Editorials

Telemedicine in developing countries

May have more impact than in developed countries

Clinical review p 557

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.² 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-Schönlein 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{at}ucalgary.ca)