Project ECHO was actually created in 2003 and one of our goals was to reduce inequity in cancer. But I got the idea of Project ECHO actually when I saw a patient in 2001 and she was a 43-year-old woman and in the room with her was a 14-year-old boy and a 9-year-old girl. I asked her, ‘How can I help you?’ She said, ‘I have hepatitis C and I want treatment.’ So I said, ‘We’ll do that. How long have you had it?’ And she said she’s had it for eight years. So I said, ‘Why did you not come earlier for treatment?’ and she said, ‘I live 200 miles away and your nurse told me that I would have to make 12 trips, 200 miles each way, to see you while getting a chemotherapy-like treatment.’ At that time treatment of hepatitis C was these weekly injections and pills of interferon. She said, ‘I’m a single mother, there is no way I could make 12 trips to see you. There are no specialists in my rural area.’ So I said I understood why you didn’t come, ‘Why did you come today?’ She said, ‘I’m having pain here in the right upper side of my abdomen.’ I did an ultrasound and she had a cancer of her liver this big and she passed away six months later leaving these two children.

So I was asking myself why did she die of a disease that I knew how to treat and it was a preventable cancer. The answer I got was she died because the right knowledge didn’t exist at the right place at the right time and she didn’t have the ability to get to the right knowledge.

So in the state of New Mexico in the US where I live there were 28,000 hepatitis C patients and only 1,500 had been treated. So I developed Project ECHO to democratise my expertise. I said, ‘I have to create more experts that can actually take care of this disease,’ and I said I would use technology, and there was no Zoom at that time, so we bought a used telecommunication bridge, put it in the basement and created something like Zoom in 2003. I went around the state of New Mexico and found primary care clinicians who would be willing to treat hepatitis C if they knew how and I shared my protocol with them but they said, ‘No, we can’t do this. This is chemotherapy and we are not trained to do this even if you’ve taught us.’ So I asked myself how did you become an expert in treating hepatitis C? When I did that I realised that when I did my Fellowship in Boston in Massachusetts I would see a patient present to my professor, see another one present to my professor and after two years they started calling me a gastroenterologist. So I said, ‘Aha, I’m going to use this model to create new hepatitis C experts in New Mexico, in every place,’ so that patients could have access to treatment right close to their home.

Using digital technology I created the first community of practice where on a Wednesday afternoon all 21 would join on an interactive video network and one by one would present patients of hepatitis C to each other and to me at the university. So first Claire would present a patient, then Saira would present a patient, then John would present a patient, and over two hours we’d discuss eight patients and 15 minutes I’d give them a lecture. What we found was in one year they became experts. The wait in my clinic fell from 8 months to 2 weeks, anybody could get access to treatment in their communities.

This was a game changer because now we had demonstrated that for a very complex problem you could really amplify access to care, which we call force multiplication, and that had occurred.

This was really proven in an article we published in The New England Journal of Medicine in 2011 where we were able to show that these rural doctors could provide as good care as safely and as effectively in a rural setting as the university. Once we did this there was interest from all over the world to actually deploy ECHO for cancer. So we started training other hubs or universities in the world, other not for profits like the American Cancer Society, like the MD Anderson Cancer Center and Memorial Sloan Kettering etc., on how to deploy ECHO to improve cancer care. Currently we have 180 hubs, academic centres, not for profits, ASCO is another ECHO hub, where they deploy ECHO to democratise the expertise using this digital technology which is now the Zoom platform but there’s a software program called iECHO which they use to help learners acquire this knowledge very quickly. The iECHO platform supports these universities and academic hubs to evaluate their programmes on a regular basis and to really do what we call force multiplication.

So that’s one use of digital technologies we have right now and we have close to 800 networks running for cancer-related issues, specifically with the idea of reducing inequity. Many, many publications demonstrating the effectiveness of ECHO now to produce a more equitable healthcare system all the way from prevention of cancer, smoking cessation programmes, vaccination programmes, cervical cancer early diagnosis, breast cancer early diagnosis, treatment, cancer genetics, pathology, cancer treatments, survivorship care, palliative care. So the entire continuum can be managed and this is particularly important in areas where there is no superspecialist, where generalist doctors have to do a significant amount of cancer care and others and where the entire workforce from ASHA workers to nurses to nurse practitioners to primary care doctors to specialists can be upskilled to provide care close to their home.

What are the future plans?

We currently work in 209 countries and areas and territories all over the world and our goal is to reduce cancer disparities in all parts of the world. A challenge that we do have to overcome is to ensure that all the relevant medicines are available, all the relevant vaccines are available. A subsequent challenge that we also need to encounter is as new technologies such as ultrasound or other diagnostic modes, mammography, easy lung cancer screening, are developed, that these be low cost enough that they can be deployed for people who have the greatest need, that is the low- and middle-income countries in the world.