“If we are going to be engaged in global advances in human health, we have to have global partners. We cannot do it by simply staying here and reading about it.”
In modern times, technology has typically flowed from West to East. But someday, Westerners may benefit from medical devices that cost less and are more durable because they were originally developed for use in the villages of rural India. At least that’s part of the thinking behind a new program initiated by the Harvard-MIT Division of Health Sciences and Technology (HST). For nearly 40 years, HST, a pioneering collaboration between the Harvard University Medical School and the Massachusetts Institute of Technology, has worked to bring innovations in non-medical fields such as information technology, engineering, and materials science to the patient bedside and to clinical research. The catchword for the program is convergence, with faculty focused on fostering collaboration among researchers from disparate fields.
Since 1970, HST has worked to build a new class of health professionals, training physicians who are at the cutting-edge of technology and engineers who have meaningful experience at the patient bedside. Driving the experiment is the core belief that innovation occurs when individuals are forced to abandon the isolation of their own academic departments or professions and gain experience in other disciplines. “It’s all about the broad connections, as well as the unexpected connections,” says HST Director Martha Gray. “And it isn’t as simple as putting the engineers next to the physicians next to the biologists. What that leads to is a condominium, a series of adjacent silos.”
Now, HST is taking the bold step of trying to translate its unique educational and research model to India. The move could be a boon, allowing researchers to make new connections in the world’s second fastest-growing economy while also enabling them to broaden HST’s focus on the convergence of new technologies on a global scale. Despite the promise, however, HST must face critics who see such moves as contributing to an erosion of American competitiveness.
This new initiative first got underway in November 2007, when Gray and Dr. M.K. Bhan of the Indian Ministry of Science and Technology signed a letter of intent to establish a new Translational Health Science and Technology Institute (THSTI) near New Delhi. As part of the agreement, HST will help recruit and train new THSTI faculty members, and each year, starting in September 2008, four recruited THSTI researchers will join HST for two-year terms as faculty fellows. A concurrent program allows HST students to rotate through Indian medical institutions as part of their training.
“This is the natural progression,” says Larry Smarr, director of another institution committed to melding cutting-edge information technology, electronics, and medical research, Cal-(IT)2, a joint program of the University of California, San Diego, and the University of California, Irvine. “HST could not possibly be at the forefront if they were not reaching out in this way.” Smarr describes his own institution as being equally ecumenical, but more ad hoc in its global outreach, with individual researchers creating opportunities for intellectual exchanges.
Still, the idea of top U.S. biomedical training programs expanding overseas has received a chillier reception in some circles. In July 2007, Congress held hearings on university globalization, seeking assurances from several university presidents that, by establishing foreign campuses—and in effect exporting American know-how—such programs would not hurt American competitiveness. At a subcommittee hearing of the House Committee on Science and Technology, some congressional leaders, not surprisingly, took an “America-first” perspective. Congressman Dana Rohrabacher (R-California) told the New York Times, “It’s one thing for universities here to send professors overseas and do exchange programs … but it’s another thing to have us running educational programs overseas.”
Gray maintains that American researchers must pursue these kinds of initiatives if they want to play a role in innovation beyond U.S. borders. “If we are going to be engaged in global advances in human health, we have to have global partners,” she says. “We cannot do it by simply staying here and reading about it.”
The India initiative represents the ultimate expression of the goal of informing the judgment among medical scientists and biomedical engineers through systems thinking. Not only will HST be producing researchers, clinicians, and technologists trained in a broad range of convergent disciplines, but the hope is that these investigators and designers will also be able to incorporate a much broader, global awareness into their technological and patient-care insights.
The test of this idea began in 2006, when HST students Christina Silcox and Kathleen Sienko, both engineering students, became the first from the Harvard-MIT collaboration to gain clinical experience in India. Even while the new HST-THSTI initiative was still under discussion, the two women did rotations in cardiology, neurology, gastroenterology, pediatrics, and community care medicine. One of the hospitals where they worked was the All India Institute of Medical Sciences, which treats more than 1.5 million patients a year. In such an environment, efficiency and cost containment are essential elements of effective care. They also visited a stem cell research and treatment facility, an organ transplant center, and the Institute of Nuclear Medicine Allied Sciences.
“Putting Ph.D.’s in a medical center is highly unusual anywhere,” says Gray. “In India, it is unheard of. So there was every possibility when our students went there that the Indian medical personnel would say, ‘Get these people out of here.’” But the program was well received, and four students are taking their rotations there in 2008.
