Digitizing Health Services in Nepal and the Importance of Primary Healthcare

Welcome, I am especially excited for this conversation because I have been intrigued by UpaCare for quite some time. And in particular, I'll tell you why I've been treated because the idea of working with my wife has been a bit a bit of a dream of mine, I wish. I love the idea of seeing it and seeing it flourish and seeing that seeing it succeed. So without further ado, I would love for us to get into into some introductions, so I'll leave it to you. And so maybe we'll start with you.

Yeah, sure. And so Hi, I'm Sumitra. I am CEO and co founder of UpaCare. A little bit of background about me. So I was born in Nepal. But I grew up mostly in the UK. And I went to secondary school and did my A levels in London. And then I moved to Bristol to study medicine at the University of Bristol. And that's where I met Nav.
Yeah, I guess I'll bring that onto me. So. So I'm Navdeep, but Nav is cool. So I'm the co founder and chief medical officer UpaCare health. I was born in the UK. Before I went to Bristol, I did an undergraduate degree in microbiology and immunology. So after I finished that in Newcastle, I then went to Bristol studied medicine. And that's I assume you said, where, we both met.

Wonderful. I've got a little bit another further connection to the two of you, my older sister is an anesthesiologist as well. Little familiar with, with the sheer amount of work that it took for her to to achieve that profession. So definitely, definitely a warm spot for us. And, and I remember very early on in her career, it was very much so like so Wait, are you just responsible for the drugs and putting us it's all you do, you don't do anything else. So that became quite a sore spot for her. I'm very familiar with the depth of what the field entails and know for a fact that I should not just limited to that because my older sister will get quite angry with her little brother.

Don't worry about it. And so I specialize before I started doing UpaCare my specialty was anesthesia and ICU. So essentially, people tease me that, you know, I just talk them to sleep I don't even need to give them drugs.

But the ICU component in that is absolutely what should be at the forefront of that role in terms of Listen, when you hear Code Blue, and you hear that someone's crashing, who do you think comes running little brother?

You know, it's interesting. I'll pivot to our next question cuz you've already kind of touched upon it and that the both of you have met in school, I'll say again, with my sister, she's going to join the fact that I'm dropping her in there, Dr. Malik, within, in the Toronto area. So she met her now husband of more than a decade. Also in medical school. He's a surgical oncologist. So I get a sense of, you know, kind of, I think that's a bit of a common story. But with the two of you, as you as you met in school, different different programs, different different fields of specialty. How did you guys actually come to start spending a little bit of time together? And obviously a lot more time together? 

Yeah, I was gonna say, I guess the whole meeting your partner med school is quite common, but common. Spend such a long period of time working together. So when we were at uni, I guess we were actually in different years. I met more on socials, didn't we? I think I'll let Sumi take this story, because I feel like she tells it better than me.

I don't tell it better. But we basically met at to what's called like a medics bar crawl. Do you have that America? 

Absolutely. I mean, I mean, I'm sorry. Sorry. No, I'm not familiar with the concept. Perhaps that's a British thing. But yes, yes.

Yeah, essentially. Yeah. So Nav, we will be both this is like a big social event in Bristol. It's a bar crawl. So you know every year and you kind of go as like a different themed person. So if you're a fresher, if you're a first year you have to wear nappies. Second year go in pink and if you're a clinical year, so that's sort of like third to fifth year. You go in scrubs. So yeah, so we basically have the bar crawl, I kind of walked into the pub, and I remember seeing Nav like I've never seen Nav before that despite the fact that we were in school they city. And there was a bit of like, Oh, who's that, but then nothing else really. And I saw that he was in pink. So I was like, Oh, he's young, like, and he looks young as well. He looked looked young. So but then he came up to me and started talking to me. And initially, I kind of ignored him or tried to, didn't want to, and eventually ended up giving my number. And is this a rest is history? Yeah. That's the short version. 

