Impact of telemedicine must be defined in developing countries

Editor—The editorial by Edworthy shows the dangers of external commentary on what is most useful for developing countries.¹ How can we measure the comparative impact of teleconsultation in Uzbekistan or Cambodia with teleconsultation in snowbound northern Canada, telemetry in Norway supporting elderly people at home, or teleradiology avoiding long painful journeys in remote parts of the British Isles? What values do we use—economic, social, quality adjusted life years, consumer feedback, political position, or provider satisfaction?

More importantly, how do we measure the impact of telemedicine on the health systems of developing countries? Will strengthening secondary care for a few disadvantage basic primary care or environmental health for the many? Will investment in the required rural telecommunications be at the expense of providing drinkable water? Will developing countries too be seduced by the expensive impact of technology led tertiary care for the few, while ignoring the endemic impact of modified health related behaviour? Will opportunistic global traders exploit the vulnerable?

Most electronically available health knowledge is from the “developed” world—it may not be appropriate for developing countries. Remote experts may not know what treatments are available, affordable, or acceptable locally. Teleconsultation through a local clinician may initially strengthen local skills, but when used on a larger scale it may stifle the development of local resources and lead to a dependence on economically draining Western commercial exports of expertise online. The risks of globalisation reducing local autonomy have been reported.²

These are real issues, but they should be debated on the grounds of local values of appropriateness and priorities. The pull of needs, not the push of supply, should be the determinant. The voices of local experts, rather than external commentators, should be heard as the lead voices.³ Initiatives to identify culturally and locally relevant yet sound sites should be encouraged, and open debate initiated on the core issues.⁴ If telemedicine is to have any significant and safe impact in developing or other countries, global agencies such as the World Health Organization need to encourage and accumulate studies on its local impact, while also seeking a global framework to ensure its safety and ethics.⁴,⁵

Opportunities for benefit from telemedicine are great; so are the opportunities for harm. The future debate should be couched in terms of local health priorities and impact, and on global ethics to ensure sustainable assured solutions.