A few years ago, Ashish Kothari thought he had found his life’s calling as a doctor. Raised and educated in Mumbai, the son of a doctor himself, Kothari graduated from medical school, became head resident at an Indian hospital and held valuable internships in Singapore and New York. Back in Mumbai, he established a private practice and helped it grow to five doctors and 30 staff members in three years.



Then in 2009, Kothari, an orthopedic surgeon, left his practice to study at MIT. Not because he was tired of helping people, but because Kothari believed he could help more people as a medical entrepreneur working to lower the cost of care in India.



“The difference between developed and developing economies is the way people are treated at every level of society,” says Kothari, who is pursuing degrees at the MIT Sloan School of Management and the Harvard-MIT Division of Health Sciences and Technology. “Not just at the top, but how people are treated at the middle and at the bottom, and I firmly believe a basic level of medical care is something everyone deserves.”



As a result, Kothari is currently at Sloan formulating a two-part plan for making inexpensive medical tools and building low-cost clinics. In 2009-2010, Kothari is one of 16 fellows at MIT’s Legatum Center for Development & Entrepreneurship, which promotes “bottom-up” global development through technology. Two other Legatum fellows are trying to connect technology and medicine in India: Arjun Nair, who wants to create electronic medical records for India’s poor, and Murali Govindaswamy, who aims to increase forms of data-sharing over rural Internet networks.



“There is a large population in India that could benefit from medical innovations,” says Iqbal Z. Quadir, the founder and director of the Legatum Center at MIT. “That’s why it’s important for all three of them to establish a sustainable presence there.”



When a knee costs an arm and a leg



These projects aim to affect a society where medical care reflects class divisions. At the high end, India has world-class doctors, clinics and technologies; the country has seen a growth in “medical tourism” among patients who, for instance, travel to Bangalore, where a relatively pain-free type of heart bypass surgery was pioneered. Yet with a population over one billion, hundreds of millions of Indians could use better, more affordable care.



At MIT, Kothari, Nair and Govindaswamy are all rethinking the relationship between technology and medicine. In the United States, medical technology has often been associated with expensive new treatments. But as the Legatum Center fellows see it, technology should lower health expenses for the masses by refining existing treatments. “There’s this huge void between the high-quality medical care available in the top 5 or 10 percent, and what is available at a price most people can pay,” Kothari says.



Consider Kothari’s surgical expertise, joint replacement. In India, an artificial knee costs $1,000 to $1,500. “I think it’s possible to get that down to $500 to $750,” Kothari says, through local manufacturing (currently more than 90 percent of India’s implant parts are imported) and better engineering management. Kothari has recruited a chief engineer for his prospective company and would like to make many types of devices — including diagnostic tools and sterilizing machines — while starting modestly and “growing as the demand grows.”



Indeed, the consulting firm Technopak Healthcare has projected that medical-sector spending in India will rise from $40 billion in 2008 to $323 billion in 2023 (without adjusting for inflation), thanks partly to India’s emerging middle classes. Inexpensive device-making, Kothari thinks, naturally helps affordable treatment and low-cost clinics become realistic.



Records for the poor



Nair’s project aims even lower on the socioeconomic scale: He would like to help people who cannot read the label on their medicine. “The poorest of the poor are mostly uneducated, illiterate, don’t have access to drugs and live in the rural areas,” says Nair. “It’s very hard for them to get educated about fundamental problems like tuberculosis or more chronic problems like diabetes.”



The first step, Nair thinks, is to create electronic medical records for them: “You need to keep track of how a patient progresses over time. But that’s an enormous task in India because there’s no infrastructure for it.” Thus Nair wants to found a business to build a record-keeping infrastructure for rural health-care providers, ideally in his native state of Kerala, in southern India.



Govindaswamy, for his part, would like to develop data applications, to be used on the mobile devices sold by Nokia in India, that would let rural residents send and receive medical data. “If you break down the information barrier using mobile phones, that can help in areas like health,” says Govindaswamy.



Being at MIT also helps the Legatum Center fellows connect with local entrepreneurs. One model for Nair’s project is suggested by Innovators in Health, a Cambridge-based firm that developed a “smart pillbox,” a mobile device that reminds tuberculosis patients to take their drugs. “It’s extremely hard to monitor what’s going on in the field,” says Innovators in Health co-founder Manish Bhardwaj, PhD ’09, whose company has roots in MIT’s International Development Initiative. Of Nair’s idea, he says, “Electronic medical records are the kind of thing that can help a good program to reduce costs.”



Think global, start local



Innovators in Health currently participates in projects in Delhi and the Bihar region. That kind of scale, Nair observes, is ideal. “If you start at the higher level, it’s an enormously capital-intensive project, and it’s not going to happen,” says Nair bluntly. “So it has to be localized; then you can build up.”



Quadir, who founded Bangladesh’s largest telephone company, Grameenphone, supports that philosophy. “That’s the nature of bottom-up development: it builds on small, initial success,” says Quadir. “Then other people can invest, and a project can become bigger. That’s why the Legatum Center encourages projects that can become commercially viable. Through local innovation, if you deliver more efficiently, the opportunities are enormous.”



Of course, the Legatum Center fellows face high hurdles before their ideas become viable enterprises. Bhardwaj, for instance, recommends that health startups become partners with nongovernmental aid organizations in India — which financial backers almost always require.



“A lot of people have narratives of technological transformation,” says Bhardwaj. “But investors are looking for reliable partners on the ground. You have to manage challenges from infrastructure to finding the right way of hiring and training workers. If an organization has everything else functioning, then it’s primed and ready for computerization.”



Whatever obstacles they face, these Legatum Center fellows are all making the same trip from India to MIT and back, in order to help others. “Being a doctor is wonderful, but I wanted to try something different,” concludes Kothari. “My father’s practice always treated people independent of socioeconomic concerns. You only need to be sick for two days to realize how much it affects you, so think about people who are unwell all the time. I’d like to do something for them.”