I know, I can appreciate that. I can appreciate that. I think I'll say for myself, in terms of my wife, there was absolutely the tenacity that I would say that I put into pursuing her. And then at the best, she was gonna give me coffee, and I pushed and made sure that that was dinner. And then as to steal, you steal your to steal your line, and obviously, yeah, the rest is, is history as my little guy is upstairs. And so things are going okay. Now that so obviously, with that, let's skip ahead. The idea of UpaCare an interesting one, maybe give us a little bit of background, maybe give us you know, give us some background in terms of the vision, the philosophy, and then how that came about the idea for it?

Absolutely. So I guess for those that don't know what UpaCare is, it's a hybrid digital primary health care model. So that means we do sort of primary health care. But at the core of it, we've got a digital platform. And we use tech for our patients, to basically make their lives easier and make healthcare more seamless. The way we initially started, so actually, it started about five years ago now. Sumitra and I went to Nepal to visit family and friends. And we were like, massively inundated with friends and family who kind of wanted us to look at their medical investigations and medical records, and kind of help them understand what was going on and what their conditions meant. And it became really clear that there was, I guess, like chronic confusion about what the health care needs really were, they don't understand a lot of the conditions. But not only that, they're most people are burdened with carrying their own medical records themselves and looking after their entire family's medical records. So they've got to coordinate and manage everyone's health, which when you have a big extended family is a massive responsibility, especially if you're not in healthcare yourself. And it just became really apparent that things were really fragmented and disjointed. And we both realized that primary care would solve a lot of these problems. So for for those who don't really know much about primary care, it's kind of very well established in the UK, and in countries like the US, Australia, in the continent of Europe. And we know from lots of research from who that actually good primary health care infrastructure will give better health outcomes to the population and reduce morbidity and mortality. So we know that countries that have good primary care, we know it works, it works for those countries. So for example, if I was in the UK need to see someone, I would go to my primary care clinic, because they know me, they've got my data. It's local. And it's run by generalists who are really highly skilled at addressing a broad range of medical problems. And normally 90% of that can be covered in the community in primary care without you even needing to go to hospital. But when you do need to go, they'll refer you so your data is sent to the hospital. And once a specialist has seen you, they send it back. So there's that loop that ecosystem for help. So data isn't lost, and it's not put on the patient to have to manage the in between. And that's what we felt in a bar really needed. But I think a bit of a problem with the culture in the bar is the focus a lot is on seeing a specialist. So patients want to see a specialist for things. And of course, there is definitely a place for specialists. But there's also a massive place for generalists too. And they're equally important. So a generalist can help diagnose, like I said, a lot of problems in the community without even needing that secondary care. But also they can help coordinate the whole person care in one place as well. So there really is, you know, they're equally important, and there is a time and place for both of them. So that's generally how we felt that we needed to introduce primary care. And initially, we were actually going to introduce just analog clinics that just set up some clinics. And then we talked to our other co-founder, Sandip, who comes from an engineering background is very creative and tech savvy. And he was basically saying, well, actually guys, like yes, primary care is needed. But if we can digitize it, and make this like a hybrid model, then we can serve the population better and make it a lot more accessible. So that's when we then got in touch with Fusemachines. And yeah, so UpaCare was born.

Right? I mean, that's brilliant. You've absolutely made me recognize that I have at times and I try not to any more take for granted having trained physicians in the family. There are there's times I remember distinctly I hurt myself ridiculously playing basketball and spraying my spare my finger to just an awful comical degree. And then as I always do I call my sister and within her network, you know she can get me into her hospital what have you but I have been playing in an area that she, she's like, Sorry, dude, I haven't haven't worked in there, you're just gonna have to fend for yourself. But it is it is something to be said about fending off fending for yourself is what most of us most folks have to do. And you have to pay attention you you've got to understand that perhaps you're not getting the best care, perhaps this person is an expert, your own records, your own medication, I know, you know, our family has to pay attention, my mother is you know, has quite the cocktail that she needs to pay attention to. But you're kind of left to your own, we do have access to that to those digital records, we've got the access to that information. And you know what, how much relief and calm that would give you if you knew that you were you're you're being taken care of. It's daunting, you know, I'm the computer guy, my family, have tons of questions about computers or cars, asked me but in this incredibly important avenue, you guys are able to provide that that access to folks that don't have, you know, a doctor married to another doctor in the family as I do. That's, you know, that's exciting.

