Information technology and telemedicine in sub-Saharan Africa
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7259.465 (Published 19 August 2000) Cite this as: BMJ 2000;321:465
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EDITOR - We who practise in sub-Saharan Africa welcome the email and
are probably more dependent on electronic communications than our
colleagues in the West. Here in Blantyre for example we run an
orthopaedic advice system for any district or mission hospital that is
able to send in text or pictures. Cheap digital cameras can take good
quality pictures of patients and even xrays which, as your leader (1)
says, can easily be transmitted as email attachments.
However a chain is
only as strong as its weakest link, and although our computers, scanners,
and
digital cameras are as good as those of our colleagues in the UK our
telephone lines are not. This week, to keep in touch, a friend sent me
five high quality pictures of his family. This was kind of him, and the
email probably only took him a minute or so to send. Here in Malawi I was
unable to receive it despite being on line for half an hour or more
several days in a row. Our email service was blocked for a week and I had
to take time off work to go to the server and cancel the file. In the UK
one can connect at over 50,000 bytes per second. Here on some lines we
can only manage 5,000 and that is on the good days when we get through.
And I live in a major city. Colleagues of mine in remote mission
hospitals are worse off. They get their emails by radio phone and can pay
the equivalent of £10 for each digital image. Imagine their joy in
getting five unsolicited holiday snaps of their cousins. We in sub-
Saharan Africa enjoy the benefits of the electronic revolution and would
find it hard to live without them. But please ask before sending large
files!
1. Fraser HS, McGrath StJD. Information technology and
telemedicine in sub-Saharan Africa.BMJ 2000;321:465-466.
Mr Chris Lavy MCh FRCS
Orthopaedic Surgeon
PO Box 256 Blantyre,
Malawi, Africa
I have no competing interests.
Competing interests: No competing interests
Re: Information technology and telemedicine in sub-Saharan Africa
HSF Fraser, SD McGrath. BMJ 2000;321:465-6
An E-Mail Health support service already operating in Africa
We agree that e-mail is an effective and practical medium for health
care support in remote regions (1) and that many patients in rural areas
may soon benefit from telemedicine projects (2). In Britain we have been
providing an international e-mail health support service since April 1998
(3) which has been accessed frequently in Sub Saharan Africa. Our service
is successful and highly valued (4), and is constantly being improved and
expanded. It was initially developed for the Overseas Training Programme
(OTP) of Voluntary Service Overseas, which is the largest independent
volunteer sending agency in the world. OTP trainees (age 18-25) are
placed in community based projects overseas for up to 12 months. Many
placements are in extremely remote areas, yet in spite of this e-mail is a
medium which can be readily used. In many cases it is easier to e-mail the
OTP doctor in the UK than contact the local doctor. A large proportion of
trainees are in sub-Saharan Africa, and so far the e-mail service has been
accessed in Cameroon, Benin, Zimbabwe, Botswana, Tanzania, Kenya,
Mozambique, Togo, Lesotho, Niger, Uganda, Zambia, South Africa and
Madagascar (see map).
We have developed a health support service which incorporates the use
of e-mail. Our service includes pre-departure advice, medical support
while in the field and follow-up on return to the UK. The success of our e
-mail consultation service hinges on personal knowledge of the individual,
their medical history, their placement and their local doctor / healthcare
facilities, which may be some distance away and not in e-mail or easy
telephone contact. Our e-mail response is within 24 hours and we can
communicate with doctors in-country when required. A variety of medical
and psychological conditions have been successfully identified and
managed, aided by appropriate background knowledge and liaison with local
services. In addition to expanding the current service we intend to
develop it further to also support local doctors involved in these
development projects.
FJ Cooke MRCP (1) A Holmes MD (2)
1. PHLS Microbiology, St George’s Hospital, London.
2. Infectious Diseases and Microbiology, Hammersmith Hospital, Imperial
College, London.
1 & 2. Overseas Training Programme of Voluntary Service Overseas,
London, UK.
