The New Navigating Force

The Geographic Information System (GIS) and the Global Positioning System (GPS) are out to create waves in healthcare, reminiscent of the PC revolution, reports Nayantara Som.

Information technology (IT) has indeed made the world smaller. Particularly, in the health sector the concept of e-health, although a new concept promises to create waves. Earlier, it was telemedicine, HIS and teleradiology that was the mantra, now it is GIS and GPS. This has integrated two disciplines which otherwise were thought to be poles apart-geography and health science.

GIS is a system for capturing, storing, analysing and managing data and associated attributes which are spatially referenced to the earth. In the strictest sense, it is a computer system capable of integrating, storing, editing, analysing, sharing, and displaying geographic-reference information. GIS allows users to create interactive queries (user created searches), analyse the spatial information, edit data, maps, and present its results. On the other hand, GPS is currently the only fully functional Global Navigation Satellite System (GNSS). More than two dozen GPS satellites are in medium Earth orbit, transmitting signals and allowing GPS receivers to determine the receiver's location, speed and direction. Since the first experimental satellite was launched in 1978, GPS has become an indispensable aid to navigate around the world, and an important tool for map-making and land surveying. Initially, used as a tool by the navigation and transport industry, it has been adopted by the healthcare industry for a multitude of tasks, thus integrating the entire system.

Making Life Easier

In a country like India, with its size, varied topography and contours, lifestyles and diverse culture, manually gathering health data of the swelling populace, going house to house and village to village is indeed a Herculean task. GIS and GPS are here to make life easier as the data is converted to a digital format, maps on different aspects are then made and based on individual needs integrated and analysed. This makes it an indispensable component for health experts to track down epidemics—their onset, causes, conditions and effects, patterns, the target groups, medical history of each family in an area and zero in on the exact position of the house. An apt instance would be the Danish International Development Assistance (DANIDA)—assisted National Leprosy Eradication Programme (DANLEP)—one of the foremost organisations to deploy GIS to eradicate leprosy in India. DANIDA introduced GIS in the Indian state of Orissa in its leprosy control programme, and subsequently for TB control. A network alliance was made with staff from Department of Geography, Utkal University, Bhubaneswar, to develop a GIS system that would be able to combine standard primary map information with an extensive database of spatial data (such as administrative units, transport network, drainage and water bodies, facilities (schools, colleges, hospitals), organisations (NGOs), health infrastructure and slum pockets, with a large amount of non-spatial data (ward-wise population/population density, other demographic parameters, service providers) and NGO activities in health. The developed GIS is now extensively used by other health sector programmes, for TB control, HIV/AIDS and maintaining cold chain equipment for pulse polio.

Aravind Eye Hospital, Madurai uses GIS mapping to chalk out the reach of its eye camps in rural areas. (Right) The figure shows the villages sorted out by GIS. (Left) The figure shows the villages within a radius of 10 km sorted through GIS

Why GIS and GPS?

Decades ago, when the first PC was launched in the market, IT pundits and health experts were sceptical about its advantages in our day-to-day life and predicted its early death with the excuse that it is beyond the reach of a layperson. But look at where it is today! GIS and GPS have created a similar revolution, especially for healthcare experts who are on the run for 'preventive' more than 'curative' care. As an expert in the IT sector pointed out, "The market for GIS and GPS is booming, especially in the public sector." This trend is particularly noticeable in Brazil, India and China, which has more or less a similar social structure and where 'the maximum amount of investments is in healthcare products'.

There are several advantages of applying GIS or GPS in healthcare. GIS is mainly beneficial in preventive care. Says Professor Jitendra Shah, Secretary, OSGEO.ORG (India Chapter), Pune, "For tracking (or predicting) an epidemic, GIS maps are handy as one can immediately chalk out its origin, look for a pattern in the spread of the epidemic, analyse and then offer solutions." This is not all. Professor Shah also opines that barring the health aspect, GIS and GPS are also an effective tool in the arena of administration to keep track of the number of doctors, paramedics, primary healthcare centres (PHCs) and hospitals in a particular village or a rural area. "If the administrative aspect is sorted out, then collection of important data will not be so tedious a task," adds Shah. In fact, Mumbai is gearing up to utilise this technology to avoid another July 26 deluge. The Brihanmumbai Municipal Corporation (BMC) is contemplating the idea of using a GIS and GPS system to control floods, predict the onset of an epidemic, extract co-ordinates of the exact location of hospitals and health centres.