Yeah. And, and, you know, even even if you were a doctor, for example, you know, if you are an orthopedic doctor, your specialty is orthopedics. So if you go to them, and they are you know, there might be a brother or whoever, and you say I've got muscle ache, because the way they see things is, you know, very much tunnel vision, they know a lot about orthopedics, but you don't necessarily have that general knowledge, right? To have what what a generalist would have. So you can go into this, like a tunnel vision and, you know, think it could be this this this stuff orthopedic related, when in fact, it might just be that you've got a generalized infection. And that's why you've got not just that, yeah. Yeah, it's not knowledge that a generalist have that maybe when you seek a specialist, you may not necessarily get the same knowledge, you'll get brilliant knowledge. 

Absolutely, it makes makes perfect sense that you, you need that kind of connective tissue. And someone that can can step back a little bit not be hyper focused in that area, ya know, that makes perfect sense. Now, obviously, the connection to Fusemachines. And, and we're going to be working together, maybe you can give us a little bit more detail in terms of what the scope of work is going to look like, and how how UpaCare and Fusemachines are going to be working together. 
Yeah of course. So, as we mentioned, were sort of a hybrid model. So from the onset, we wanted an interdisciplinary approach between like health professionals and computer scientists, to sort of create the future of how healthcare is going to be received, we've actually already started working with Fusemachines. So we started working with them back in summer. And we've been discussing how we can use tech and AI to automate workflow processes, make healthcare seamless, and also look at how we can incorporate AI, and look at tagging data. So in the future, we can aid in diagnostics, primary target with us really is to make sure that whatever we're developing is giving the patient signals health care, and making life easy for both doctor and patient. But also, we want the software to be impactful and make a big difference, I think with Fusemachines, where things have worked really well is that they completely understood our vision from day one. And they absolutely matched us with passion. So they matched us exactly how we wanted and passion. And I think because of that we've worked really well together. It's been really fun, creative and innovative. And it's something I think both teams are really proud of what we did. 
And the impact is what's really, really striking for me in terms of what you're going to build. I mean, obviously, I'm getting ahead, but the idea that that what you're building can can aid in diagnostics, in particular, and in terms of adding an increased level of precision and adding speed to all that adding in that also for someone like me, a layman, being able to have access to that type of information in a way that makes sense for me with all those other factors is really exciting, because it's the scalability of AWS, I obviously in my role here, I'm getting way ahead of myself, I'm seeing you guys taking over the planet. But having said that, you know, that first step towards that vision and doing it in this use case, and, and perhaps you know, in that in one clinic in a in a series of clinics in one country in a series of countries. I mean, I'm really I see that as an absolute possibility, if not an inevitability that you've built it. And I know with the tools that we build, there's that scalability baked into what we build so you know, your vision done in a way process. The process builds out the technology built out the reusability built out, but it's interesting because the tools that we build, may or may or may may not necessarily have that type of a social impact to health impact people impact truthfully, this, you know, a client needs something will build it this one I think is I'll speak for I'm very connected to kind of our delivery teams and our engineers, you know, this one's kind of definitely, you spoke of that, that that matched passion. I absolutely can second that in that I've had the conversations with the teams and I know that again, working with you and and reason why I wanted to make sure that I was excited to have this conversation, because we've been talking about you guys for since since the you know, since the summer. So quite excited. Hopefully. It's it's just been a very organic, very, very, it's the passion just gets baked into into the work. And I mean, what else do we all kind of want to do with it? You know, we, we want it we want to come to work, energized. But if you're working on something, it's going to have that type of that impact and the potential to have pretty significant impact where we're all we're all very excited here.
You know, fingers crossed.