Gray is sensitive to the fact that skeptics of such internationalism complain about a perceived threat to America’s global competitiveness. Nonetheless, she remains optimistic that the payoff will flow in both directions. “A core value at HST is the belief that, in order to have a big impact, you have to bring together not just different disciplines, but also the different professions, and that includes the academy, the government, and the private sector,” she says. “We’ve worked very hard to make that happen in Massachusetts, trying to bring industry closer together with what we were doing at Harvard and MIT. In India, we have the chance to build that kind of synergy from scratch.”
But Gary Pisano, a professor at Harvard Business School, says the venture could still be tricky. “The idea of setting up shop in India from a U.S. economy point of view is an interesting policy question that I don’t have a good answer for,” he says. “But I do know that every attempt societies have made to keep the crown jewels to themselves have failed, dating back to the beginning of the industrial revolution. Knowledge has this way of moving.”
Gray argues that the India experiment is a smart way to tap into the innovation potential of such a burgeoning environment. “There is no way that the U.S. is going to outdo India in terms of the raw number of people,” she says. “You have to create an environment that inspires the people who are most likely to come up with the innovations in your own community, who tend to be young and crazy enough to try. If they’re going to create that kind of environment in India, then at a minimum we want to be a part of that community as well.”
Breaking down such conceptual boundaries has been part of HST’s mission since its inception. In 1966, shortly after the President’s Commission on Heart Disease, Cancer and Stroke outlined a national initiative to conquer or mitigate these diseases, Dr. James Shannon, director of the National Institutes of Health, asked MIT to establish a new school of medicine. The Cambridge-based institution already had the highest number of NIH fellowships awarded to any university without a medical school, and was rapidly expanding its programs in biomedical engineering and life sciences. Even so, the leadership was not convinced that it was worthwhile to invest so heavily just to increase the number of physicians.
Instead, they chose to focus on developing a new kind of physician, one who could systematically integrate and exploit the full power of modern science and technology—imaging, biomicroelectromechanical systems, materials science—into clinical research and ultimately into the practice of medicine. Rather than reinvent the wheel—or the medical school—MIT began to explore, eventually with resources from the Commonwealth Fund, the idea of an alliance with the medical school at Harvard.
In 1967, the two institutions set up a joint committee on engineering and living systems to consider the desirability and feasibility of establishing a joint program. Three years later, that program was launched with a fairly simple concept: physicians in training would be exposed to serious work in medical engineering and medical physics, and physical scientists and engineers in training would be initiated into clinical medicine through classwork and clinical rotations alongside medical students. The program offered an M.D., M.D./Ph.D., as well as Ph.D.’s in medical engineering and medical physics. Over time, additional programs were established in biological informatics, even bioastronautics. In 2002, HST established a Biomedical Enterprise Program in conjunction with MIT’s Sloan School of Management.
Like-minded institutions established more recently, such as Cal(IT)2 and QB3, a partnership among the University of California, Berkeley, the University of California, San Francisco School of Medicine, and University of California, Santa Cruz, focus more on the mathematical, informational, and electronic end of the spectrum of convergent disciplines. At HST, however, the intellectual anchor has always been the tangible reality of the patient-clinician bedside interaction, and the day-to-day constraints and opportunities of that exchange.
Since its inception, HST has graduated 1,267 students, 75 percent of whom now hold faculty positions at 70 institutions in the United States. Notable alumni range from former FDA Commissioner Dr. Mark McClellan, who, through the program, received his medical degree from Harvard and Ph.D. in Economics from MIT, to Dr. Peter Diamandis, who received his medical degree on top of an MIT undergraduate degree in aerospace engineering. Diamandis then went on to found and direct Zero Gravity Corporation, which offers the experience of weightlessness to the general public through 90-minute sub-orbital flights. Other companies launched by alumni include Cambridge Heart, NeuroMetrix, and Apex Surgical. Among HST’s 64 current faculty, the average number of patents is 11 each.
“One of the big problems in the whole of the life sciences is the very Balkanized way in which not only the basic research and development gets done, but essentially the way the industry follows that same model,” says Pisano. “Everybody does a little piece, which they inherit from the academic world.” Pisano and Gray both note that traditional departmental structures in academia maintain a “guild-based” reward system that, in effect, imposes disincentives for pursuing objectives outside one’s narrowly circumscribed discipline. Assistant professors of internal medicine, for instance, would not necessarily gain credit toward tenure for research and publication in chemistry or engineering.
The business world has worked to overcome intellectual fragmentation by finding people to mind the big picture, Pisano says. “In computers,” he notes, “there are lots of people who worry about components, but there are also people who are called architects, who worry about integration,” he says. That is also the case in aerospace, automobiles, semiconductors, and in software. “These architects are not necessarily experts in each of the little pieces, but they really understand the interactions.”
