First, the country is poor and most people work in agriculture. The average yearly gross national income in Nepal is US$ 400. Many people therefore have difficulty paying for hospital tests and treatment. Second, the terrain is mostly mountainous with very few roads that would be recognised as such in developed countries.
This means that if you need healthcare you usually have to walk about 4 hours to a health worker and then if you need to go to hospital it may be another 4 hours in a vehicle along a bumpy road. UK readers can try imagining living in Islington, walking to their nearest health worker in Bedford, and then driving along C roads to the nearest hospital, in Glasgow. And when they get there they may also find that the doctors have difficulty understanding them!
It is small wonder that people who are ill use traditional healers who live in the community, at least.
So what about telemedicine/telehealth?
Well, there are only ever two reasons for doing this: first, if healthcare can’t be provided any other way or, second, if healthcare can be provided better. In the industrialised world the second reason drives most telemedicine applications but in Nepal the first reason is the driver.
So, can telemedicine work? Well there are people who need to see doctors (patients) and there are doctors living in Kathmandu, so that’s the first two requirements. What about the telecommunications infrastructure? CDMA phones (code division multiple access!) seem to work better than GSM phones in rural Nepal and there is no doubt that in the last two years coverage has increased.
On the mobile. Two years ago there was no coverage in this village
Does everyone in Nepal have a mobile phone?
I asked 20 consecutive patients who came to see me at rural clinics last month if they had a phone and 50% said they did. This is very encouraging! It is more than the percentage of Motor Neurone Disease patients in Northern Ireland who use the internet, for example.
Can medicine be practised in Nepal using the phone?
Although the personnel and the infrastructure are present, are the patients and doctors content to use it?
Well, almost all studies of telemedicine in the world show that patients are usually happy to use these modern techniques but doctors are often the problem as they have been imbued with the notion that the face-to-face consultation is the only way to practise medicine and that if they deviate from this it will result in profound medicolegal consequences for them. This is a common view even in Nepal where there is very little medical litigation.
There is, of course, precious little evidence to support this belief or, should I say, prejudice. In the ‘real world’ most out-of-hours GP work depends on telephone medicine as does much inter-specialty referral in hospitals. Yet telephone medicine is not generally taught in UK medical schools or as part of specialty training programs and doctors are left to pick it up as they go along.
There is therefore an overwhelming theoretical case that telephone medicine can make an impression on healthcare in Nepal and the rest of the developing world, which shares similar problems. So how best to make it happen? One way is by teaching it formally in the local medical schools where, in my experience, the medical students are more enthusiastic and knowledgeable than comparable UK medical students.
Once it is incorporated into the fundament of medicine then they might be able to apply it to develop the necessary care systems for the rural parts of their country.
Another way is by gathering and publishing data to show how effective telephone medicine can be. This is what we are trying to do by setting up an epilepsy program at Dhulikhel Hospital which uses the telephone to diagnose and follow up patients with epilepsy in the surrounding part of rural Nepal.
It’s certainly all a bit different from telemonitoring heart failure patients. So if you fancy a big challenge, connect yourself up with a health care institution in a developing country and get going.
You could become the world’s first Professor of Telephone Medicine!
27 April 2010
Victor Patterson is a retired consultant neurologist from Northern Ireland and Honorary Professor of Neurology at Queen’s University Belfast. He is founder and Chairman of Synapse Teleneurology Ltd. Help his fundraising efforts for the project in Nepal or ask him a question, below.