This article first appeared in Unlisted, digitaledge Weekly, on September 14 - 20, 2015.

The ancient Egyptians, obsessed with the afterlife and a leading civilisation in the field of medicine and surgical techniques, used to remove internal organs of the dead in a mummification ritual, with minimal incisions to avoid causing major damage to the external body. 

The idea was to prepare and preserve the body — a vessel for the soul — for its descent into the afterlife as without a body, the soul would not be able to continue existing the way it had while he was still alive, for eternity.

But with the advent of modern medicine and technology, less importance is given to preserving the sanctity of the deceased’s body, with post-mortems having little regard for treating the dead with the same respect as the living.

However, Matt Chandran and his team of experts at iGene Sdn Bhd, a medical informatics company, are determined to change how post-mortems are done by reducing or, in some cases, even doing away with the need for surgical incisions as a means of determining the cause of death.

Aptly named Digital Autopsy, the process is speedier than a classic post-mortem which, as Chandran points out, has not evolved very much from the methods employed by Italian polymath Leonardo Da Vinci, who performed dissections on the human anatomy more than 500 years ago.

Chandran, founder and group CEO of Infovalley Group, which specialises in life sciences, made headlines in 2013 when Agensi Inovasi Malaysia (AIM) pumped RM70 million into subsidiary iGene, making it one of the largest venture capital investments by the government body. 

Conventional post-mortems are done by slitting open the body cavities from the neck to the pelvis in one long, clean cut. Then, the organs are examined, one by one, and the parts removed, weighed and sent for toxicological studies. 

At the end of it all, the skin is sewn up, with the empty chest and abdominal cavities hidden from sight. This is the main reason people refuse consent for an autopsy if given a choice. 

Like the ancient Egyptians, religions such as Islam and Judaism teach that bodies should be buried as soon as possible after death, and must not be defiled. 

In countries like the UK, prior to the introduction of digital autopsy methods, the devout were allowed to opt for alternative examinations of their loved ones, such as having pathologists use a Magnetic Resonance Imaging (MRI) scan of their remains. 

As such, conventional post-mortems are not conducted unless coroners overrule the request if they believe the cause of death could not be concluded through an MRI scan, commonly used to look for tumours and abnormalities in the spine. 

Post-mortems, however, play a vital role in determining the cause of death and in medical education. A commonly recited verse is mortui vivos docent or “let the dead teach the living”, to justify the dissection of human cadavers.

“A post-mortem starts only when a death is classified as unnatural. There are seven billion people on Earth and in the end, everyone must die,” says Chandran. 

Citing figures from the World Health Organisation (WHO), he points out that at least 70 million people die every year. “And of the 70 million, an absolute minimum of seven million are subjected to post-mortem because their death is suspected to be due to unnatural causes.”

With the quantity pathologists have to deal with at the moment, Chandran describes the conventional practice as “butchering” rather than a proper cognitive process. “The best educated individual should be deploying his thinking power and not spending time on laborious activities.”

To make the medical process meaningful and to ensure that post-mortems are less distressing for those who have lost a loved one, iGene has developed a three-dimensional (3D) visualisation software and a modified whole body scanner known as the Multi-Slice Computerised Tomography (MSCT).

The digital process, which replaces the scalpel with a non-invasive process, uses imaging technology to scan the whole body and capture the data needed for the post-mortem within 10 minutes — from the time the cadaver is put through the CT scanner to capturing the 3D visuals of the body.

The built-in software then captures the raw data, which enables virtual dissection of the digital body in high-definition visuals, rendering the conventional neck-to-pelvic dissection unnecessary.

“The post-mortem examiner can peel off the skin, layer by layer, or view the bones and muscles. One can turn the body up or down at will. None of these are possible in a regular autopsy because the body of the deceased is so heavy,” says iGene’s senior forensic research scientist Dr Vinay Hallikeri.

The digital scalpel allows the pathologist to rotate the image and peel away layers of the body without harming the remains of the deceased to have a microscopic view of the body tissues and organs. 

“Say the examiner wants to observe the muscles. While this is not possible in a classical autopsy, using INFOPSY [the software iGene has been developing since the inception of Infovalley in 2000], the pathologist can zoom in and view individual muscles and the skeleton in high definition, which is made up of about 3,400 slices of 0.5mm each,” says Hallikeri while demonstrating the capability of the equipment.

“Say the medical examiner suspects something was wrong with the kidney of the deceased, he can digitally dissect at will and make a cross-section, as well as rotate the kidney to check the abdominal aorta — the biggest artery in the body — to check if it was supplying blood to the kidney. If the deceased had hypertension, it would be a flea-bitten [pockmarked] kidney,” he adds. 

This way, the remains are not harmed in any manner, and the examiner is able examine and view the full volume of the body repetitively as the data is saved to a secure file on one screen. 

