Developing Enduring Professional Relationships in a Changing World Climate

1. Developing Enduring Professional Relationships in a Changing World Climate By Zina C. Munoz, R.N., B.S., C.E.N. Director The Renal-Tech Donation Project

2. Introduction While healthcare workers in the developing world struggle on the front lines of the world's most serious public health problems, their efforts are severely hampered by a lack of information. The inability to access and use medical information readily available to those in the developed world remains one of the most serious obstacles to better health in the developing world. Building enduring professional relationships in the current climate of political and social unrest depends upon bridging the gap between developed and developing nations.

3. Communication The key to developing enduring professional relationships within the global medical community is COMMUNICATION. Communication is the basis for all human interaction. Technology has given us a variety of methods to communicate efficiently over vast distances and in short amounts of time. It is a fact that technology and access to it is not evenly distributed among the peoples of the world. Those who need technology the most, have the least access to it.

4. The Information Gap Of the 52 million deaths worldwide during 1996, over 40 million of them were in the developing world. More than 12 million of them were children under the age of five, most of which died from preventable causes. Many of these deaths could be avoided and several of the problems faced by health professionals could be overcome if the adequate information was at hand when needed. But, information poverty is one of the most serious obstacles facing health professionals in the developing world. For example, Africa is estimated to have only 4.15 million of the 544 million estimated Internet users as of February 2002.

10. Barriers to Global Communication • Accessibility • Reliability • Cost • Language

11. Accessibility Prerequisites for Internet use - telephone and electricity There are three pre-conditions for using the Internet. First you need a phone connection, second a computer and a modem and third electricity. One in three people globally lacks access to electricity. 80 % of world population doesn't have a telephone line. Ownership or even access to a computer and modem is limited to a relatively minute portion of the world’s population.

12. Reliability A shortage of infrastructure, notably of telephone lines, is a major obstacle to increasing Internet access in developing countries. For example, the average waiting time for a telephone line ranges from 5.3 years in Zimbabwe, to 10.9 years in Tanzania, to 48 years in Nepal. Even when telephones are available, they frequently malfunction. In some African capitals, phone lines can be down up to 50 percent of the time. Completion ratios for local and long-distance calls within the Southern Africa Development Community average 30 percent--and are far lower at peak calling periods. Similar problems are faced with respect to electrical service. Such service can cut out at any time with brownouts and power surges that destroy computer equipment rather quickly.

13. Cost The cost of a computer and modem in many developing nations can be as much as 8 times the average personal yearly income. Institutions in developing nations fare little better than individuals in obtaining computers for use by their medical staff. Even when technology is available, it becomes quickly obsolete in comparison to the equipment used by developed nations. Conditions in many developing nations put more stress on delicate equipment and the availability of technical support and repair is limited.

15. Language It is not just a matter of the infrastructure not being readily available, nor the costs being too high. Even if the telecommunication resources were in place and affordable, most of the world's poor would still be excluded from the benefits of global communication due to illiteracy or the total lack of computer skills. Further obstacles arise with four-fifths of web sites being published in the English language, which although favorable to the West and global patterns of commercial transactions, ultimately excludes the majority of the people on the planet.

16. What Developing Nations Need • Training • Reference Material • Access to Journals and Professional Publications • Clinical Support • Specialized Services

17. Training • Basic skills – IV certification, BCLS, ACLS, PALS, etc. • Specialty training - dialysis nursing, critical care, emergency/trauma, etc. • Continuing medical and nursing education • IT training, PC repair and network administration

18. Reference Material Medical libraries in the medical schools of developing nations are severely limited in size and content. Often the texts that are available are outdated. Most hospitals have no reference facilities at all. The cost of one textbook is often more than the what it takes the average family of four to survive for three months. The situation for nurses is even more acute and the costs more prohibitive.

19. Access to Journals and Professional Publications The cost of just a one year subscription to a medical journal is often as much as a physician’s yearly income is some developing nations. For nurses, the problem is more acute as their rate of pay is substantially less. Journals for other support services such as dialysis technicians, dieticians and social workers are even less readily available. This problem keeps the medical staff of developing nations from access to the latest medical information.

20. Clinical Support In specialties such as Nephrology, there are often few physicians in a given region with whom to consult. In rural areas, specialty practitioners are basically on their own. Access to laboratory facilities and pathology services is limited. The cost of lab tests we take for granted are extremely high. Because of delays in delivering and processing specimens, the results may be unreliable or come too late to be of benefit to the patient. Complex patients often do not have the benefit of multi-specialty referrals.