References
1. HSF Fraser, SD McGrath. Information technology and telemedicine in
sub-Saharan Africa. BMJ 2000;321;465-6
2. Remote Indian Villages to benefit from telemedicine project. Lancet
2000; 355:1529.
3. Cooke FJ, Holmes A. E-mail consultations in international health.
Lancet 2000; 356;138.
4. Cooke FJ, Holmes A. The Health of Young Volunteers Overseas: Analysis
of five year’s experience of travel-related health issues in 18-25 year
olds. Clin Inf Diseases 1999; 29: 966.
Competing interests: No competing interests
Thanks to everyone who posted these valuable and
constructive comments (well all but one…) and the many personal emails on this
theme. This issue generates a great deal of heated debate and frequently rather
polarized opinions. Clearly the Internet and related technologies are not going
to solve all the healthcare problems in Africa, let alone all development problems.
Nor do we need to install broad band video conferencing to make significant
progress. It is not the number of people online in Africa that is impressive
(it’s not) but the rapid rate of new access. The question is “should IT be part
of the solution to healthcare needs in developing countries?” As Dr Madzimbamuto
makes clear, the Web is playing a very valuable role in providing access to
up to date journals.
A literate population is clearly a very valuable
goal but it is not an essential prerequisite for telemedicine or improved medical
education. We only need to reach a select group of the population to have a
beneficial effect. Are we to denigh medical information to dozens of countries
until they reach high levels of development and literacy? I believe it is necessary
to tackle these problems with a range of tools and approaches, not one technique
at a time. The University of Natal and other institutions are training radiologists
from many African countries, but the huge deficit will take many years to bridge.
Low cost teleradiology can surely play a role particularly in spreading access
within countries.
Regarding hardware costs, several points need to
be considered:
1) Prices
are falling rapidly, the cameras used for most studies quoted in the editorial
are under $300 US and falling. $700 is for the top resolution (2048 x 1533).
2) We
are talking initially of small numbers of cameras, basically one each for hospitals
that already have basic x ray equipment worth thousands of dollars.
3) Less
than 10 doctors per 100,000 means a total of less than 50,000 for all of sub-Saharan
Africa. Even if one in 10 got a new computer and camera it would cost about
$5-7M. This is a small fraction of current development aid even for one year.
4) The
Grameen bank has been successful in funding the use of cell phones in rural
Bangladesh and is starting to support telecenters with Internet access[1].
5) Retired
Pentium 100 –150mhz PCs, properly serviced and with new software can be had
for $100 - $200. The refurbishment must be done carefully, but is an obvious
task for volunteer groups who can probably get the machines as donations.
Clearly some countries are in a particularly bad
situation because of war, the former Zaire (capital Kinshasa) being an obvious
example. However Internet access has been used with considerable success to
coordinate reconstruction and relief efforts in the post war period in Kosovo,
East Timor, and should soon be set up in Sierra Leone. Even Somalia got a basic
Internet link last week:
http://news.bbc.co.uk/hi/english/world/africa/newsid_899000/899781.stm
There are a number of additional useful references
that could not be included. Della Mea has a review of email for telemedicine[2]
and for teledermatology there was an interesting study carried out recently
between Switzerland and Tanzania[3]. Richard Wootton, who edits the Journal
of Telemedicine and Telecare, has written an insightful review on telemedicine
in developing countries[4]. That
journal has many good articles and though sometimes hard to get is worth the
effort. David Wright, formerly at INMARSAT has written several articles in this
area [5 6]. He also authored a
useful report for the International Telecommunications union in 1997 [7
8]. On teleradiology, there is a recent study from South Africa
on the accuracy of reading x rays that were digitized using a standard digital
camera[9].
Finally Professor Fenton’s ability to publish a
reply within 24 hours of the BMJ appearing, from one of the world’s poorest
countries, also tells a story…
Hamish Fraser, Umtata, Eastern Cape, South Africa
References
1. Yunus M. Alleviating Poverty Through technology.
science 1998;282(5388):409-10.
2. Della Mea V. Internet electronic mail: a tool
for low-cost telemedicine. J Telemed Telecare 1999;5(2):84-9.
