Initial Experience with TelemedicineInitial Experience with Telemedicinein in

Eastern Hills of NepalEastern Hills of Nepal

Saroj Dhital M.D., D.Med.(Surg)Saroj Dhital M.D., D.Med.(Surg)

Kathmandu Model HospitalKathmandu Model HospitalPublic Health Concern Trust - NEPAL Public Health Concern Trust - NEPAL

When a visitor from the developed When a visitor from the developed world goes to poor countries like Nepalworld goes to poor countries like Nepal

Some of the most Some of the most common questions common questions that come to her that come to her mind could be :mind could be :

Why is this country so Why is this country so poor?poor?

Why is this country so Why is this country so much behind others?much behind others?

Perhaps the right questions to Perhaps the right questions to ask would be:ask would be:

What can and should What can and should be done be done

so that the gap so that the gap between the rich and between the rich and the poor of the world the poor of the world is reduced?is reduced?

so that the so that the utilization of utilization of available available resources in the resources in the ‘poor’ countries ‘poor’ countries are optimized?are optimized?

What can and should be done What can and should be done

so that the poor countries can gain higher so that the poor countries can gain higher speed and catch up with the rich ones?speed and catch up with the rich ones?

so that globalization becomes a real so that globalization becomes a real opportunity for the poor countries and no opportunity for the poor countries and no more a curse?more a curse?

so that the fruits of science and so that the fruits of science and technological advances are shared by all technological advances are shared by all citizens of the world? citizens of the world?

There There AREARE answers to these questions answers to these questions

And there are individuals And there are individuals and organizations that and organizations that have already started have already started providing these answersproviding these answers

Kathmandu Model Kathmandu Model Hospital of PHECT has Hospital of PHECT has been working with them been working with them

In countries like Nepal, In countries like Nepal,

Socially responsible health care providers Socially responsible health care providers

sensitive to the needs and realities of sensitive to the needs and realities of people people

are are

torn between two extremes of realitytorn between two extremes of reality

In one hand, the In one hand, the unfinished agenda of unfinished agenda of basic health care is basic health care is holding them on the holding them on the groundground

On the other hand, On the other hand, they have to stretch they have to stretch their hands to reach their hands to reach the sky to access the sky to access advances in science advances in science and technologyand technology

BUTBUT

How can this be made possible?How can this be made possible?

Especially when not everything is favorable Especially when not everything is favorable in the present day worldin the present day world

When everything is gettingWhen everything is getting

more and more costlymore and more costly

and and

less and less accessible less and less accessible

When the gap between the rich and poor When the gap between the rich and poor citizens of the world has not yet stopped citizens of the world has not yet stopped wideningwidening

When the expectations of people are rising When the expectations of people are rising higher and higherhigher and higher

When these expectations are very much When these expectations are very much technology dependenttechnology dependent

And when the cost of technology is And when the cost of technology is decided by international market while the decided by international market while the buying capacity is limited by local realities buying capacity is limited by local realities

How can we make it possibleHow can we make it possible

for the hands to reach the sky for the hands to reach the sky with legs standing firmly on the with legs standing firmly on the

ground?ground?

Perhaps we know betterPerhaps we know betterwhat we should not do rather than what to what we should not do rather than what to dodo And one of the things that we in less And one of the things that we in less privileged countries like Nepalshould not privileged countries like Nepalshould not do is: do is:

simply copying what the more privileged simply copying what the more privileged countries are doing countries are doing

So far, science and technology has been So far, science and technology has been of more use to the already rich countriesof more use to the already rich countries

Now, we should appropriately and Now, we should appropriately and innovatively use that very science and innovatively use that very science and technology for speeding the growth of technology for speeding the growth of poorer countries like ourspoorer countries like ours

And that can be doneAnd that can be done

The fruits of Information Technology are The fruits of Information Technology are some of those rare things in the present some of those rare things in the present day world that are getting more and more day world that are getting more and more efficient and more and more affordable at efficient and more and more affordable at the same timethe same time