Yeah, fingers crossed. But no, I think I think, yeah, I think we've got a lot of a lot of a lot of belief in your leadership. And we've got a lot of belief in our team, as well. You're gonna get us to the finish line here.

Absolutely. I mean, it Fusemachines team have been brilliant. Yeah. Without a doubt. Yeah. Yeah, definitely.

So we've spoken about kind of the current state of primary care, or, I guess, the current state of health care in Nepal. And we spoken about kind of what your vision for primary care in Nepal, that digitization seems like a simple aspect, but why why is it important to get to push digitization within within healthcare?
Well, are you taking this one? Yeah, okay. Okay. Yeah.

So I think I mean, digitalization is the future. And you know, all other industries have innovated and evolved to reflect how as societies we communicate, but also how we  receive services. So from how we get our money to even how we get our groceries. I think healthcare has lagged a bit behind in innovation, and there is a lot of opportunity to make a big impact on population health, throughout the power of people's smartphones, and changing that point of care. So through digitizing health, we can make health care more accessible. And although it is lagging, you know, we are seeing it evolve. And when we are implementing sort of digitization, it means that we are essentially needing less extensive physical infrastructure, we can streamline processes more and use resources a lot more effectively, which again, makes it more sustainable which is obviously very important, you know, the current climate and how things are. So I guess all of that means that really, that's why health care needs to get digitized, we need to sort of achieve all those goals.

Right? Yeah, I can also, one thing that I've heard recently, in terms of what's it's funny, I've just kind of looked at the last decade, and how quickly things have changed, I feel a lot older than then I feel like I should. And one of the other reasons was that again, that digitization of information, coupled with computer processing power coupled with access to super high speed internet, allows us to build out solutions that have been that we've dreamed about for 50 years. And and in this short time, this in this time period is gonna be quite an asymptotic rise to, to, to new solutions and new ideas that we're having. And I imagine that you guys are going to benefit quite a bit from from all of that happening. processing power is kind of the next way we get into quantum computing, and then being able to crunch numbers that much more, that much more quickly, going back to the diagnostics, you know, something that would have required 10, 15 years of education could potentially with, you know, with supercomputing be done through computer vision, and then that processing power is going to be it's going to be pretty, pretty interesting in terms of what we can we can do. I imagine you guys might have some other ideas in terms of how how technology in general can kind of help help doctors in terms of I imagine their applications for physical, psychological, social problems almost on a on a daily basis.

Yeah, so I mean, I think technology provides, like we discussed, it provides a different avenue by which doctors and healthcare professionals can reach patients. And that traditional interaction between physician and patient is no longer limited to the confines of a physical clinical consultation room. And technology allows for that continued therapeutic relationship to go beyond the consultation. So with our app to address as you've mentioned, sort of physical, psychological, social wellbeing, we essentially want to become a health and well being and lifestyle app that patients interact with on a daily basis. So it becomes an integral part of their everyday life. They can look on their app, for example, to get personalized, holistic care that is tailored just for them. So for example, meditation advice, nutrition advice, but also what medication they need to take that day, what things they need to do when their next appointment is so it kind of becomes forms, you know, essentially their health style guide really and something they interact with on a daily basis.