3. Schmid-Grendelmeier P, Masenga EJ, Haeffner
A, Burg G. Teledermatology as a new tool in sub-saharan Africa: an experience
from Tanzania. J Am Acad Dermatol 2000;42(5 Pt 1):833-5.
4. Wootton R. The possible use of telemedicine
in developing countries. J Telemed Telecare 1997;3(1):23-6.
5. Wright D, Androuchko L. Telemedicine and developing
countries. J Telemed Telecare 1996;2(2):63-70.
6. Wright D. The sustainability of telemedicine
projects. J Telemed Telecare 1999;5(Suppl 1):S107-11.
7. Wright D. Telemedicine and developing countries.
A report of study group 2 of the ITU Development Sector. J Telemed Telecare
1998;4(Suppl 2):1-85.
8. Wright D. The International Telecommunication
Union's report on Telemedicine and Developing Countries. J Telemed Telecare
1998;4(Suppl 1):75-9.
9. Corr P, Couper I, Beningfield S, Mars M. A simple
telemedicine system using a digital camera. Journal of Telemedicine and Telecare
2000;6:233-236.
Competing interests: No competing interests
EDITOR -
The authors of a recent editorial (1) provide a good overview of the possibilities for information technology and telemedicine in developing countries. The situations in which these may be used are so diverse that no single method or system could ever be universally applicable or else "the best" overall. Whatever the circumstances, it is important to recognise that compromises will be both inevitable and essential. With this in mind, it is worthwhile thinking beyond the usual desktop and laptop platforms to consider what "handheld" computer technology has to offer in this role.
Handheld computing encompasses a wide range of technologies and probably the best-known examples are the machines made by Psion (2) and Palm (3). These have several advantages over laptop and desktop computers, which make them especially suitable for use in developing countries. The most obvious of these are their cheaper price, smaller size, lower weight, increased robustness and long battery life. Other advantages include instant start-up/shut-down, screens which are touch-sensitive and viewable in direct sunlight and operating systems which are both simple and stable. At any time the information on a handheld computer can easily be synchronised with a laptop or desktop machine by either a direct connection or a variety of remote methods. Handheld devices are extremely suitable for recording patient data and storing reference materials such as guidelines and formularies. Many users will testify that these machines are also capable of email, Internet and telemedicine functions to rival those of laptop computers.
When developing countries have so many health problems and also so many problems in delivering even basic healthcare, then expenditure on information technology may be difficult to justify. Instead it will probably be those humanitarian relief organisations and military medical services who work in developing countries that gain most from such advances. These groups would do well to consider the possibilities of handheld computer technology and should try to share their experiences wherever possible.
Dr. Mark Bailey
Medical Advisor, www.PDAMD.com
physik@physik.co.uk
(1) Fraser HSF, McGrath SD. Information technology and telemedicine in sub-Saharan Africa. BMJ 2000;321:465-6
(2) www.psion.com
(3) www.palm.com
Competing interests: No competing interests
The writer makes an interesting contribution. However he seems to
forget that one needs to be literate to be able to the so mentioned
technology. With the economic hardships biting even harder in most African
countries the evidence is that literacy rates are falling. What an
interesting garget a modem would be to a cluster of villagers at the heart
of Africa, only three of which could read and write, I wonder? To sum up,
technology could be an answer but not today. Education always precedes
technology.
Competing interests: No competing interests
Sir, the editorial written by Fraser and McGrath on the use of
telemedicine in sub-Saharan Africa (1) and of Internet as a diagnostic
tool is very interesting. However, we think that the debate must be open
on the possible consequences of this approach on the health system.
As specialists in public health, we are at present working on a
project of reinforcement of training methods in Public Health through a
network of exchange of knowledge between Northem and Southerm institutions
and by the use of multimedia tools. We intend to produce computerised
courses for paramedical to be integrated into local existing on going
courses. Fraser's and McGrath's project is also directed at the workers in
rural health care.
