Telemedicine in Low-Resource Settings

Telemedicine is a fuzzy term with several synonyms (telehealth, e-health, etc), which cover a wide range of topics, all concerning the delivery of health care at a distance. “Health care” itself is a broad concept, encompassing diagnosis and treatment of patients, education of staff, patients, and the general public, and administrative activities, such as collecting public health data, as well as research. All of these may be assisted by judicious use of telemedicine. The main advantage of telemedicine is that it can improve access to health care, often by increasing the speed with which a specialist opinion can be obtained (e.g., tele-stroke) or by reducing the need to travel (e.g., teledermatology); in certain disciplines, evidence has also been obtained that telemedicine is cost-effective (1). Much of the experience with telemedicine in the last 20 years has concerned its application in high-income countries. In contrast, there has been relatively little use of telemedicine in low-income countries, which is surprising in view of the difficulties of accessing health care there. In those countries where telemedicine has been trialed, it seems to have worked well and a small number of programs have provided services for periods of 10 years or more (2). These long-running telemedicine programs have mainly used store-and-forward methods, although there has been some limited use of real-time video. The present Research Topic focuses on Telemedicine in LowResource Settings, environments where it is always a challenge to provide patients with the best level of health care. The term “low-resource settings” covers most low-income countries, and also includes regions in middleor high-income countries where under-served populations have difficulties in accessing specialists. The Research Topic documents real, practical experience with the use of telemedicine in low-resource settings and identifies research problems of current interest. This collection of articles shows the rich diversity of applications for telemedicine. Examples come from all over the world and from a range of clinical settings and medical specialties. Mobile phones have great potential in the delivery of health care in low-resource settings. Patterson (3) developed a mobile-phone app to enable non-doctors to diagnose episodes as epileptic. In a pilot trial with health workers in Nepal who used the app in small numbers of patients, there were no false diagnoses. This represents a potential method of empowering health workers to help the millions of people in the resource-poor world with untreated epilepsy. Ndlovu et al. (4) conducted trials with mobile-phone telemedicine in Botswana, in four medical specialties: radiology, oral medicine, dermatology, and cervical cancer screening. The benefits reported by pilot project users were sufficient to convince the government to scale up the program, which is now in progress. Both senior management support and local “ownership” of the program are thought to be important for future success. Piette et al. (5) also reported on the importance of collaborating with the local ministry of health when scaling up a mobile telemedicine application in Bolivia. All these experiences reinforce the need to develop telemedicine by scaling it up from pilot projects, to do so in collaboration with local healthcare workers (rather than trying to impose telemedicine from above) and to enlist the support of the appropriate ministry of health. One of the longer-running examples of telemedicine used in low-resource settings is the RAFT network, which provides both educational and clinical services to centers in Africa and South America (6). The educational activities include the weekly delivery of video-lectures for continuing and postgraduate medical education. Much of this early video delivery depended on the use of satellite links, which are relatively expensive, and in recent years the RAFT program has begun to make use of lowbandwidth Internet connections. In South Africa, a tele-education network evolved from a failed government telemedicine program (7). Over 1000 h of videoconferenced lectures are delivered each year in KwaZulu-Natal, using ISDN transmission. Finally, the EHAS group has provided video-based telemedicine services in South America (8). In order to secure sufficient bandwidth for the delivery of video, they have developed long-range WiFi transmission. An alternative method of transmitting video for telemedicine is to make use of free or low-cost web-based tools. For example, Jefee-Bahloul (9) conducted a pilot trial of telepsychiatry in Jordan using Skype, while Adambounou et al. (10) used the file transfer facilities of the LogMeIn web service for tele-ultrasound between Togo and France. It is clear from these reports that video telemedicine is possible in low-resource environments, but it is also the case that non-realtime (store-and-forward) telemedicine is more common in these settings, not only because it is usually cheaper but also because the non-synchronous nature of the interaction between the parties makes it easier to organize. The longest-running such network