Right now that's that's really it because good Lord do I spend a lot of time staring at my phone, let the idea I flirted with, you know, health apps apps to help me with, you know, with with with diet and nutrition, I've had apps that have helped me with meditation, but the idea that not only would I have it in one spot, addressing all of those areas, but then having kind of the machine learning behind it, and have it be tailored, and not just be and I think there's there's, there's a benefit to something maybe just boilerplate written in stone and passed to me, I think I could benefit from something like that, but free for you to build something that's looking at, at me my life, my stress is my complete lack of self care. And be able to, to give me those those I imagined bite sized amounts of information that I can actually action on. I mean, it just, you know, these days, this week's been quite busy. And I'm, you know, I'm just trying to get done whatever I need to kind of get done and what the first thing that I that I sacrifice is myself in terms of in terms of care, but if someone just kind of digitally tapped me on the shoulder, and said, Hey, man this morning, just kind of take a couple of take take care of this thing. world's been obviously insane. The last the last few years, you know, you guys have both spoken about the, the the there's no limits right now, in terms of physical space, which I found really interesting. I've been able to build really, really strong relationships across an ocean, which I've always been been been shocked at, but also now I feel very connected to other parts of the world, my team in Nepal, my team in New York, and and you know, paying very much attention to kind of health, healthcare, overall health care of different countries. It's been it's been interesting to see what's what spiked, and what's, what's changed. And what has been interesting. And I think in our conversations with you, finding out the the the rise of non communicable diseases such as heart disease, cancer, diabetes, and the fact that those are now the leading cause of death worldwide. I mean, I might, my stats might be off, but I'm definitely significant, and representing, you know, an emerging global health threat, you know, and if I, my numbers might be off, but I, what I had last check was the death from NCDs, you know, had now exceeded all communicable disease deaths combined. And that's, that's, that's been shocking to me. Could you guys talk a little bit about that, that rise in NCDs, and how, how good primary care can stem from that?

Yeah, and of course, I think you have explained what NCDs there is beautifully, so essentially, is a group of conditions that are not usually caused by an acute infection. So, you know, previously when people died of infection or during birth, whereas now these NCDs, so chronic conditions like stroke, COPD and diabetes account for, you know, 71% of deaths globally, which is huge. And unfortunately, 77% of all NCD deaths are in low and middle income countries. So countries like Nepal, which which is really sad, because, you know, not only do these countries, you know, are affected by communicable diseases, but this is such a growing, you know, pandemic, I suppose, of non communicable diseases, but not able to meet the needs of the people to manage it almost. And the root cause of many of these conditions are lifestyle factors and genetics. However, lifestyle factors can be modified. And as such diseases can be prevented, and where this is where primary care really comes into its own. The therapeutic relationship that you established in primary care allows the clinician and their team to identify patients and their risk of disease. And so you can intervene early as a result of that. Whereas, you know, in contrast to say, for example, in hospital specialists, when you go and see them, you typically they typically only see patients regarding a particular condition in a snapshot setting. Hence, you miss this opportunity to intervene. A primary care physician who not only knows you, but also knows they, for example, your family's history or your social history, can look at you as a whole person rather than just a disease or you know, a chronic condition that you've come to seek help for. And hence, by optimizing that patient's lifestyle risk factors and their chronic illness, they will ultimately help patients to live their happiest and healthiest lives. And so I think it's very clear that a good primary health care isn't essential, almost precondition for any healthcare system. And so going forward it's clear that implementing effective primary health care infrastructure will just lay the foundations for essentially better health care for all. So this is why primary care can really help with non communicable diseases, not only help, champion it. Would you agree? 

Right. No, and it's so interesting that you say that you've made me recognize that. So my, I mentioned that my younger sister lives with my mom. So she lives in the house that we kind of grew up in. And, but she's what I what I found interesting is our, our primary care physician, the one that I had, as a as you know, in my youth, now see, my, my niece, and my nephew are eight. And and four so so with and but I didn't recognize because Dr. Tanaka knew me knew my family knew us knew how we grew up, knew what fields studied in school knew what our current careers, our new new lives in the area where we live in So has a really good sense of what the community is, like, has no end because I never realized this, but because he knows my you know, my family, so Well, my sister so well, that when it's time to start looking after her children, he will natively have that information and understand a lot more such that, you know, the greatest specialist in the world that you might have access to that see that gets your information, I'm not even sure what type of slice of information that they would get, doesn't have that history, like Dr. Tanaka knows, knows me knows my family, I've moved away. And he's not he doesn't take care of my family at this point. But the fact that, you know, he asks about me, he knows my sister, he, he knew my older sister when she was in, in school, and that she wanted to become a doctor. And he was, you know, kind of key in those early conversations with her so intertwined. Very interesting, I never made the connection back, that that is going to make him care for be able to care for my family and my extended family that much better.
Absolutely. And he's almost I don't know how to describe it, but he's big. When you call him a family doctor, that is what he is, right? He's, he's they're looking out for you. He's not just going to spend, you know, two minutes, because you're there to, you know, he's a condition. He genuinely like family doctors genuinely do care about you. And because involved in your life.

