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BMJ. Aug 19, 2000; 321(7259): 465–466.
PMCID: PMC1118376

Information technology and telemedicine in sub-Saharan Africa

Economical solutions are available to support health care in remote areas
Hamish S F Fraser, instructor in medicine
Children's Hospital Informatics Program and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA (ude.tim.scl.gdem@hsimah)
St John D McGrath, co-director

Many developing countries have an acute shortage of doctors, particularly specialists. Sub-Saharan Africa has, on average, fewer than 10 doctors per 100 000 people, and 14 countries do not have a single radiologist.1 The specialists and services that are available are concentrated in cities. Workers in rural health care, who serve most of the population, are isolated from specialist support and up to date information by poor roads, scarce and expensive telephones, and a lack of library facilities.2 Can information technology offer solutions? If so, what technologies are likely to be most effective and economical?

The internet is making inroads into Africa: whereas three years ago only 12 countries in Africa had internet access, it is now available, at least in the capital city, in 53 out of 54 African countries.3 Free online resources include journals,4 research databases, and training courses.5

Email has many advantages in poor countries: it is cheap, hardware and software requirements are simple, and the information does not have to be transmitted in real time. These benefits have been shown by SatelLife, a charitable organisation based in Boston.6 Using a low earth orbit satellite and phone lines, it provides email access in 140 countries, serving over 10 000 healthcare workers. Where adequate telecommunications links exist, SatelLife and other organisations provide higher capacity email and internet connections. These allow sending email attachments such as image files, permitting a form of low cost telemedicine. The patient's findings are described in an email, and digital photographs of the patient and their investigations, such as electrocardiograms and x ray films, are attached. This “store and forward” telemedicine does not allow real time interaction, but it permits specialist support in the management of difficult cases and is economical. Modern digital cameras are small, robust, easy to use, and cheap ($300-800). They can create high resolution images (1900×1400 pixels or better) that are adequate for teledermatology.7 With modification this technique can be effective for telepathology and teleultrasound.8,9

Access to radiological expertise remains a challenge in developing countries. Digital radiology offers a potential solution but is expensive—laser film scanners cost around $30 000.10 Consumer image scanners are cheaper and can provide reasonable quality but are not suitable for full size radiographs. Another approach is to photograph an x ray image on a lightbox with a digital camera. This can provide adequate diagnostic quality in many cases and is becoming increasingly practical as cameras approach the ideal resolution for digital x ray images of 2048×2048 pixels.1012 Digital image compression techniques (wavelet compression) can reduce a file of high quality chest radiographs to a size suitable for email (under 300 kb), thus enabling anyone with email to consult a radiologist for an opinion.13

These techniques may not provide the quality of data we expect in modern hospitals. However, if used by healthcare workers trained to follow simple photographic and email procedures they can improve specialist access in remote areas. Photographing x ray films taped to the window of a clinic in Ghana, West Africa, may seem rudimentary, but this approach allowed doctors in Massachusetts to advise Ghanaian healthcare workers in 1998 (D Carlin, personal communication). Clearly, further evaluations of diagnostic accuracy, usability, and cost are required.14

With the falling costs and increasing capabilities of computers and imaging systems, a store-and-forward telemedicine system can now be set up for little more than $1000. Basic email capability costs much less than this, and while many hospitals do not yet have electronic communications an email is the cheapest and most efficient way to provide this. Connectivity and training remain the biggest challenges. The rapid growth of satellite phones, cell phones, and wireless networking is helping with the first problem. In more remote areas, however, we need to be inventive to overcome the many challenges to using information technology, including intermittent power supplies, unreliable phone lines, and maintenance. To reduce the training requirements, our group is developing free email software that helps the user to organise images and incorporates encryption (for security) and efficient image compression.

It is vital that local healthcare workers take a lead in developing and operating telemedicine projects. Initiatives to train African healthcare workers in the use of information technology are also essential, such as those set up by the Fogarty International Center of the US National Institutes of Health.15 Simple, low cost techniques should be emphasised, rather than expensive video conferencing approaches that struggle to achieve sustainability even in developed countries.16

References

1. WHO advisory meeting on radiology education. Geneva: World Health Organization; 1999.
2. Mohga Kamal Smith. Hospitals in developing countries: a weak link in a weak chain. Lancet. 1999;354 (suppl 4):26. [PubMed]
3. African internet connectivity. www3.sn.apc.org/africa/ (accessed 1 June 2000).
4. FreeMedicalJournals.com. www.freemedicaljournals.com (accessed 1 June 2000).
5. The Global Health Network supercourse: epidemiology, the internet, and global health. www.pitt.edu/~super1/ (accessed 1 June 2000). [PubMed]
6. Groves T. SatelLife: getting relevant information to the developing world. BMJ. 1996;313:1606–1609. [PMC free article] [PubMed]
7. Krupinski EA, LeSueur B, Ellsworth L, Levine N, Hansen R, Silvis N, et al. Diagnostic accuracy and image quality using a digital camera for teledermatology. Telemedicine J. 1999;5:257–263. [PubMed]
8. Johnson MA, Davis P, McEwan AJ, Jhangri GS, Warshawski R, Gargum A, et al. Preliminary findings from a teleultrasound study in Alberta. Telemed J. 1998;4:267–276. [PubMed]
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10. Corr P. Teleradiology in KwaZulu-Natal. A pilot project. S Afr Med J. 1998;88:48–49. [PubMed]
11. Whitehouse RW. Use of digital cameras for radiographs: how to get the best pictures. J R Soc Med. 1999;92:178–182. [PMC free article] [PubMed]
12. Buntic RF, Siko PP, Buncke GM, Ruebeck D, Kind G, Buncke HJ. Using the internet for rapid exchange of photographs and x-ray images to evaluate potential extremity replantation candidates. J Trauma. 1997;43:342–344. [PubMed]
13. Goldberg MA, Pivovarov M, Mayo-Smith WW, Bhalla MP, Blickman JG, Bramson RT, et al. Application of wavelet compression to digitized radiographs. AJR Am J Roentgenol. 1994;163:463–468. [PubMed]
14. Yellowlees P. Practical evaluation of telemedicine systems in the real world. J Telemed Telecare. 1998;4(suppl 1):56–57. [PubMed]
15. John E Fogarty International Center: research and training opportunities. www.nih.gov/fic/programs.html (accessed 1 June 2000).
16. Wootton R, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, et al. Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost-benefit analysis. BMJ. 2000;320:1252–1256. [PMC free article] [PubMed]

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