On a second screen, the examiner can mark any areas of interest in red to follow up on. In cases where there is a suspicion that the death is a result of a crime, the scene of death or crime can be reconstructed digitally in 3D using panoramic photos taken at the scene. In such circumstances, the binary data and 3D images captured can be remotely accessed by the courts. 

“You can bring back the same feel instantly, as opposed to procedures before this, when the body was cut opened — it’s irreversible. If I remove the body from the covers, there are stitches on the body. It is so distressing to the family, which we don’t want,” Hallikeri says. With a simple click of the mouse, everything can be reset to its original state. 

However, deaths due to poisoning or blood clots cannot be detected by the scan. But this is not a limitation, says Hallikeri, as such conditions just require a minimal incision or blood sample to run tests. 

Digital autopsies, however, were not Infovalley’s first creation. Under the group’s other initiative called Life Sciences Sdn Bhd, Chandran’s team of biotechnology and medical experts worked on developing a thorough molecular screening service.

Molecular screening, commonly referred to as DNA testing, is a genomics-based concept, which enables thorough screenings, diagnostics and prognosis of one’s genetic predispositions. While it enjoyed some success from the molecular screening service, with a plethora of private hospitals adopting it, iGene’s innovative digital autopsy solution is effectively its killer app.

iGene was being developed at around the same time as the molecular screening service, but the former received a RM5.42 million R&D grant from the Ministry of Science, Technology and Innovation, under the Techno Fund, in 2005. It also attracted the attention of Malaysia Venture Capital Management Bhd (Mavcap), which invested RM7.5 million in 2007. 

With the series of funding, iGene fitted its first fully functional digitised equipment in Hospital Kuala Lumpur (HKL) in 2010, funded by the Malaysian government. According to Chandran, as at December last year, more than 2,500 post-mortems have been conducted at HKL using iGene's digital scanning tools.

But the company hit a brick wall after the installation in HKL, as no other hospital was willing to give the new technology a chance. This was despite an edict issued by the National Fatwa Council in 2006 recognising virtual autopsy, which uses an MRI scan, as a go-to procedure in the event a post-mortem is required to determine the cause of death. 

This derailed Chandran’s plans for local expansion. But as one door closes, another opens. So, he worked on expanding abroad. 

With AIM’s RM70 million investment in 2013, iGene made a breakthrough in the UK by scoring a 20-year contract to build 18 state-of-the-art digital autopsy facilities in the region.

There are 550,000 deaths a year in England and Wales alone (excluding Scotland and Northern Ireland). Of that figure, 220,000 are referred to the coroner for examination. But the numbers are pretty overwhelming and there are fewer than 100 qualified pathologists in the UK who can perform the required examinations.

“The 220,000 cases are divided into two sub-categories. Comprising 120,000 cases, one of the sub-categories only goes through an external examination, meaning it was concluded that the body would not have to be cut up. But for the other 100,000 cases, which go under the knife, there is an opportunity to present it in a better way,” says Chandran.

iGene London Ltd, the UK subsidiary of iGene Sdn Bhd, built a £3 million (RM19.9 million) facility at the Medico-Legal Centre in Sheffield, England, in 2013. Two more facilities, in Bradford and Sandwell, have been completed since. 

Each facility is equipped with its specialised scanners. The company also trains and supports the pathology team in the districts where the facilities are located.

The entire UK contract, which is expected to be completed in the next couple of years, is anticipated to cost iGene £50 million. “We are like the North-South Expressway of the UK,” Chandran quips, referring to Projek Lebuhraya Usaha Sama Bhd, the largest toll expressway operator in Malaysia, which has several decades-long concession contracts. 

The company reached another milestone last year when the Sandwell council in Birmingham became the first local authority to offer the service to residents in their locality free of charge. The other councils, in Leeds, Bradford and Sheffield, charge £500 for the service. 

The cutting-edge equipment can also be used in medical education and surgical simulation. 

“Once the whole network is completed, our actual numbers show that a minimum of 70% of the cases can be completed using digital autopsy alone. Only about 15% to 20% of the cases require minimal incisions in targeted areas. So that brings us to about 85%,” says Chandran. 

“The remaining 15% of the cases will require both procedures to have a better understanding of the remains before the examiner begins cutting. And we are okay with that because we think that by cutting up the physical body, you actually improve your skills as a pathologist. But you don’t need to cut 100,000, 200,000, 300,000 bodies.”

Chandran points out that one’s thinking power is reduced when doing a repetitive task, whereas a pathologist doing quality work on a cadaver deploys 80% of his time and effort on thinking and only about 15% on the cutting proper. “Right now, 95% of your time is cutting, only 5% is thinking or hardly any thinking is involved,” he says. 