However, of all the advantages, 'cost effectiveness' is the key, say experts. Says Dr BN Nagpal, Deputy Director, National Institute of Malaria Research, New Delhi, "Earlier, to conduct a survey for research, health personnel had to be sent out, which meant costs on conveyance and subsequently other amenities. But technology has reduced all that." Research and survey are the main benefits of this technology. Utilisation of resources can also be meticulously planned and experts can channelise resources.

Healthcare institutes in India are resorting to GPS receivers to track out the exact point of an epidemic out break or for collection of health data

Cases in Point

Christian Medical College, Vellore: Vellore's Christian Medical College (CMC) has integrated healthcare with technology, making life easier and faster for physicians and academicians. The most talked about technology is GPS and GIS at Bagayam, five kilometres from Vellore, in the Community Health and Development (CHAD) programme. CHAD provides primary healthcare for a population of nearly 2,50,000 in the nearby rural, urban and tribal communities. Dr Vinohar Balraj, Professor for the Community Medicine Department, CMC, says, "CHAD aims to provide training in the principles and practice of community-based healthcare for medical, nursing and paramedical students, postgraduates and staff from within CMC. We provide immunisation, mother and child care, and collect data on chronic and acute diseases." The CHAD hospital is the base-point for the field programmes and a centre for primary healthcare. Outpatient services include special clinics for antenatal patients, high-risk infants, tuberculosis, leprosy, ENT, eye and infectious diseases in addition to daily general clines. "We have been collecting data since 1985. Every month our health team reviews the data collected at various levels, analyses it and then monitors it. This version is used for teaching and research," adds Dr Balraj. It is in this background that CMC decided to apply GIS and GPS for analysis and research. For this, GIS maps had to be prepared. With software supplied by the Environmental Science Research Institute (ESRI), California, it took approximately two years to collate all the data, train personnel and make the GIS maps. "Today, we have mapped every street, road, lane, and around 25,000 houses," adds Dr Balraj. Each individual in a given area has a unique identification number. Dr Jayaprakash Muliyil, Professor and HOD, Community Health, CMC, says, "Our GIS system has carefully recorded data on every household, pregnant woman, and every individual's life travails."

GIS and GPS were also utilised to find out the suicide rates in rural areas. "Areas with high suicides rates were known to us. We co-ordinated and looked at the concept of clustering and then wrote a software used for bringing out analysis in clustering," adds Dr Balraj. This led to asking the likelihood of the suicide whether by chance or accident. While the GPS helps in collection of data and a particular point and coordinate, GIS with reference to this point and co-ordinate helps getting all the co-ordinates, lines together and the spatial dimensional data.

The turning point for CMC was its tie-up with ISRO, Bangalore. That is when data on natural resources was integrated with the health data. Considering the climate, soil vegetation, a direct relation was observed between natural resources and people's health. "Basic data for the last three years of ISRO was taken into account. For the first time, ISRO was looking at a health team that would deal with data at a micro level," adds Dr Balraj. Natural resource data was collated with data like sewage, sanitation, water resources, location of toilets in villages, and the outbreaks of dengue and cholera were analysed. Similarly, the geographical positions of low rate of birth of babies were analysed. "We analysed through GIS maps whether low outcome births was directly proportional to the distance from the healthcare centres. This was then compared with co-ordinates of roads and hospitals through GIS maps," informs Dr Balraj.

"Each doctor has to examine 150 patients. This is when GIS helps" - R Meenakshi Sundaram Senior Manager - Outreach Aravind Eye Hospital Madurai

Aravind Eye Hospital (AEH), Madurai : Introduced in 2003, AEH, Madurai also uses GIS for its eye camps across the country. AEH allots 50 per cent of its resources for free eye camp community services. One of the challenges for AEH at the onset was optimal use of resources. Says R Meenakshi Sundaram, Senior Manager,Outreach, AEH, Madurai, "In each eye camp, each doctor had to examine 150 patients. In addition to this, adjoining villages within a radius of 5-10 kilometres are also supposed to be covered. This is when GIS helps."

Prior to the introduction of GIS in 2003, the productivity of these eye camps was dismal. Says Sundaram, "In 1998, on an average, the number of patients coming to these camps was 200. But in 2003, we saw a huge boost to 310 patients per camp. This was a near 45 per cent rise. Similarly, for surgeries at these camps, if in 1999 there was a 30 per cent increase, year 2003 showed a sharp rise of 77 per cent." Currently, the hospital uses the Arc View version of the software and plans are afoot to update this soon.

