Telemedicine in developing countries
May have more impact than in developed countries

The advent of modern communication technology has unleashed a new
wave of opportunities and threats to the delivery of health
services.1 Telemedicine, a broad umbrella term for delivery of
medical care at a distance, has reached around the world, and now
health professionals can communicate faster, more widely, and more
directly with clients and colleagues, no matter where they are.
Telemedicine may in fact have a more profound impact on developing
countries than on developed ones. 

Satellite stations in Uzbekistan, wireless connections in Cambodia,
and microwave transmission in Kosova have shown that the low
bandwidth internet can reach into remote areas, some of them with
troubled political situations and uncertain economic environments. It
has been more difficult and costly to implement broad bandwidth
applications in these locations. Nevertheless, with the internet come
email, websites, chatlines, multimedia presentations, and occasional
opportunities for synchronous communication via internet phones and
videoconferencing. Each of these communication vehicles provides an
opportunity for medical education and medical care, not to mention
collegial support.3 Of course, they also provide the threat of
mischief occurring within the health community, with breaches of
security, inappropriate use of equipment, and engagement of terrorist
tactics to reach political ends. For example, malicious hackers have
been known to electronically deface websites. Threatening messages
have been sent to health providers by opposing forces in some
conflicts. Lack of systems support may lead to higher levels of virus
and worm infections of electronic patient data. 

Many physicians who travel to developing countries now take their
laptops with them, or check in to internet cafes to maintain their
medical contacts.4 Although connections are sometimes unreliable, and
often the practitioner needs more than a passing knowledge of
communication protocols, modems, and software, it is remarkable how
many locations are accessible via the internet. This connectivity
allows greater flexibility in consultation, whether it is on health
policy for hospitals or unique therapy for rare autoimmune diseases.
For example, I have recently communicated with a visiting health
professional in Cambodia who suspected a case of Henoch-Schonlein
purpura (vasculitis) and sent a complete case history plus digital
photographs of the lesions. The patient, living in a hill community,
improved dramatically on prednisone after languishing for weeks with
an undiagnosed illness. Another example of the value of the internet
was the implementation of educational web servers in Kosovo,
established with satellite links only months after the conflict
abated. The installation of an internet server allowed the local
physicians to gain access to literature and websites which replaced
their 10 year old collection of journals. 

There are threats, however. Technology from developed countries can
replace guns in the fight for economic and social control.4 Reliance
on foreign non-governmental organisations may provide a short lived
stability to the situation. Selection of a particular technology will
often dictate many other developments in health care. It may even
dictate the type of medical training programme that is embarked on,
depending on which country has underwritten the new technology. 

Successfully implementing telemedicine services within developing
countries demands consideration of how the local people will support
the services when the "foreign developer" has moved on. Expertise in
the specific software is only one component. There must be a
commercial capability that allows replacement parts to be provided
and "evergreening" of the equipment and software. There must also be
a stable communications strategy that connects the developing country
with the global internet, without huge debts to pay for the
connectivity. In addition, there should be a security framework that
protects health professionals and their patients from electronic
snooping.1 

As we learn more about distance medicine we will also learn more
about the diversity of disease, healthcare systems, and outcome
expectations around the world. There is a temptation to introduce
Western technology into health systems that are naive with respect to
Western approaches to health care. Without paying attention to the
historical underpinnings of each country's current health system,
telemedicine could have a negative impact on the wellbeing of those
countries. And unless we understand the technological and cultural
readiness of each country and its healthcare practitioners, much
effort can be expended with little gain. 

Nevertheless, telemedicine is beginning to have an important impact
on many aspects of health care in developing countries. When
implemented well, telemedicine may allow developing countries to
leapfrog over their developed neighbours in successful health care
delivery.5 Places such as Pakistan may find that local practitioners
can provide the best advice to their patients without having to send
them from small communities to large urban centres. Outposts in the
highlands of Papau New Guinea may replace their radio communications
from the 1970s with internet communication at little extra cost.
Trainees from the United Kingdom, Canada, and the United States may
find excellent opportunities to gain experience in Bangladesh,
Guatemala, or Nepal, while continuing to pursue their learning
objectives in concert with mentors from their home institutions.6
These trainees will develop collaborations with local students, which
could last a lifetime, opening the way for more equitable
distribution of knowledge and medical care throughout the world.
Medicine rests on solid principles which can transcend political and
social divisions. Telemedicine should allow us to implement advances
in the spirit of our historical roots, even at a distance. 

Steven M Edworthy, associate professor of medicine and community
health sciences. 

University of Calgary, Calgary, Alberta, Canada T2N 4NI
(sedworth@ucalgary.ca)

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1.  Wright D. Telemedicine and developing countries. A report of
study group 2 of the ITU Development Sector. J Telemedicine Telecare
1998; 4 (suppl 2): 1-85[Medline]. 2.  Wootton R. Telemedicine. BMJ
2001; 323: 557-560[Full Text]. 3.  Cooke FJ, Holmes A. E-mail
consultations in international health. Lancet 2000; 356:
138[Medline]. 4.  Nakajima I, Chida S. Telehealth in the Pacific:
current status and analysis report (1999-2000). J Med Systems 2000;
24: 321-331[Medline]. 5.  Mitka M. Developing countries find
telemedicine forges links to more care and research. JAMA 1998; 280:
1295-1296[Medline]. 6.  Vassallo DJ, Hoque F, Farquharson Roberts M,
Patterson V, Swinfen P, et al. An evaluation of the first year's
experience with a low cost telemedicine link in Bangladesh. J Telemed
Telecare (in press). 

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[thanks to "Aamir Javed Khan" <ajkhan@jhsph.edu> for posting it on
the PPHF mailing list]