Table Of ContentTELe-Health
Series Editors: Fabio Capello · Giovanni Rinaldi · Giovanna Gatti
Michelangelo Bartolo
Fabio Ferrari E ditors
Multidisciplinary
Teleconsultation
in Developing
Countries
TELe-Health
Serieseditors
FabioCapello
CumberlandInfirmary
NorthCumbriaUniversityHospitals
Carlisle,UnitedKingdom
GiovanniRinaldi
OspedaliRiunitiMarcheNord
Pesaro,Italy
GiovannaGatti
EuropeanInstituteofOncology(IEO)
Milan,Italy
Recentadvancesintechnologyandmedicinearerapidlychangingthefaceofhealth
care.Arevolutionisoccurringindiagnosisandtreatmentthankstotheimplementa-
tion of instrumentation and techniques deriving from engineering and research. In
addition, a cultural conversion is taking place in which geographical and social
boundariesareabouttobeovercome,resultinginenhancedavailabilityandquality
ofcare.Telemedicinehasbeenconsideredapossiblemeansofimprovinghealthcare
worldwidethat islikely tochangetheway inwhichdoctorsdealwith patients and
diseases.Whilevariousrestraintscontinuetolimittheapplicationoftelemedicinein
different settings and different areas of health, the innovations emerging from
eHealth and telecare could stimulate a great leap forward for medicine, provided
thatsomebasicrulesaretakenintoconsiderationandfollowed.Inthisseries,diverse
aspects of tele-health – preventive, promotive, and curative – will be covered by
leadingexpertsinthefieldwiththeaimofrealizingthefullpotentialofthenewand
excitingtechnologicalsolutionsatourdisposal.
Moreinformationaboutthisseriesathttp://www.springer.com/series/11892
(cid:129)
Michelangelo Bartolo Fabio Ferrari
Editors
Multidisciplinary
Teleconsultation in
Developing Countries
Editors
MichelangeloBartolo FabioFerrari
TelemedicineUnit UniversityofRome‘LaSapienza’
SanGiovanniHospital Rome,Italy
Rome,Italy
ISSN2198-6037 ISSN2198-6045 (electronic)
TELe-Health
ISBN978-3-319-72762-2 ISBN978-3-319-72763-9 (eBook)
https://doi.org/10.1007/978-3-319-72763-9
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Foreword
Nowadays,globalisationisperceivedassomethingnegative,aninevitableevilthat
creates inequality, and something that nobody seems to be able to avoid. Conse-
quently,anythingthatbringspeopletogetherandletsthemcommunicatewitheach
otherisseenassuspicious.Threatssuchasanincreaseinthemigrationflowsandthe
spread of terrorism, which appear to be encouraged by globalisation itself, only
increasepeople’sfear.
The reality is actually more complex than that. History, for example, is full of
periodsofmigration,likethoseinvolvingItaly,between1800and1900.Likewise,
therehavebeenothertimesofterror,eveninrecentEuropeanhistory.
Nonetheless, there is another aspect of globalisation, which is related to the
development of technology, infrastructures, connections and greater accessibility.
This is the case of the improvement of the global health service which has come
aboutthroughtheopportunitiesofferedbynewformsofadvancedcommunication.
In this way, high-income and technologically developed countries could offer
support to those left behind, making life in poor-resource settings easier at a
relatively low cost. Helping people in their own countries would give one reason
lessforthemtoleavetheirhome.
Thisbookinfactdealswiththecreationoftechnologicalnetworkstobeusedfor
training and health. In technical terms, this is called “telemedicine”; it offers “best
practices” through connections between places that are very far away from each
other—a sort of globalisation of medicine. This subject is fully discussed in the
followingpages:itisawaytocreateanewformofinternationalcooperationthrough
technology,whichwillbringafutureanddevelopmentnotonlytothecountriesthat
benefitfromitdirectlybuttobothsidesofthenetwork.
Until2011,therehadbeenadecreaseintheItaliancommitmenttoInternational
Cooperation in Africa. In the 1990s and in the 2000s, donations were significantly
lower compared to the previous decades; sub-Saharan Africa was particularly
affectedbythat.During theseyears,supporttoAfricawasgrantedmainlybynon-
governmentorganizationsthatreceivedmoneyfromtheCatholicChurchandother
religious movements, or from NGOs and government organizations. However,
v
vi Foreword
fund-raising for health projects and developing programs became increasingly
difficult. In 2012 the trend was reversed and now Italy is again one of the main
EU,G7andOECDdonors.
We also changed our approach: in August 2014, a new cooperation law was
approved1(n.125),whichwehadbeenlookingforwardtofor20years.Asaresult
there was the creation of the Development Agency and the possibility for the
Deposits and Loans Fund to become an Italian development bank. There was also
anexpansionintermsofthetypesofpeopleinvolved,withthediasporas,theprivate
sector,thenon-profitorganisationsandthenon-profitsectoringeneral.Thisimme-
diately caused an all-round increase in the number of people involved and in the
numberofprojects,anditalsoheightenedtheinterestoftheEuropeanCommission.