"Using data from the various layers of a GIS map, officials from AEH plan out the fashion of publicity for our eye camps according to the village's population. We then plot out an area where we expect to receive a large number of outpatients and since we have the adjoining villages to focus on, we plan out the type of surgeries which are to be conducted," adds Sundaram. In this way, critical eye problems in a particular area are indicated merely by correlating GIS maps. Location of the base hospitals of the eye camps can also be traced with the co-ordinates in hand. Similarly, the cataract surgery rate (CSR), which is the number of surgeries conducted per million and an indicator to eye care delivery, can also be improved by using GIS.

GIS also helped AEH to collate cases from base hospitals in the villages of their eye camps and arrive at a conclusion. "By listing out critical ophthalmologic problems, and culling out cases from a particular area and relating it to a geographical data, we arrive at a conclusion about the disease typical to an area," adds Sundaram.

National Institute of Malaria Research (NIMR), New Delhi: Formerly known as Malaria Research Centre and a part of the institutes of the Indian Council of Medical Research (ICMR), NIMR, New Delhi has been over the past few years, involved in research carried on mosquito fauna, development of genetic and molecular markers for important malaria vectors, cytotaxonomic studies identifying major vectors as species complexes and laboratory and field studies to examine the biological variations among sibling species, development of molecular identification techniques for sibling species, monitoring of insecticide resistance through space and time, preparation of action plans have yielded valuable information.

Using ecological parameters, GIS and GPS have been used where crucial information and research data has been mapped on thematic areas. Says Dr Nagpal, "Using GIS we have mapped out 58 types of mosquito fauna vectors across the country and tracked down six types of mosquito vectors and their local area of influence." With information and data from different sources, six types of vectors were identified, namely in the rural areas, the foothill areas, forests, coastal regions, urban areas and the North-eastern region.

"After digitally transforming the data into GIS maps and marking the co-ordinates, the latitude and longitude, we then predict conditions and situations likely to take place for a particular region," adds Dr Nagpal. Once officials are sent on field, using GPS devices (which are connected to satellites), the exact position of co-ordinates are tracked and also used to mark out the altitude of a place.

An apt instance would be the outbreak of malaria in 1995 in Mewad, Rajasthan which was tracked down by NIMR using GIS and GPS. An adjoining dam had broken allowing water to filter into human settlements and subsequently stagnating. The stagnation become an ideal breeding place for mosquitoes that led to an outbreak. "Using GIS maps, we analysed the soil types and variations, climate, the water and its percolation and identified risk factors, chalked out the conditions of the area and the areas that were likely to catch the epidemic," adds Dr Nagpal. In fact, a comparative study was done by comparing GIS maps showing water conditions prior to the epidemic and maps of the water condition post a likely-epidemic.

In another project, ecological data on malaria over a span of five-six years was collected from 11 states in the country. Some states included Assam, Meghalaya, Orissa, Andhra Pradesh and Mizoram. In each of these states, approximately a block-wise analysis of each district was carried out through GIS maps to detect the occurrence and incidence of malaria. "Not every block comes up with equal number of cases. Maybe out of 10 blocks, only two blocks might have a high rate of malaria prevalence," adds Dr Nagpal. Solutions were then suggested that were cost effective in nature. "In areas where the prevalence of malaria was not so high, we discontinued use of sprays which would add to the cost and instead used it in areas that needed most," says Dr Nagpal. Similarly, the comparative analysis of the receptivity of malaria in Nadiad, Gujarat was analysed using GIS maps. In this way, NIMR has used GIS maps in three projects. A project on the micro distribution of mosquitoes in Meghalaya with the help of GIS maps is in progress at the moment.

"We have a range of geo-environmental variables customised on GIS platform" - Dr S Sabesan Deputy Director, Senior Grade Vector Control Research Centre Pondicherry

Vector Control Research Centre (VCRC), Pondicherry: The VCRC (ICMR) has initiated activities in the field of environmental health, with special reference to the application of GIS and remote sensing to address issues on epidemiology, control
and monitoring of Vector-Borne Diseases (VBD). Mapping of VBD distribution and stratification, identification of risk zones, space time cluster analysis, developing of early warning system and generating decision making tools for the control of VBD.