21. Specialized Services Renal transplant services are not available in many developing nations. Physicians must refer patients who need such services to medical facilities in other countries. The communication between the referring physician and the transplant physician is hampered by the general problems of the particular nation’s communications infrastructure. The absence of organ banks and coordinated donor programs has given rise to the system of “Kidney Brokers”. Even after transplant, patients do poorly because of inadequate follow-up and the inability to obtain anti-rejections medications on a consistent basis.

22. The Importance of E-mail and E-Mail Discussion Groups The web may be the part of the Internet that gets all the attention but e-mail gets a lot of the work done. Users e-mail important documents, discuss urgent issues, and make new contacts by using this simple convenient and efficient part of the net. The strategic importance of e-mail is particularly significant for developing nations, where internet connections are still relatively scarce and expensive. Reducing "bandwidth" waste is at a premium. While many older computers can not be configured to provide Internet access, they can be configured to send and receive e-mail. Thus, e-mail discussion groups become critically important to many professionals in developing nations as it is their only link to their colleagues.

23. A List of Nephrology E-Mail Discussion Groups For Nephrology Professionals • NEPHROL* - general nephrology, all subjects including renal pathology and transplantation(In the body type: subscribe NEPHROL) • NEPHADMIN  - for nephrology administrators(In the body type: subscribe NEPHADMIN) • NEPHBSCI* - nephrology basic science discussion(In the body type: subscribe NEPHBSCI) • NEPHCNPT* - discussions of individual clinical nephrology cases(In the body type: subscribe NEPHCNPT)

24. Nephrology E-Mail Discussion Groups continued: • NEPHDEVEL* - discussion of humanitarian projects and ISN Sister Centres Program(In the body type: subscribe NEPHDEVEL) • NEPHINDIG* - discussion of renal disease in indigenous peoples(In the body type: subscribe NEPHINDIG) • NEPHJNL* - nephrology/transplantation journal club(In the body type: subscribe NEPHJNL) • NEPHMIN - a stripped down version of NEPHROL-DIGEST with all repetition and North American specific content removed, designed for subscribers in developing countries(In the body type: subscribe NEPHMIN)

25. Nephrology E-Mail Discussion Groups continued: • NEPHNPPT* - discussions of individual renal biopsy cases(In the body type: subscribe NEPHNPPT) • NEPHRONOL* - Spanish - English discussion of nephrology subjects(In the body type: subscribe NEPHRONOL) • NEPHHIST* - history of renal medicine, ISN Video Legacy Project interview transcripts(In the body type: subscribe NEPHHIST) • KFINT-L* - discussion relating to the International Federation of Kidney Foundations(In the body type: subscribe KFINT-L) • MDDIALYSIS - for US dialysis unit directors(In the body type: subscribe MDDIALYSIS)

26. Nephrology E-Mail Discussion Groups continued: • PDIAL - peritoneal dialysis(In the body type: subscribe your_email_address) • PedNeph - paediatric nephrology (for renal healthcare professionals)(In the body type: subscribe PedNeph) • RENALPRO - e-mail list for nephrology professionals - nurses, technicians, dieticians, social workers, administrators, physicians, engineers, etc.(In the body type: subscribe RENALPRO) • RENALRD - a listserv primarily for those in renal nutrition.(In the body type: subscribe RENALRD) • CNSW - member listserv social workers. This complete list can be found at: http://www.cybernephrology.org/communication/commProviders.htm

27. Nephrology E-Mail Discussion Groups continued: For Nephrology Patients • DIALYSIS - dialysis(In the body type: subscribe DIALYSIS) • IGAN - IgA Nephropathy(In the body type: subscribe IGAN) • KidneyDisease - for adult patients with renal disease(In the body type: subscribe KIDNEYDISEASE) • NephKids - for parents of children with renal disease(In the body type: subscribe NEPHKIDS) • PKD - a patient's email discussion group for polycystic kidney diease(In the body type: subscribe PKD) • TRNSPLNT - transplant patient discussion group(In the body type: subscribe TRNSPLNT)

28. Guidelines for Developing Internet Sites to be used in Developing Nations • Text and Graphics • Language • Photographs, Video and Audio • Links • Support

29. Text and Graphics Text should be simple and easy to read. Fancy fonts may look good but can make it more difficult for someone with limited skills in English to read. Graphics should be used only when necessary and be limited to graphs and diagrams that enhance the demonstration of a particular concept or skill. (Fancy logos and other graphics that take a long time to load should not be used.) Web pages should be configured to be visually appropriate to low resolution monitors.