Getting on board the life sciences train

Despite being involved in an advanced and high-tech medical sector, Chandran was not a trained in this field. He graduated with a degree in biochemistry and chemistry from Universiti Pertanian Malaysia (now known as Universiti Putra Malaysia) in 1992. 

Having grown up in Kampung Baru Ulu Tiram in Johor, Chandran says he has always had an innate curiosity about how nature works. This, plus some acumen in the field of inorganic chemical analysis, eventually saw him drawn to the field of life sciences. But the journey was not a walk in the park. 

Upon graduation, he joined the R&D division of Metacorp Bhd — the chemicals subsidiary of the Renong group of companies — as a chemist. He went on to win the Inventor of the Year award in 1995 for leading a team of scientists from Metacorp and Petronas Research and Scientific Services for R&D in zinc-based catalysts for natural gas treatment. 

Subsequently, Chandran took up the position of regional business manager at Hong Kong-based Peregrine Direct Investment, which gave him exposure to the international market. From there, he went on to serve as a regional manager for UCB Chemicals Asia Pacific. It was after leaving UCB Chemicals in 2000 that he decided to become an entrepreneur.

“If you remember, 2000 was the ultimate year for the human genome project and Y2K problem. While Y2K was the pinnacle for information technology, the human genome project was like opening the Pandora’s Box of DNA,” he says. 

“These two things took Europe by storm. I was there at that time, and I witnessed how it actually impacted people, the importance of it. And Asia was being left behind. But Asia wasn’t immune to it.”

Chandran knew that it was simply a matter of time before Asia hopped on board as well. “It had to happen eventually,” he says.

He saw an opportunity. He was a budding entrepreneur and he understood the scientific language employed. “I’m not a scientist myself, but I do understand the connections.”

The idea behind iGene was conceived when he was bouncing off ideas with someone he had met while attending a conference in the US at around the same time. “We were talking about some of my ideas and he brought up the fact that post-mortems were still being conducted in a very old-fashioned way. He pointed out that probably [it could be done better with] the use of imaging and suggested that I should probably be looking into this. But at the time, I knew nothing about forensics,” says Chandran.

But this sparked his interest and he did some research on the internet. When he shared this conversation with Hallikeri and his other colleagues, to his surprise he found that Hallikeri as well as another doctor actually specialised in forensic medicine. What followed seemed almost inevitable. “The rest, as they say, is history,” he quips.

Although his product has gained traction in the UK, the company is not standing still. Chandran is chockful of ideas. For instance, the company is considering developing a digital scanner for horses because, as he points out, the equine industry is a multi-billion dollar one. These scanners, however, will be for checking the health and performance of the horses, rather than for post-mortems.

Chandran says the Fédération Equestre Internationale requires pre and post-competition examination of the competing horses. But with the lack of the right technology, the process is not methodological and it relies on subjective observations. 

“There are usually two or three guys, who claim to be horse experts, who will observe the horse while it walks and trots to check if it is limping. Then, they will deduce if the horse is sound,” says Chandran.

“We believe a digital scanner will resolve all of this by using quantitative and visuals to provide an objective assessment of the overall health of the horse for performance.”

But such a venture would require equipment that is able to accommodate a horse weighing between 400kg and 800kg. There are also some kinks to be worked out.

“You cannot sedate a horse before competition … So how do you digitise a horse in its natural state? Also, the horse gets spooked easily, and when it does, it kicks. If the extremely expensive scanner is in the way, it is bound to break,” he says.

Nevertheless, the project has been in research for the last 1½ years as it requires iGene to come up with not only the software but also the hardware.

As for iGene’s digital autopsy services, following its success in the UK, Chandran is now looking to expand to the Middle East and the US. The facilities that were constructed in the UK and upcoming facilities in the region are mapped against existing post-mortem facilities.

“This is so we don’t have to chase the bodies; the bodies are being handled and managed in the same locations ... so, these are the catchment areas. All we have to do is build up our facilities in those locations and seamlessly integrate all of them, so that the pathologists … regardless of whether they are within our facilities or not, can conduct the post-mortem digitally,” he says. 

Chandran hopes to build an ecosystem that will serve as a hub to support global demand. “If I build the computation capability in Malaysia, Abu Dhabi, San Francisco and Sao Paulo, that covers about 60% to 70% of the global need,” he says. The company is in the midst of finalising a turnkey deal with the United Arab Emirates capital. 

“Once there is an ecosystem like ours, we are not going to be just a post-mortem service provider or a digital autopsy servicer; we are going to operate like a national registry — confirming and documenting death,” Chandran says.

“While we accept that conventional post-mortems will remain the gold standard for a long time, and that’s how it should be, nothing is stopping digital autopsy from emerging as the best practice. I can tell you that digital autopsy is already being embraced as a best practice.”