Using GIS as a platform, a model known as the Geo-environmental Risk Model (GERM) was developed for determining areas of potential transmission of lymphatic filariasis (LF). Says Dr S Sabesan, Deputy Director, Senior Grade, VCRC, Pondicherry, "Here, a range of geo-environmental variables has been selected, and customised on GIS platform to develop GERM for identifying the areas of filariasis transmission in terms of 'risk' and 'non-risk'. The model was validated through a 'ground truth study' following standard procedure using GIS tools for sampling and Immuno-chromotographic Test (ICT) for screening individuals. The model was structured on data collected from Tamil Nadu. A map for filariasis transmission was created and stratified into different spatial entities, depending on Filariasis Transmission Risk Index (FTRI)." For district level digital map of the state of Tamil Nadu (Survey of India), a scale of 1:50,000 was used. All GIS database are developed, using ArcView 3.2, ArcGIS 8 software (ESRI, Redlands, CA) and ERDAS, IMAGINE 8 (ERDAS, Atlanta, GA), an image processing software.

"Here, a combination of various factors like altitude, temperature, rainfall, relative humidity, soil type and land use/land cover (Level I category) was considered for the study. Since all these factors were spatial components, without GIS mapping nothing could have been achieved," adds Sabesan.

After an analysis of all these factors, an observation was brought out whereby the conducive factors for transmission of LF were detected. "Most importantly, GIS mapping gave an opportunity to give a lot of scope to each factor taken into consideration. We could even plan out our resources and channel them to the low risk areas," adds Dr Sabesan. Published in November last year using GIS mapping, the observation matched actual facts by 95 per cent. After the implementation of this model in Tamil Nadu, the ICMR has now requested VCRC to structure out a similar model across the country. This is likely to take a year.

Another model in progress is for brain fever (Japanese encephalitis) in Tamil Nadu. A particular breed of mosquito (Culex vishunui gr) mainly breeds in rice fields. Here the main objective of using GIS mapping is to bring out a co-relation between rice fields and the disease vector mosquitoes. (The particular breed of the mosquitoe breeds only in rice fields). "The rice fields will be monitored thoroughly and systematically on ground initially and through spatial data derived from satellite images subsequently. It can help us to bring about a solution for preventive actions," adds Dr Sabesan. In addition to this, other factors like the prevalence of pigs and ducks around the vicinity and their viral activity will be monitored. The project will be conducted in collaboration with Hyderabad-based National Remote Sensing Agency.

Emergency Medical Services: GIS and GPS is also a beacon of hope for Emergency Medical Services (EMS). Hyderabad-based Emergency Management and Research Institute (EMRI), is using it. EMRI had launched the 108 Emergency Response Service (ERS) in August 2005, which utilises the GIS and GPS technology for tracking down patients and guiding ambulances in Andhra Pradesh. Says Venkat Changavalli, CEO, EMRI, "We have GIS maps of all the towns in Andhra Pradesh. The moment a person dials 108, a GIS map appears on the computer screen of the person sitting at the call centre. This helps to zero in the exact location of the call. An ambulance is then dispatched." All GIS maps here have a scale of 1:1,000. Apart from being an apt tool to instruct the ambulance paramedics, the GPS system is a big boon, as doctors sitting at the call centre can give instructions.

The Future

In the near future, Maharashtra plans to use GIS-GPS for PHCs. Again, Gujarat's EMS Council is planning to introduce the GIS/GPS in their operational services. Says Manjul Joshipura, Honorary Co-ordinator, EMS Council, Ahmedabad, "Every ambulance has a card reader which is connected to a satellite. This helps in locating and directing the nearest ambulance to the accident spot.”

In a situation where the ambulance cannot be reached, the nearest ambulance is tracked to reach the emergency spot. "After tracking the ambulance we then superimpose this on a digital GIS map to calculate the distance," adds Joshipura. Currently, the EMS Council is exploring possibilities with a local service provider and the system is slated to kickstart within 6-12 months.

The Council has adopted a Japanese technology and are still in the process of maturing the system.With several healthcare experts adopting this technology, prices of GIS and GPS receivers are also expected to come down. As of now, investment varies between Rs 50,000 - Rs 10 lakh depending on the application used. An expert predicts that the cost of GIS/GPS is expected to come down 10 times than what it is today! "This will make microplanning a lot easier," concludes Professor Shah.

nayantara.som@expressindia.com