If you're lucky enough to have someone in your life. And I'll go back, I'll go back to the technology aspect of it, if I can empower my my healthcare providers with that much more information, ability to diagnose history, analysis, all of that, then, you know, then in those cases, even as much as they may care for my family, there's, there's, there's a limit to the cognition of a human being, you can enhance that, I don't think there's a world in which I'm going to be, I don't think in my lifetime, I'm going to be seeing of when I say a virtual doctor, or you know, some, an artificial intelligence to be taken care of me. But I absolutely do think in my lifetime to be enhanced by that and to have that human being had that extra information, all the all the better. It just, it just takes that one disruption story to come in. And then hopefully, ideally, kind of push everyone forward. But I am, I am excited to be attached, you know, connected to folks that are on the kind of bleeding edge of that.

So we were very excited. I think, essentially, this is where the world is heading. And, you know, hopefully we can be the pioneers in trying to do that in Asia, especially starting in Nepal. Just because, you know, technology, although we do have internet here. And you know, it can it's probably better than landline and things like that. But in terms of innovation doesn't always come from places like Nepal. So we're excited to be starting out here and getting to know the population here and getting to learn more about what affects the population here and how it is different from the Western world, for example. I'm very excited about it.

Yeah, I and you know, I'll piggyback on that a little bit in terms of perhaps the world isn't isn't as familiar with Nepal in terms of kind of our, our technology and engineering talent. But the one thing I absolutely see, you know, our engineers flourish now with that access to that training. We were very proud of our fellowship and the engineers that go through Sameer being our CEOs, Sameer Maskey being a CEO, our CEO, but being a PhD at Columbia, you know, for him to recognize that the quality of talent and the ability is on par with his students at you know, a preeminent School of Engineering is exciting. Yeah. So, you know, regardless of the project, you know, I think we're excited. There's there's never anything that we don't have the talent to do that, you know, yeah, I would absolutely put us up against the best of the best around the world in terms of machine learning and data talent. But we are also a services company. So we I, you know, again, like I've said 1000 times been in this podcast, but being tied to passionate people looking to make change, and have that vision. You know, again, our folks will absolutely be excited to help build that. I've really enjoyed our time together. As I said, before I had been I had been dying to finally get some face time with the with the both of you. And I, I imagine that you do need to get back to your to your day jobs back to your family, but I would very much want to follow up with and finish off with was what is next for UpaCare? And both of you specifically?

Yeah, so I guess from a business perspective, where our FDI is going to be through so we'll be launching as a UK company that are very shortly. We're looking now at managing operations and recruitment. And with regards to Fusemachines, were like continue to work with the app. We're we're kind of at the point where we nearly completed but we're just working on our MVP and working on things that we think are more essential. So yeah, so it's kind of an ongoing process. But it's kind of getting there now. So we're getting to that point where we're actually getting ready to start, which is quite exciting. Because we've been on we've been working on this for a while, so to actually see it to fruition is really exciting. 

Yeah. And on a personal level, we're obviously trying to do more playdates just like with Ruchi and other families, and get to know people in Nepal.
Absolutely. Well, Ruchi is one of my favorite people, not just at Fusemachines, but just in general. As one of my colleagues.

I can definitely see that. We've met her once and we are fans.

I'm going to be incredibly jealous of your playdate. And but, but again, wishing you all the best and I will be paying very close attention to to your successes and making sure to watch your story and sharing any of your successes, on our on our socials in my personal as well because again, just very excited for the work that you're going to be doing. Thank you both for your time. I know you're incredibly busy, but excited for your success and hopefully we'll talk soon.

Thank you. Thank you everyone. Thanks Ruchi, Lizzie. Bye now.