indians face a medical emergency. Each year some 136,000 women die in childbirth, and some 600,000 Indians lose a limb in an accident, which means they are “worse than dead” because they lose their earning power and become a burden for the rest of the family to support.

Raju floated the idea to various colleagues, including his friend Krishna Palepu, the Ross Graham Walker Professor of Business Administration and senior associate dean for International Development at HBS, and a member of Satyam’s board. Palepu recalls that he was intrigued by the idea, but skeptical that it would work. But where Palepu saw potential obstacles, Raju simply saw management challenges to overcome.

“People are just astounded that this can be done,” says Palepu, who explains that the service is unique in India. “EMRI is actually helping everyone — rich and poor. It’s offering a solution. It really resonates with everybody.”

Raju’s initial investment in launching EMRI in 2005 came to some $12 million in start-up funds and some $25 million in property, along with much donated time and effort from employees at Satyam. It was, in a way, a gift back to the country that has allowed him to prosper.

To understand just how transformative the work of EMRI is, one must first grasp the scarcity of emergency medicine, which is nearly nonexistent in India. In most of the country, people are on their own to get to a hospital after an accident or in an medical emergency.

Beyond that, though, there’s no cultural understanding of emergency care, and few doctors are schooled in emergency medicine. “When we started, people would think that to be an emergency there had to be bleeding,” explains Venkat Changavalli, the CEO at EMRI. “If someone just collapsed or fell down, people would stand around and look.” A massive statewide advertising blitz and public education campaign by EMRI is beginning to change citizens’ understanding of the need to seek medical care, although cultural differences still persist. “One man called us in the middle of the night and said, ‘I need a lady now.’ To him, that was an emergency, to us it wasn’t,” Changavalli laughs.

Raju has been a strong backer of corporate social responsibility at Satyam, which also funds programs that bring clean drinking water, medicine, and literacy programs to rural Indian villages. He runs the nonprofit EMRI like he does any of his other myriad enterprises, by driving the staff hard and carefully measuring their performance. Changavalli remembers being given the Herculean task of getting EMRI up and running in six months. When he accomplished the nearly impossible in seven months, launching the service on August 15, 2005, Indian Independence Day, Raju pointed out that he was a month behind schedule.

And just like at Satyam, where Raju tallies profits and losses, at EMRI’s quarterly board meetings he focuses on the organization’s very human bottom line. “We track the number of lives saved. It’s like our earnings per share for the quarter,” Palepu explains. “It’s a very inspiring statistic to pay attention to.”

Today EMRI is much more than just an emergency call center. There are three different components: emergency management, research, and an institute. The first is the most immediately transformative. Using sophisticated software developed by Satyam, 108 operators use GPS and mobile technologies to dispatch state-of-the-art ambulances with EMTs to the scene of emergencies. In the yellow-and-blue call center, which could easily be any other Indian call center, the operators — mostly young and including many dressed in traditional Indian saries — speak English, Hindu, and the local Indian dialect. In some ways, EMRI’s approach is more advanced than most emergency response networks in the United States. Each shift is staffed with three doctors who are available to interview and question callers and to advise EMTs on treatment.

Out of the 13,000 calls a day, some 800 are medical emergencies — response to fire and police emergencies are coordinated with local agencies. In roughly 10 percent of the medical emergencies, EMTs save a patient’s life. Ambulances generally arrive on the scene in under 15 minutes, and the mean service time from a call to 108 to arriving at the hospital is just 34 minutes — long by Western standards but amazing for India.

Falls are a leading cause of emergency calls, but traffic accidents are also a huge problem. India has only 1 percent of the world’s vehicles but accounts for 6 percent of the world’s traffic accidents.

As the 108 service has expanded, there have been plenty of surprises. In recent months, as 108 began to cover areas outside of Andhra Pradesh’s cities, the ambulances had to be outfitted to deal with snake bites, which turn out to be common in rural villages.

Treatment and transportation in EMRI’s ambulances are free, funded through private donations and government support. EMRI also has developed partnerships with more than 850 hospitals across Andhra Pradesh that will provide 108 patients with 24 hours of free medical care. Hospitals that had been initially reluctant to sign on to the service quickly came around as they realized that EMRI’s emergency care and response plan was encouraging more patients to seek medical care.

The second component of EMRI — research — focuses on the longer term. More than fifty doctors work as researchers, constantly tracking emergency calls to better position ambulances to respond quickly. The doctors also identify dangerous intersections and pass the information along to local governments to encourage better traffic management. They review 108 hang-ups, study best practices of emergency medicine in other countries, evaluate the level of care available at various hospitals, and parse the numbers of calls to 108 — each carefully coded by the operator — to understand the area’s emergency needs.

The third component, the institute portion of EMRI, organizes emergency medicine conferences and helps to focus attention on the need for India to develop emergency response systems. Last spring, it launched a two-year training program for paramedics in partnership with the Stanford School of Medicine.

In its first year of operation, EMRI saved some 4,000 lives, and as it expanded, in its second year it saved more than 7,000. Since the service launched, more than fifty children have been born in the 108 ambulances.

“Everyone who knows about EMRI sees it as an ally and a friend in need. In a place where the government isn’t particularly effective in creating that sense of security, it’s really amazing,” says Palepu, who personally used 108 when he was visiting India and his father was ill.

Today the 108 service covers all of Andhra Pradesh, roughly 80 million people, through a network of hundreds of ambulances. EMRI has aggressive expansion goals for the coming years and an ambitious “profit” goal set by Raju: By 2010, EMRI should respond to 1 million calls a day and save 1 million lives a year. All of this comes relatively cheaply. Coverage runs about 10 rupees per person per year, roughly 25 cents, meaning that nationwide coverage could be achieved for about $250 million annually — a bargain considering the economic impact of saving the estimated million lives annually. Nationally, EMRI officials estimate that India would require more than 10,000 ambulances and some 35,000 trained EMTs, but even that number would be roughly only a quarter of the number of ambulances deployed in the United States to service a much smaller population.

The service has earned the strong backing of local officials who see it as a successful model for public-private partnerships. “They’ve helped us not just at the funding level but with integrating police and fire into the emergency system,” Raju explains. “We are now in the process of appealing to the national government to grow the public-private partnership throughout the country in a very short amount of time.”

While it has already been approached by politicians and leaders from across the country who want EMRI to expand emergency response in their home districts, EMRI’s leaders have been careful to manage future expectations. As they point out, India is vast — with huge differences in governance, language, culture, and even the reliability of local police. “Ultimately the plan is very important, because it’s a promise of security we’re giving to people. We can’t get into a situation where we can’t do it consistently,” Palepu explains. “These are all problems of success — not problems of failures.”

Garrett M. Graff is editor-at-large at Washingtonian magazine. His first book, The First Campaign: Globalization, the Web, and the Race for the White House, will be published in December by Farrar, Straus and Giroux.

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