Telemedicine in Eastern Hills of Nepal: Closing the Gap

1. Initial Experience with Telemedicinein Eastern Hills of Nepal Saroj Dhital M.D., D.Med.(Surg) Kathmandu Model Hospital Public Health Concern Trust - NEPAL

2. When a visitor from the developed world goes to poor countries like Nepal Some of the most common questions that come to her mind could be :

3. Why is this country so poor? • Why is this country so much behind others?

4. Perhaps the right questions to ask would be: What can and should be done so that the gap between the rich and the poor of the world is reduced?

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

6. What can and should be done • so that the poor countries can gain higher speed and catch up with the rich ones? • so that globalization becomes a real opportunity for the poor countries and no more a curse? • so that the fruits of science and technological advances are shared by all citizens of the world?

7. There ARE answers to these questions And there are individuals and organizations that have already started providing these answers Kathmandu Model Hospital of PHECT has been working with them

8. In countries like Nepal, Socially responsible health care providers sensitive to the needs and realities of people are torn between two extremes of reality

9. In one hand, the unfinished agenda of basic health care is holding them on the ground On the other hand, they have to stretch their hands to reach the sky to access advances in science and technology

10. BUT How can this be made possible? Especially when not everything is favorable in the present day world

11. When everything is getting more and more costly and less and less accessible When the gap between the rich and poor citizens of the world has not yet stopped widening

12. When the expectations of people are rising higher and higher When these expectations are very much technology dependent And when the cost of technology is decided by international market while the buying capacity is limited by local realities

13. How can we make it possible for the hands to reach the sky with legs standing firmly on the ground?

14. Perhaps we know better what we should not do rather than what to do And one of the things that we in less privileged countries like Nepalshould not do is: simply copying what the more privileged countries are doing

15. So far, science and technology has been of more use to the already rich countries Now, we should appropriately and innovatively use that very science and technology for speeding the growth of poorer countries like ours

16. And that can be done

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

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

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

20. But then the first step needs to be taken

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

22. Long back in early 90s when internet and e-mail were still a luxury for few elites, We at phect had already started musing over the possibility of using wireless sets for providing instructions to paramedics in remote areas And starting ‘Doko Ambulance Service’

23. But then having radio-transmitters was illegal And to get the license for one was impossible Non-government institutions were not allowed even to run FM stations

24. Actually we did approach the then information minister and asked for allowing us to do what we wanted to do But his diplomatic smile brutally translated our plea to something cheaper at the level practical joke!

25. Then we started a surgical out reach training-cum service program - the SCALPEL

26. Scalpel Surgeons and surgically oriented medical doctors from Kathmandu Model Hospital and other hospitals would go to hospitals in remote areas Spent 2 weeks in those remote hospitals training the local primary care doctors to do primary surgery

27. Things moved well before the full scale civil war started in the country. Then, SCALPEL program came into a halt

28. Not ready to give up, we started consulting some technicians about the possibility of starting telemedicine But again, the ‘security’ came in the way.

29. Even under such circumstances, however, our friend Mahabir Pun had been engaged in using the cyber-space for education and health And he had already started showing results

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

31. It has not been easy for an organization like phect-NEPAL that has the goal of creating a non-government model of health care delivery system providing better service to larger number of less fortunate section of people

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

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

34. Dolakha, a relatively remote district in the eastern hills, did not have regular services from doctors in the local hospital for long One of the reasons behind this was difficulty in getting doctors to work in the area, and to retain them

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

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

37. All this discourages these doctors to stay long in the area

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

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

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

41. But finally, regular contact was made possible And that had a visible impact on every thing.

42. Daily ‘tele-rounds’ by doctors in Kathmandu model hospital has become a routine

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

44. ‘Tele-Consultations’ on patient’s condition have become frequent

45. As a result • Health workers in Dolkha have stopped feeling detached from Kathmandu • They have gained confidence • Consultations from specialists have become possible for difficult situations

46. Where there were no doctors, now 7 doctors are working with a total of nearly 30 staff • And their growth process has been highly facilitated

47. Very soon • Virtual class rooms are expected to start for more organized continued education for health professionals in Dolkha Hospital • When it gains maturity, we hope to start a network of virtual schools in more remote hills producing paramedics of different category

48. And we hope This will contribute in building a new Nepal with healthy and educated citizen

49. Friends, We extend our invitation to all of you to visit that new Nepal

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