30. Language Most medical web sites are in English. While some physicians in developing nations speak english, most of the nursing and support staff does not. Use volunteers to translate the basic information on your web site to other languages. Link to on-line and downloadable translation programs.

31. Photographs, Video and Audio Sometimes a picture is worth a thousand words and sometimes it is not. Photographs should be presented at the lowest possible resolution for faster loading. Many computers in developing nations are not equipped to handle video or audio playback. Provide links to free Internet programs that can be downloaded and used to accept video and audio playback. Make your more complex content available in Zipped File Format. Offer to place complex video and audio portions of your page on CD-ROM so it can be ordered to be sent by mail.

32. Links While many of us are sophisticated enough users to be able to “surf the net” for information we want, please bear in mind that physicians and nurses in developing nations generally do not have that level of expertise. Provide as many links as possible to sites that will enhance the information provided on your site. Rank your links according to relevance and provide a short synopsis of their content so that someone working with limited Internet access can decide if going to the referral site is worth the time and cost. Eliminate any banner ads or other pop-ups that are not directly related to your content. Provide a search engine referral on your site.

33. Support Support is not readily available to persons using computers and the Internet in developing nations. Include a support page that addresses common problems that may be encountered by someone using your page. Provide an e-mail address to someone in your organization who can answer support questions. Make available free programs that will benefit the user of your site who has limited computer expertise.

34. The Renal-Tech Donation Project www.renal-tech.org Founded in 1998, this project is dedicated to providing computer hardware, software and Internet access to physicians and nurses in developing nations. Much of the equipment we provide is donated used and reconditioned by volunteers. These volunteers are high school and college students who exchange their time for training we provide in PC repair and networking.

35. More About Renal-Tech All equipment we provide to developing nations comes with software for word processing, spreadsheets, databases and communications. We provide hands-on training during our visit to a country as well as remote support via our support site. During each of our visits, team members give lectures and clinical demonstrations in their area of expertise.

36. How to Donate to Renal-Tech We accept donations of computers (Pentium I or above), monitors, printers, modems, digital cameras, fax machines, UPS units and software. Both desktop and laptop units are needed. We accept textbooks and journals for both physicians and nurses. We also accept donations of medical supplies, equipment and medications. Donations can be sent to: Zina C. Munoz The Renal Tech Donation Project 7661 Forest Hill Road Burr Ridge, Illinois 60527

37. Nepal • Pilot Project - June, 1998 • June, 2002 - Follow-up • On-Going Programs

38. Pilot Project – June, 1998

39. June, 2002 – Follow-up

40. On-Going Programs • Helping to build a new Kidney Center so that the money currently used on rent can be used to serve patients without sufficient funds for treatment • Developing a monthly continuing education program for nurses • Working to help Kidney Center to attract dialysis patients from tourist population • Helping to develop a disaster plan with the three major hospital Emergency Departments in Kathmandu

41. Kosovo • Fact Finding Mission – December, 1999 • June, 2000 – Connecting the Central Pristina Medical Center Nephrology Department to the Internet • September, 2002 – Setting Up a Network at the Central Pristina Medical Center Radiology Department

42. Fact Finding Mission

43. June, 2000 Connecting the Central Pristina Medical Center Nephrology Department to the Internet One networked computer and two free standing units were placed in the Nephrology Department. Medical software was provided by Dr. Wendy Brown.

44. September, 2002 The Central Pristina Medical Center Equipment for a network in the Radiology Department (20 stations, three floors)

45. September, 2002 Consulting with nursing staff about patients in the ICU Working with physicians from Radiology Department regarding placement of computer stations

46. Plans for the Future • Helping to build a Dialysis Center in Nepal • Coordinating an effort to update nurses training in Kosovo • Traveling to other nations who need assistance in entering the global medical community with equipment and funding for Internet connections • Sponsoring a web site that will provided continuing education programs for nurses in developing nations

47. Technology with a Human Face

48. Conclusion Humanity looks to us, the healers, who minister to the sick and comfort the dying, to provide sanity in a world gone mad with conflict and hate. Our differences in race, religious beliefs and political ideologies are not important. It is our primary goal of giving our patients the best possible care that unites us in a common cause. If we can communicate and build enduring professional relationships, we can help each other care for those precious lives entrusted to us. And, maybe, we can provide an example for the world to follow.