A path forward: Global health, telemedicine, and hematology
Authors: Adam F. Binder, Janice Gabrilove
Journal: American Journal of Hematology (2016)

Health organizations as well as individual providers continually develop programs attempting to close healthcare gaps. However, in resource-limited countries, this can be particularly challenging given the dearth of medical specialists including hematologists. According to the World Health Organization (WHO), anemia accounts for 8.8% of all years lived with disabilities 1. In addition, moderate to severe anemia can be associated with significant morbidity and mortality. We proposed a tele-hematology pilot/feasibility study to assist in the diagnosis of patients with anemia in clinics without access to hematologic expertise. Similar global tele-medicine models have been successful in both Dermatology and Pathology 1, 2. While well described tele-hematology programs have been implemented on a national scale, we are unaware of any well studied tele-hematology programs between international collaborators 3-5. In 2004, Luethi et al. reported that the store and forward method is an effective model for hematologic consultation, particularly when evaluating anemia cases 3. Across all disciplines, the process of developing and implementing new, innovative programs poses significant challenges. Therefore, it is important to anticipate roadblocks that might impact the study's feasibility. Scenario planning is critically important, allowing for the prediction of obstacles, identification of solutions, and delineation of alternative pathways to achieve one's goals. However, regardless of planning, there will be unforeseen complications. These complications may vary with respect to the scope of the project, location, costs, and timing. Here in, we will discuss some of the challenges that we faced when establishing a tele-hematology program in a resource-limited setting. As technology is integrated into our healthcare systems, international collaborations will become important drivers of creative, innovative global tele-health solutions. As a result, learning from the dilemmas and challenges posed by this research experience may provide insight and facilitate the construction of better models for similar projects in the future. One of the most important steps to maximize the likelihood of success in establishing a clinical program is obtaining the support of the local community. Gaining support requires understanding the community's needs and how the intervention will integrate into the current health system. Without the interest, dedication, and backing of local providers, it will be difficult to initiate, build, and maintain a program. In addition, in order to reinforce its sustainability, training local providers should be folded into the program's objectives. The program should empower, not overburden providers. As a result, each attempt to pilot the tele-hematology initiative was developed in concert with local physicians, laboratory technicians, and healthcare administrators. We next considered specific challenges of implementing a tele-medicine program. Tele-medicine relies on the integrity of the country's internet infrastructure. A slow Internet speed would result in delays uploading images, fragmented video conferences, and frustrated providers. Consequently, this inefficiency would likely result in decreased service utilization over time. Fortunately, tele-communication infrastructure has been improving globally and reliable Internet connectivity is becoming commonplace even in remote areas. An equally important factor is reliable electricity. In some areas, the internet infrastructure may exist, but frequent electrical outages will limit functional capacity. The presence of backup generators can address this issue. We met a few organizations who were interested in the project, but they did not have the infrastructure needed to sustain a tele-medicine program. Available materials and skilled technicians are two additional key components impacting the project's success. Preparing the peripheral blood smear is relatively simple, but the materials required may not be readily available. If a skilled laboratory technician is not available, then we would need to train individuals to make blood smears and recognize morphologic abnormalities. For materials that are not readily available within the region or country, supply-chain issues could arise. While we anticipated many potential roadblocks, three major unforeseen challenges impeded the successful launch of this project: (1) a regional/global health epidemic; (2) political instability; and (3) barriers enforced by the local healthcare authorities. On further inspection, the nature of these challenges should be taken into consideration when designing interventional strategies to improve healthcare in any underserved area. The events we confronted in the context of this project could occur anywhere in the world. However, the first two, in particular, are more prone to occur in resource-limited countries. Health epidemics can disrupt and alter the focus of society even in the most developed nations, but in resource-limited settings, it can drastically alter the economy, overwhelm the health system, and interrupt daily living. In January 2014, we developed a relationship with an organization working with a clinic in Sierra Leone. The project was evolving smoothly and there were plans to initiate the program mid-summer. However, early in the summer, it was evident that the Ebola virus outbreak was a regional epidemic. By August, the W.H.O. declared the epidemic to be of international concern 6. Epidemics of this proportion can consume any health infrastructure, but in one of the world's poorest nations, it not only overwhelmed the health infrastructure, but also every aspect of daily life. Communities were quarantined, transportation halted, borders closed, and patients were not receiving basic medical care 7. Supply-chain links broke down. When we attempted to ship supplies to the clinic, the materials never arrived and we were unable to track their location. Subsequently, the local clinic temporarily closed to retrain its healthcare workers to treat patients with Ebola and then re-opened focusing on much needed intensive, supportive care. This disrupted the implementation of the tele-hematology project as all energy was refocused appropriately. While this epidemic interfered with the implementation of our project, depending on the scope of the project and the urgent need of the community, these challenges may not de-rail a project so much as slow it down. With respect to the Ebola epidemic, international efforts to treat and control Ebola exemplified many of the successes as well as the challenges of implementing programs in resource-limited settings. Since the project in Sierra Leone was placed on hold indefinitely, we began looking for other collaborators and were introduced to an organization working in Burundi. They had an outpatient clinic and were planning to build a small inpatient facility. There was significant interest in the tele-medicine project; however, an upcoming Presidential election in the country was causing political riots. As the elections neared, the country's capital seemed to become increasingly unstable. The clinic was located in a region unaffected by the political turmoil, but instability in the capital prevented me from travelling to the clinical site. Political instability surrounding elections is not unique to this country. In 2015 alone, upcoming elections in various countries resulted in temporary turmoil and instability 8. While we might have been able to predict that there would be conflict surrounding the elections, it is difficult to predict the degree of instability and its duration post elections. While the political climate prevented us from visiting the site, programs already in place continued to grow and new projects are being developed with local and regional support. In addition, there are ways to circumvent this challenge. One strategy is to design an interactive web-based training module in order to train community members without visiting the site. This strategy may be difficult if you do not have a pre-existing relationship with the organization, but may be achievable if there is a local provider acting as your representative. Another strategy is to weigh the risks and benefits of visiting the country regardless of political stability in order to establish and develop health initiatives for those that need them most. With respect to our project, it was felt that the tele-hematology project was not vital to the current needs of the community to heed the travel warnings. The last roadblock we faced was unexplained opposition to the project by local hospital administrators. This issue underscores the need for optimizing the utilization of grass root initiatives and community-based participatory strategies. At a third clinical site, we initially had overwhelming support from physicians and the hospital administration. As we moved forward, logistical issues and internal disagreement regarding the laboratory infrastructure halted the project's implementation. Thereafter, any proposed solutions were ignored reflecting a loss of support. Some of our misunderstandings with the administration may reflect a lack of cultural understanding or perhaps lack of understanding of the needs of the hospital. This roadblock re-enforces the importance of understanding the local community, their needs and their culture. While determining the needs of the local community, garnering their interest in and support of a project are integral to any implementation plan; it is only the starting point. It is important to anticipate unsuspected hurdles prior to establishing an effective, impactful, and sustainable program. We hope that this commentary will provide a framework on which to minimize barriers, maximize pre-implementation planning, and encourage creative solutions to newly encountered obstacles. Adam F. Binder* and Janice Gabrilove Icahn School of Medicine at Mount Sinai Hospital, New York, New York