The missions toAfrica and the African delegationspassing through Rome became
farmorenumerous.
ItisnotjustamatterofrenewedItalianinterestaimingtoincreasehumanitarian
worksandprojectsinsomecountriesthatlackinfrastructures.Africahasbecomea
strategic priority, as former Italian Prime Minister Matteo Renzi stated during his
visit to Mozambique: “an opportunity and not only a continent receiving develop-
mentassistance”.2Thisnewstrategicpresenceistheresultofhavingunderstoodthat
AfricaisofstrategicvalueforItaly,forEuropeandforthefutureglobalgeostrategic
balance.
Africahaschangedtoo.Thecontinenthasgrownandtherearenewopportunities
forItalyandforEurope.ThepresenceofactivismofChina,Turkey,andotherAsian
countries,whichtodateiswellconsolidated,expressesthisnewglobalinterestinthe
continent.Africaisayoungcontinenttoday.Forty-threepercentofthepopulation
ofsub-Saharaisunder 14yearsold3—ageneration bornwith digitaltechnology—
and despite the digital divide, they are perfectly technology savvy. Practically
everyoneownsasmartphonetoday,andthiscanbecomeavehiclefordevelopment
andcloseness.
Duringtheyears,IhavebeenresponsibleforItalianinternationalcooperationand
havevisitedseveralexcellenthealthfacilitiesinAfrica,setupbymanyofourNGOs.
Last November I went to the Global Health Telemedicine multi-specialist
teleconsultationcentreinBangui,CentralAfrica.Withthissystem,CentralAfrican
doctorscanrequestandreceiveanyconsultationfromspecialistsintheWestwhoare
inthenetwork,inrealtime.Clinicalrecords,admissioncharts,orconsultationnotes,
togetherwithimaging,andreportsfrominstrumentalandlaboratorytestsareeasily
accessible and sharable. This allows real-time or delayed consultations offering
support for diagnosis and treatment. With this technology, even very poor Central
Africa can come out of isolation and benefit from the best treatments. One of the
problems with the global medical sector is in fact its separation, which technology
1http://www.gazzettaufficiale.it/eli/id/2014/08/28/14G00130/sg
2http://www.huffingtonpost.it/2016/05/18/conferenza-italia-africa_n_10024618.html
3https://www.internazionale.it/opinione/nicolo-cavalli/2015/08/20/africa-economia-sviluppo
Foreword vii
canovercome,andthesametechnologycanbeusedtoprovidedatathatisusefulfor
medicineinrichcountries.
Everythingdescribedinthesepagesisscientificallybased;itisnotjustaseriesof
successstoriesinhealthcooperationbutitrepresentsamodelthatcanbereplicated
in other geographical contexts and, why not, even in our countries. I visited many
DREAM centres (in Mozambique, Malawi, Tanzania, etc.) and people with HIV
whostartedlivingagain.Ialsometmotivated,well-trainedAfricanhealthstaff,with
career prospects, precisely because they can operate within a network and use the
bestinstrumentsanddevices.TheseareItalianprojectsthatexpressnotonlyanew
health model that consists of thehighestqualitytreatment anddiagnostics butalso
warmth,support,developmentandtraining.
Awhileago,theHealthMinisterofGuinea,adoctor,toldmeunhappilythatall
thestudentswhograduatedfromAfricanuniversitiesendedupworkinginEuropean
hospitals.Irealisedthatitwasnotjustforthesalary:ifarecentlygraduatedAfrican
student expects to be isolated from the continuous cycle of research, which is
particularly true inmedicine, he will go wherethe informationis. So how can you
keep healthcare in Africa at a level of excellence and also hold on to its doctors?
Technology can solve this problem by creating a global network. The network of
exchanges and contacts that are created through the thorough application of tele-
medicinerepresentsaformoflong-distancetraining,aswellasanexchangeofdata
and research. This provides dignity and increases the scientific knowledge and
awarenessonbothsides:healthmodelsthatareintegratedandcanspreadandgrow.
ItisnottruethatpoorhealthcareisenoughforAfricabecauseAfricaispoor:the
experiencesdescribedinthisbookshowthatthereisonlyonekindofhealthcareand
onlyonekindofhealth,thatis,foreveryone.