Its use for health and education in Its use for health and education in countries with difficult terrain should be countries with difficult terrain should be promoted and speeded up without any promoted and speeded up without any hesitationhesitation

One should not be ridiculed for predicting One should not be ridiculed for predicting that remote controlled robotic surgery in that remote controlled robotic surgery in future may be more feasible, faster, and future may be more feasible, faster, and more affordable than building and more affordable than building and manning traditional hospitals in the remote manning traditional hospitals in the remote hills of Nepal hills of Nepal

But thenBut then

the first step needs to be takenthe first step needs to be taken

We had been trying to take that step for long We had been trying to take that step for long

Long back in early 90s when internet and Long back in early 90s when internet and e-mail were still a luxury for few elites, e-mail were still a luxury for few elites,

We at phect had already started musing We at phect had already started musing over the possibility of using wireless sets over the possibility of using wireless sets for providing instructions to paramedics in for providing instructions to paramedics in remote areasremote areas

And starting ‘Doko Ambulance Service’And starting ‘Doko Ambulance Service’

But then having radio-transmitters was But then having radio-transmitters was illegalillegal

And to get the license for one was And to get the license for one was impossibleimpossible

Non-government institutions were not Non-government institutions were not allowed even to run FM stations allowed even to run FM stations

Actually we did approach the then Actually we did approach the then information minister and asked for allowing information minister and asked for allowing us to do what we wanted to dous to do what we wanted to do

But his diplomatic smile brutally translated But his diplomatic smile brutally translated our plea to something cheaper at the level our plea to something cheaper at the level practical joke!practical joke!

Then we started a surgical out reach Then we started a surgical out reach training-cum service program -training-cum service program -

the SCALPELthe SCALPEL

ScalpelScalpel

Surgeons and surgically oriented medical Surgeons and surgically oriented medical doctors from Kathmandu Model Hospital doctors from Kathmandu Model Hospital and other hospitals would go to hospitals and other hospitals would go to hospitals in remote areasin remote areas

Spent 2 weeks in those remote hospitals Spent 2 weeks in those remote hospitals training the local primary care doctors to training the local primary care doctors to do primary surgery do primary surgery

Things moved well before the full scale Things moved well before the full scale civil war started in the country.civil war started in the country.

Then, SCALPEL program came into a haltThen, SCALPEL program came into a halt

Not ready to give up, we started consulting Not ready to give up, we started consulting some technicians about the possibility of some technicians about the possibility of starting telemedicine starting telemedicine

But again, the ‘security’ came in the way. But again, the ‘security’ came in the way.

Even under such circumstances, however, Even under such circumstances, however, our friend Mahabir Pun had been engaged our friend Mahabir Pun had been engaged in using the cyber-space for education and in using the cyber-space for education and healthhealth

And he had already started showing And he had already started showing resultsresults

And Finally,And Finally,

When the Royal control over people’s lives When the Royal control over people’s lives started weakening, started weakening, contact with Mahabir revived all the contact with Mahabir revived all the aborted dreamsaborted dreamsand and PHECT jumped into the task of making PHECT jumped into the task of making telemedicine a reality telemedicine a reality

It has not been easy for an organization like It has not been easy for an organization like phect-NEPAL phect-NEPAL

that has the goal of that has the goal of creating a creating a non-government modelnon-government model of health of health care delivery system care delivery system providingprovidingbetterbetter service service to to largerlarger number number of of

less fortunateless fortunate section of people section of people

For organizations like this, with lots of For organizations like this, with lots of commitments, the lack of resources is a commitments, the lack of resources is a rule rather than an exception : especially rule rather than an exception : especially when you are not bowing down to when you are not bowing down to irrational demands from the ‘donors’irrational demands from the ‘donors’

Thanks to the organizational commitment, Thanks to the organizational commitment, and to the cooperation of like-minded and to the cooperation of like-minded friends that are mentioned earlier, phect-friends that are mentioned earlier, phect-NEPAL has been able to start the NEPAL has been able to start the telemedicine program with minimum telemedicine program with minimum expenditure of slightly above twelve expenditure of slightly above twelve thousand US dollarsthousand US dollars

