Long-distance house calls
Doctors here link up with patients in remote Cambodia via innovative system
A cart pulled by two oxen makes its way slowly along a dirt road in rural Cambodia. In an isolated area without electricity or running water, this cart bears an unusual load -- computers.
Once installed in Ratanakiri province, in northeastern Cambodia, these solar-powered computers will become part of an innovative electronic network. The mission: to use the power of the Internet to allow doctors from Partners Telemedicine in Boston to provide health care to patients in far-flung places.
Ratanakiri has been largely cut off from the rest of the world because of the poor quality of its roads. The province, which lacks telephone service and regular mail, is accessible mainly by oxcart and motorcycle.
But Ratanakiri is gradually emerging from the shadows due in part to technology developed by First Mile Solutions, a Cambridge-based company founded by two MIT graduate students, Rich Fletcher, 38, and Amir Hasson, 28, which in turn has enabled a telemedicine link with Massachusetts General Hospital to be forged.
Their wireless system, which Hasson calls "wi-fi on wheels," uses a combination of wi-fi technology and motorcycles to bring the Internet to places like Ratanakiri. The system relies on an Internet access hub in the provincial capital, Ban Lung, wireless-equipped solar-powered computers in Ratanakiri, and five motorcycles, each with a storage device, a wireless transmitter card, and an antenna fitted to the back.
Each morning, "motomen" begin their day in Ban Lung, where they connect to the Internet and download e-mail addressed to residents of Ratanakiri. With their electronic cargo in tow, they take off on motorcycles and negotiate the dirt roads to Ratanakiri, a trip of about 20 miles. As they pass the schools with the solar-powered computers that had been carried in by the oxen, the wireless transmitters on the motorcycles send messages to the computers and download new outgoing mail. By nightfall, the motomen head back to the capital and transmit these new messages back through the Internet.
"Ratanakiri does not have copper phones, and it is out of the range of cellular phones, but it does have roads," said Hasson. "This is a way to leverage the transportation infrastructure to create a telecommunications infrastructure."
On Nov. 8, a ceremony was held in another town, Pailin, the last stronghold of the Khmer Rouge, the former communist government of Cambodia, to mark the launch of its link to the rest of the world through wi-fi. Although Pailin is less remote than Ratanakiri, Dr. Joseph Kvedar, director of Partners Telemedicine, said the expansion now going on there is particularly exciting. "It is a place," he said, "that was purposely isolated from the rest of the world for so long."
Among the dignitaries who were at the ceremony in Pailin's hospital were Hasson and Dr. Paul Heinzelmann, a 39-year-old family practitioner from Wisconsin who is attending the Harvard School of Public Health.
"Launching this in Pailin will be different for us and for all of the people involved," said Hasson. "Literacy rates are higher in Pailin than in the other areas we have worked. There is more of an interest in the Internet and communications, and we are going to make an effort to get the whole village, including the elders, involved."
Heinzelmann came to the School of Public Health with an interest in the role information technology can play in improving international health care. A year ago, he got involved with the Partners program when he applied for a fellowship in telemedicine.
"I will be conducting a needs analysis in Pailin," Heinzelmann said, before he left Boston for Cambodia last month. "I will be trying to figure out the equipment, transportation, and diagnostic needs of the existing health centers. There has been a tendency in the past for people to get really excited about the technology but not think so much about how people will actually use it."
Heinzelmann was sent to Cambodia by Partners Telemedicine, an affiliate of Harvard Teaching Hospitals, which has been providing remote medical advice to health-care workers in Cambodia since 2001. Forty to 50 doctors from MGH, Brigham and Women's Hospital, and Dana Farber Cancer Institute have volunteered on the project. Through telemedicine, a local practitioner can send a patient's medical file to doctors at a hospital like Mass. General. Specialists there can then provide guidance on how to treat the patient, sometimes for illnesses the local practitioner is not even familiar with.
The primary problems doctors at the hospital in Pailin see are malaria, childhood respiratory infections, and trauma such as that caused by land mines.
"I'd like to see how we could assist with these and other problems both in terms of educating the local doctors and assisting in clinical care," Heinzelmann said.
Kvedar wants to refine the way telemedicine is approached and make it more responsive to the needs of Cambodian villages. Heinzelmann's findings will shape that effort.
Partners also plans to launch a pilot initiative called "Lab-in-a-Box," a kit designed to allow local practitioners to do more diagnosis at their health centers, which includes simple "dip-strip" tests to help determine what is wrong with a patient. These tests are designed to be quick, effective, and require minimal technology or other resources.
In its early experience working in Ratanakiri and Rovieng, Partners learned that the effectiveness of telemedicine is often limited by a lack of diagnostic resources at local clinics.
The doctors at Partners Telemedicine analyzed the top 14 complaints that remote health centers encounter -- including abdominal pain, palpitations, and chest pain -- and are trying to develop simple tests for them.
"Often, in order for us to provide a diagnosis, the patient needs to go to the hospital for testing," said Kvedar. "In many cases, the nearest hospital is two to three hours away, and many patients cannot afford the taxi ride to get there. An American doctor can provide all the advice in the world, but if I can't get a simple blood count, all that does no good."
The Partners-First Mile Solutions team hopes to build on its experience in Cambodia to address health-care issues in other parts of the developing world.
"We're not yet in other countries together," Hasson says, "but we are in the process of putting together a package. We don't have any specific plans, but we would look into opportunities in Africa, or maybe Malaysia."
But the immediate focus is on making the efforts in Cambodia pay off. "To make something like telemedicine truly sustainable, we need to address the technological, economic, and cultural issues," said Heinzelmann.
And, he said, "put the people before the technology." 