Is it possible to contemplate the use of telemedicine as a tool in
medical decision in very decentralised structures when in the majority of
these structures in Africa, the quality of activities (curative and
preventive) is often insufficient or absent ? The new communication
technologies must first reinforce health systems in particular by
stimulating the access to information and to on going training. It must
avoid the destabilisation of the local system and existing activities with
the introduction of hypersophisticated tools for medical decision which
would not be adapted to the local technological know-how. The use of
telemedicine should only be done in pilot projects areas where the primary
health care system is well developed and the level of technology high
enough. The basic training of health care workers (quality of care,
diagnostic approach, decision making, etc) should be included at the start
of such a project or during the course.
We think that telecommunication should be part of the process of
development in poor countries in addition to other factors. One has to be
delighted to see that Internet could give health informations, at low
cost, to health workers (2), knowing, of course, that Internet will never
pay for aspirins or syringes !
The danger might be in the following question : "what technologies are
likely to be most effective and economical ?" (1). The use of new
technologies is, indeed, most attractive. Nevertheless, it is not an aim
in itself but must be a pertinent and efficacious argument in order to
reinforce more global strategies.
1. Hamish S F Fraser, St John D McGrath. Information technology and
telemedicine in sub-
Saharan Africa. BMJ 2000; 321: 465-6.
2. Heather E Hudson. Global Connections : International Communications
Infrastructures Policy. Panos Media Briefing, 28, London, April 1998.
Florence Parent, MD, MPH,
Observatoire de la Santé du Hainaut,
Department of health Information System, Rue Saint-Antoine 1, 7021 Havré,
Belgium. (florence.parent@hainaut.be).
Yves Coppieters, MD, MPH,
School of Public Health, Health Promotion &
Education Unit, Free University of Brussels, Route de Lennik 808, 1070
Brussels, Belgium.
Competing interests: No competing interests
Talking of digital technology, it can be highly instructive to look
at the costs from a Third World perspective. Did I hear someone say that a
good digital camera can be 700 British Pounds--US$1,000? If so, that
represents, in a Third World country like many African Countries (and, for
that matter, Pakistan--where I am), a FULL YEAR'S SALARY for many health
and education workers!
Yes! Digital Technology "promises" to help. But not right now. Not in
the immediate future at any rate. Let the costs come down to Third World
levels and maybe THEN we can see some of the amazing changes promised by
technologies.
Competing interests: No competing interests
While the internet has developed rapidly in many centres in Africa, those outside of major centres still face considerable challenages. As part of a collaborative project between the Dept. of Pediatrics (U British Columbia) and the Child Health Unit(U Cape Town)I have been involved in the development of a distance education M.Phil. degree program in Maternal and Child Health designed for rural health workers. Most are Medical Officers of Health in their region.
When the project started about 5 years ago, we anticipated using email though Healthlink. When the pilot program began, students were provided with computers for their program. We soon found that those outside of major centres had difficulty finding basic technical comupter support, phone lines varied considerably in quality and in the modem speeds that they would support, and the costs for what were frequently long distance calls to connect to a provider were almost prohititive.
More recently, private sector ISPs have developed a such a rate that it is conceivable to have a web-based program. Many of the same constraints still apply however, plus the limitations of University computing services which are difficult and costly to upgrade.
For more information on the project see http://www.uct.ac.za/depts/chu/edu.htm
Competing interests: No competing interests
at our teaching hospital the only way we can keep up to date even
with what is happening in developing country medicine is because of our
internet access. We email journal articles to interested friends on
Healthnet and hope to soon be using CDs for distance education for
anaesthetics. We wish that more journals were free on the internet,like
the BMJ is. Even journals that are a year old should be made available to
us free on the internet. This is something realistic that first world
medical professionals could do to support us in development.
Competing interests: No competing interests
Skyscape Medical Software
Skyscape (www.skyscape.com) offers a large number of attractive
medical programs for Palm and Pocket PC users. A wide range of
specialties are covered. The 5 Minute Clinical Consult, PDR Drugs and
Washington Manual are particularly useful. Trial versions can be
downloaded free for evaluation. The interface of these programs is
attractive, and if you have more than one program installed on your palm,
it is possible to cross-reference through them.
Competing interests: No competing interests