Dolakha, a relatively remote district in the Dolakha, a relatively remote district in the eastern hills, did not have regular services eastern hills, did not have regular services from doctors in the local hospital for longfrom doctors in the local hospital for long

One of the reasons behind this was One of the reasons behind this was difficulty in getting doctors to work in the difficulty in getting doctors to work in the area, and to retain themarea, and to retain them

Those few who Those few who offer themselves offer themselves to a place like to a place like Dolakha have to Dolakha have to be responsible 7 be responsible 7 days a week and days a week and 24 hours a day24 hours a day

Life becomes Life becomes even harder if even harder if they don’t get they don’t get advices from advices from higher centers or higher centers or authorities in authorities in difficult situationsdifficult situations

All this All this discourages discourages these doctors to these doctors to stay long in the stay long in the areaarea

In the first phase of In the first phase of the telemedicine the telemedicine program, we program, we established the real- established the real- time linkage between time linkage between Kathmandu Model Kathmandu Model Hospital and Hospital and Gaurishankar General Gaurishankar General Hospital in Dolkha.Hospital in Dolkha.

Besides the technical Besides the technical issues, extensive issues, extensive communication had to communication had to be done with people be done with people even to erect the even to erect the ‘towers’ which were ‘towers’ which were actually no more than actually no more than simple poles for the simple poles for the radio deviceradio device

Wherever the trees Wherever the trees blocked the waves, blocked the waves, they needed to be cut they needed to be cut down and that was down and that was quite exhausting quite exhausting politically and politically and otherwiseotherwise

But finally, regular But finally, regular contact was made contact was made possiblepossible

And that had a visible And that had a visible impact on every thing.impact on every thing.

Daily ‘tele-Daily ‘tele-rounds’ by rounds’ by doctors in doctors in Kathmandu Kathmandu model hospital model hospital has become a has become a routineroutine

Academic discussions Academic discussions and presentations in and presentations in Kathmandu Model Kathmandu Model Hospital is telecasted Hospital is telecasted to Dolakha and to Dolakha and participants from both participants from both ends discuss ends discuss efectively and efectively and efficientlyefficiently

‘‘Tele-Tele-Consultations’ on Consultations’ on patient’s condition patient’s condition have become have become frequentfrequent

As a resultAs a result

Health workers in Dolkha have stopped Health workers in Dolkha have stopped feeling detached from Kathmandufeeling detached from Kathmandu

They have gained confidenceThey have gained confidence

Consultations from specialists have Consultations from specialists have become possible for difficult situationsbecome possible for difficult situations

Where there were no doctors, now 7 Where there were no doctors, now 7 doctors are working with a total of nearly doctors are working with a total of nearly 30 staff30 staff

And their growth process has been highly And their growth process has been highly facilitated facilitated

Very soonVery soon

Virtual class rooms are expected to start Virtual class rooms are expected to start for more organized continued education for more organized continued education for health professionals in Dolkha Hospitalfor health professionals in Dolkha Hospital

When it gains maturity, we hope to start a When it gains maturity, we hope to start a network of virtual schools in more remote network of virtual schools in more remote hills producing paramedics of different hills producing paramedics of different category category

And we hopeAnd we hope

This will contribute in building a new Nepal This will contribute in building a new Nepal with healthy and educated citizen with healthy and educated citizen

Friends,Friends,

We extend our invitation to all of you to We extend our invitation to all of you to visit that new Nepalvisit that new Nepal

But, in order to bring that day closer, we But, in order to bring that day closer, we need to have you as our partnersneed to have you as our partners

With your efforts in equipping us with more With your efforts in equipping us with more efficient devices, we can make great efficient devices, we can make great changes possiblechanges possible

And that will help to create a better world And that will help to create a better world to live in – for you, for me, for all of us …to live in – for you, for me, for all of us …

Initial Experience withInitial Experience with