For its part, HST has attempted to create the kinds of “systems architects” in biomedicine who could bring all the moving pieces together in healthcare innovation. To do so, HST requires that Ph.D. candidates in engineering or applied mathematics take basic science courses at Harvard Medical School. They then go through three preceptorships, which are six-week rotations at Harvard-affiliated hospitals. But they do not merely observe. They engage, just as if they were training to become physicians, in learning such basic aspects of clinical practice as taking a patient’s medical history and administering a physical exam.
“You can’t escape the power of it,” says HST’s Erez Lieberman, a Ph.D. candidate from New York City. And the benefit for an engineer is particularly profound, as Lieberman explains, because within the context of biomedical innovation, solving any given problem is actually secondary to knowing what questions to take on. “The hard thing is problem choice,” he says. “One of the most powerful pieces of myself as a researcher is to be able to sit in the driver’s seat and say that this is really the problem that is going to have a big impact.”
What are the things that doctors know that the engineer needs to know in order to communicate with them? What is the cycle that a patient goes through in a hospital? Who is paying, and at what point does cost become a barrier to care? “These are the raw facts on the ground,” says Lieberman. “Once you’re familiar with them, they inform your judgment about what is most clinically relevant.”
For her part, Sienko, one of the India program’s pioneers, says the debate over information transfer and global competitiveness never crossed her mind. “Coming from a medical standpoint, I just want to provide care,” she says. But like fellow HST student Lieberman, she says having the firsthand, clinical experience HST provides is important in selecting what projects to focus on, all the more so when the population to be served is very different culturally and economically—and living on the other side of the planet. “One of the most challenging things is sitting in a first-world seat, attempting to design for a developing country where you’re not familiar with the environs or the context for how the equipment would be used, and you don’t have a real assessment of their needs.”
Now an assistant professor of engineering at the University of Michigan, Sienko also warns against the dangers of technological tourism or, as she terms it, a “hit-and-run” philosophy. When she was in India, she often came across equipment left by other students from other Western technology programs, including a handheld device to collect medical records. “The Indians showed these to us, and they looked like relics from a museum,” she says. “They weren’t designed for the actual needs of the user, and—no surprise—the users had abandoned them.” She says that a situation in which researchers and professionals are constantly taking from one environment and learning, but aren’t exchanging with their foreign counterparts, is not going to be sustainable.
As an engineer, Sienko says that knowing how medicine is actually practiced globally will be an invaluable aid in avoiding such mismatches. And in India, the need to create devices that are simple, durable, and low cost is reinforced everywhere you look. “Patients there are responsible for paying for their own medicines as well as for blood chemistries,” Sienko says. “In the case of cardiovascular procedures, not only was balloon angioplasty chosen over stents to save expense, the balloons, which are designed to be disposable, were often reused.”
Sienko’s own research is directed toward producing a low-cost monitor to assist patients with impaired balance owing to brain injury or disease. Pager motors like the ones found in cell phones are put on an array around a person’s torso. Depending on how the person moves, the pagers vibrate at certain points. “If you lean too far forward, you’ll get a vibration on the front of your body, which is your cue to move away from the vibration, which will silence it,” she says. “Balance becomes a game of keeping those sensors quiet.” Such a technology could be as adaptable to the needs of a wounded soldier coming back from Iraq as it is to an Indian farmer recovering from a stroke.
Despite the serious financial constraints India faces in trying to treat its population of 1.13 billion, the amount of money available for research and development in the country is increasing at a rate of 400 percent a year, notes Shiladitya Sengupta, an HST professor at Harvard Medical School. “In India we say that we don’t need money,” he says. “We need partnerships. That is why we are trying to create bridges to develop capabilities and collaborative ventures.”
And as Sengupta adds, the new translational institute being established near Delhi will serve the West as well. There are regions in the U.S., such as rural Mississippi, he says, where communities have challenges that are not entirely different from those in rural India. “Certainly, there is the need for affordable technology,” he says. “Funding institutions like the NIH want to partner to get more bang for the buck, and the Indian government is putting up the bucks.”
As for Gray, she agrees that what’s crucial is finding ways to capitalize on technology to improve global health by making tools and providing services that cost less and that are more adaptable. As to the specific nature and scope of the HST/India alliance—fellowships, internships, corporate partnerships—“This is the stuff we have to figure out,” she says. But 40 years ago, bringing together MIT and Harvard Medical School across the Charles River seemed like a daunting challenge, with competing interests in every academic department and hospital service. “Ultimately, all we are trying to do is to create the same sense of community across the globe that we have succeeded in creating across the river.”