Abstract
People can be vulnerable to avoidable disease, disability, or death due to a lack of medical care. The vulnerability could be due to disaster, epidemic, poverty, or any combination of chronic diseases where the access to appropriate healthcare is compromised because of physical or cognitive resources, distance, or complexity of the problem. The power of telemedicine to overcome distance and provide unprecedented access to healthcare has long been celebrated and chronicled in Telemedicine and e-Health.
The magnitude of global health issues is difficult to comprehend. Let us consider three issues that have been powerfully addressed in the first 20 years of the Journal. First, let us consider poverty. In excess of 80% of the world population lives on less than $10 per day. 1 The consequence of such ghastly poverty is poor hygiene, inadequate nutrition, tragic lack of education, and certainly a low level of expenditure for health. The cost of health per capita in the United Kingdom is $3,647, and the outrageous expenditure in the United States is $8,895 as reported for 2012. However, India can only afford $61 per year, and the amount in Burundi is an annual amount of only $20. In a nation like Sierra Leone, with the current challenge from the Ebola virus, it is unlikely all cases can be evacuated by air to prominent medical facilities when the nation can only summon an expenditure of $96 per year for all health needs. 2 Telemedicine can make an enormous contribution to improve healthcare in even the worst situation by providing information, accurate data management, patient education, and coordination or resources.
India is an excellent example where telemedicine has been systematically applied to vast rural populations locked in seemingly inexorable poverty. 3 Telemedicine can contribute through expert consultation where specialist care is simply impossible. 4 –6 Telemedicine has shown immense value in program and data management 7,8 and in the coordination and facilitation of primary care. 9,10 Telemedicine has had a major impact on nursing, other health disciplines, and even advanced clinical activities by non-physicians. 11 –13 Telemedicine is a vehicle to educate the provider and the patient. Information is extraordinary in its energy. The use of telecommunications to inform is amazingly effective to empower and embolden patients and practitioners. 14 –16 Telemedicine is not the complete answer, but an informed and capable local population may insist upon the kinds of development and human improvement that will accomplish so much more than care of a single case of a rare disease. 17
Second, telemedicine can be the instrument of choice to extend the bubble of care and competence beyond our sophisticated medical environments to the home or near home. Such an extension may be considered an essential element in a new care model. 18,19 Indeed, telemedicine makes home healthcare even less in cost than physical visits 20 and makes the travel of patients for specialty care unnecessary even in short-supply specialties like psychiatry. 21 –23
The threats to human health are varied. The threats of war, famine, new diseases, climate change, etc., are imponderable. Malthus would have predicted dire consequences from our steady growth of population in the world to the current 7 billion persons with steady advances of war, famine, and pestilence. However, nuclear war seems less likely than any time in the last 50 years. At the same time, the deadly little wars of sectarian, tribal, and nationalist origin do proliferate. Famine has been averted in many ways by the green revolution principles of Borlaug since the 1960s. Despite the fluidity of the population and the possibility of rapid spread of new infections, we still seem to get by, albeit with great human suffering in the short run from, for example, human immunodeficiency virus and Ebola virus, even when some old enemies are gone or almost gone such as smallpox and polio. However, the growth of an aging population in the developed and developing world seems inexorable and astonishing in terms of implied health issues and resource requirements.
Let us consider the third issue: aging. The Administration on Aging notes that in the United States, persons over 65 years of age numbered 39.6 million in 2009 at 12.9% of the total population. That number is expected to grow to 72.1 million in 2030. Sadly, older people are not very healthy! In 2010–2012, only 42% of Americans over 65 years of age identified themselves as in excellent or very good health. In 2009–2010, people over 65 years of age had three times the rate of short-stay hospitalizations compared with the rest of the population. Older people reported a 43% increase in out-of-pocket health expenses since 2002. That is, not only are there so many more older Americans, but their individual healthcare costs are increasing at a pace far above those of the general population. 24 Here is one vulnerable group that is a sure bet to challenge healthcare initiatives, and telemedicine must be a prime tool to avoid overwhelming the economies of the world. The Journal has long attracted excellent articles on telemedicine to alleviate the problems of aging patients. 25 –27 This could be an extension of rehabilitation, cardiac care, or disease management of, say, diabetes or hypertension. 28 –30 It is an irony that the outcome of improved healthcare in the world has indeed made possible the general growth in population and poverty with an especial emphasis on the longer lives of our peoples.
Telemedicine is a great tool to be applied generously and expertly to the problems of health in the world. The pages of your Journal have been replete in the scientific and basic clinical studies that instruct our use of this powerful technology. We in the telemedicine community are in some link or another part of the greater healthcare worker community of the world. It is clear that we are energetic and sometimes very effective in making our contribution. It is not easy. We insist that health workers learn daunting new technical skills. It is necessary that old practices go away in favor of those that can be proven effective in the coming challenges of medicine. We insist that patients join us in the technical challenge and become full partners in human health.
Let us take a moment to recognize that the health workers of the world have been extraordinary acolytes of telemedicine if the procedures presented to them are acceptable and compatible with their workflow. This robust application of technology speaks loudly to the ethics of global medicine with always the interest of patients held above personal interest and personal sacrifice.
Furthermore, let us recognize that the greatest enthusiasm for telemedicine is not in the healthcare world but among patients. They are not passive in the least. As information makes it clear that expectations for health can be stratospheric, the world population leaps at technical solutions and information sources with an almost mystical confidence once reserved for spiritual guides and charlatans. Vulnerable populations will never be abandoned by medicine, and the needful peoples of our world will always expect the best of us and spur their own efforts to new and astounding levels of participation and self-care. They do it for themselves, their children, and their elders. We do it for them all.