Rome,Italy MarioGiro
DeputyForeignMinister
Responsiblefor
InternationalCooperation
Foreword
Therichestandmostdevelopedcountriesintheworldhaveaseriesofservicesfor
theirmanydailyhealthcareneedsthatareextremelyevolved,althoughtheydohave
theirlimitsandproblems.Theyreachalmostallthepopulation,andingeneralthey
alsocreateanelementofsocialstability.Wearesousedtothemthatwedonoteven
askourselveshowtheyaresetup,howmuchtheycostandwhatittakestokeepthem
going. We just use them; that’s all. In more advanced healthcare systems, like in
Italy,weareabletomaketreatmentsandassistance,involvingconsiderablycomplex
technologicalandorganisationalaspects,easilyaccessible.Oneexampleisthefact
thatinsomeItalianregions,itisevenpossibletohaveabloodsampletakenathome;
it is taken immediately and safely to a laboratory that operates within the regional
healthservice.Thelaboratoryperformsthebloodtestandrecordstheinformationin
the region’s computer systems, the administrative work is carried out and the
laboratory is then paid through an electronic bank transfer. People who use this
servicecanreceivetheirresultsinjustafewhoursandforwardthemtotheirdoctor
inrealtimeintheInternet.Thisallappearstobequitenaturaltothem.Actuallythis
service works, thanks to this complex system that absorbs considerable economic
resourcesandrequiresthattheinfrastructuresinvolvedbeworkingperfectly,likethe
electricpowerdistributionandtheInternetconnectionnetworks.
Unfortunately,systemslikethisarenotyetpracticalindevelopingcountries,like
thoseofsub-SaharanAfrica.Therearemanyreasonsforthis,butitismainlybecause
of the lack of resources that has obstructed the evolution of the infrastructures and
the distribution networks (of drugs, biomedical products, instruments, etc.). It is
therefore difficult for healthcare organisations to be set up throughout the whole
country, and progress in the use of digital technologies is very limited. Then the
healthcarefacilities,mostofwhichareprivate,donotcollaboratewitheachotherto
createanorganisedsystem,sotheyareunabletocarryouteffectivepreventionand
providecontinuingassistance.
Inordertolookatthisinrealisticterms,onecanconsidertheideaofmovingthe
wholelaboratoryofourexampleabovetooneofthesecountries.Ifitwerehanded
overtothepeoplewholivethere,theywouldnotbeabletomaketheserviceswork
ix
x Foreword
ontheirown.Infacttheywouldnotbeabletoprovidethenecessaryinfrastructures
and supplies, which in developed countries are considered routine and in fact do
involveroutineactivities.Theywouldnothave,forexample,efficientelectricpower
supply networks to avoid the malfunctioning of any of the sophisticated electronic
laboratory systems. Neither would they have enough qualified technicians to take
careofthemaintenanceoftheequipmentandrepairingbreakdowns.Moreover,the
Internetconnectionswouldbeunstableandnotevenbeavailableineverypartofthe
country.
Inthepoorestcountries,theseissuesconcernallthehealthcareactivities,boththe
most basic ones and even more so the highly technological activities, such as
telemedicine.Soitlooksasthoughitwouldbeverydifficulttosetuptelemedicine
services and impossible to keep them running efficiently, in the very places that
wouldbenefitfromthemmost.
ThebenefitofthecollaborationbetweentheDREAMprojectoftheCommunity
ofSant’EgidioandtheGlobalHealthTelemedicine(GHT)non-profitorganisationis
thatitproposedaneffectivesolutiontotheabove-mentionedproblems,whichcanbe
maintained over time, and this solution has already been successfully set up in
several countries in Africa. In fact, by using the features of telemedicine and the
brilliantinnovationsintermsoftheITprocesses,theDREAMandGHTnetwork,in
collaboration with the local authorities, is able to overcome these apparently unre-
solvable issues, and it also covers the costs of setting up and running all the
necessary IT systems. With extensive telemonitoring and clinical teleconsultation
services, this network makes it possible for the African healthcare staff to use
biomedicaldevicesandreceivespecialistmedicalconsultingfreeofcharge.
What has made it possible to achieve this extremely valuable result is basically
the fact that the whole telemedicine system was designed and set up with the very
highest clinical standards. This is why the Italian Society of Digital Health and
Telemedicine is actively promoting the DREAM and GHT platform, which has
alreadybeensupportedbyauthoritativeItalianexperts,andislookingforwardtoand
encouragingamoreandmoreextensiveuseofthissolution.
Another interesting aspect of this solution is that the teleconsultation activities
performedbytheGHTnetworkhavemadeitpossibletoincreasethecollaboration
betweenItalianexpertsandlocalhealthstaff.
The local health staff obviously had to be trained to be able to use the digital
instrumentsandbecomefamiliarwiththeinnovationsintheprocessesused.Onthe
other hand, the Italian GHT Teleconsultation specialists sometimes found them-
selvesdealingwithsevereclinicalsituations,withoutbeingabletoresorttosophis-
ticated diagnostic instruments. Theyhadto rely on simple rural healthcare centres,
maybe run by just one nurse, for the advice they gave regarding diagnosis and
treatment. This was a new situation that the specialists, although experts in their
field,hadtoquicklylearntocopewith,frombothatechnicalandahumanpointof
view,inorderto“rethink”theiroperativeclinicalresponses.
Itwasaquestionofdirectingthetherapeuticsolutionstowardsthegoodpractices
they areused toandoffinding solutions thatcould be applied inthelocalcontext.
