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No place is too remote or baffling for the telemedicine system that has helped doctors in Antarctica and solved unusual cases. In its 10th year of operation, the system, run by the UK-based Swinfen Charitable Trust (SCT), links up with the Oasis Hospital in Al Ain.

Kabul, Afghanistan, May 2007: Fatima, 26, writhes in pain. She clutches her abdomen even though she barely has enough energy to stand.

Her mother and maternal uncle prop up her sick, emaciated body to prevent her from collapsing.
Their faces are streaked with worry.

"Aagh," Fatima gasps, her voice filled with agony.
As mother and daughter make their way to the consultation room, the worry lines on the mother's face gently merge with those of relief and hope.

Their journey has been excruciatingly lengthy both in terms of Fatima's suffering and their travel to the hospital. Fatima has suffered abdominal bleeding for six months and they have travelled for two days by road to reach the hospital.

Prior consultations with
unlicensed practitioners had been futile. Dr Jacqueline C. Hill, the gynaecologist at CURE International Hospital in Kabul, suggests an immediate blood transfusion.

Preliminary tests indicate the presence of a malignant gynaecological tumour. Two days
later a two-member surgical team and Dr Hill operate to debulk it.
Fatima bleeds profusely, indicating decreased chances of survival. After the two-hour operation, her condition stabilises. For the team, this betokens temporary relief; the operation is ineffective because the tumour is advanced.

Dr Hill contacts the telemedicine system set up by the Swinfen Charitable Trust (SCT), a UK-based system based on e-mail referrals between doctors in developing countries and leading specialists in developed nations.

She receives a reply from a world-renowned gynaecology oncologist who tells her the patient's condition is incurable.

His opinion takes the edge off their distress because they did their best given the limited resources – supplies and staff. They have confirmed knowledge of procedures that will
not help. Fatima is terminally ill. For a little while she will be well enough to return to her village, husband and two children to spend the last days of her life.

***
Fatima's case and thousand others are discussed, diagnosed and treated through the Trust's telemedicine system that currently links 145 hospitals worldwide, including those in disaster and post-conflict regions.
The most recent hospital to be linked is the Oasis Hospital in Al Ain. This link was facilitated by Dr Hill who relocated from Afghanistan where she worked for five years.

At the Oasis Hospital, she hopes "to work as a consultant obstetrician gynaecologist and director of physician training and research, contingent on the medical licensing procedures through the Ministry of Health".
She says, "We now have access to world-renowned medical specialists from several fields of medicine and surgery, enabling us to consult on difficult and rare medical conditions to achieve the best possible treatment."

The system has proved to be a valuable tool in regions beset with political, geographical and inveterate cultural constraints.
"I used the system frequently, especially with unusual conditions that were hard to diagnose. I even used it in emergency cases," says
Dr Hill who worked at Medair, a Swiss emergency relief and rehabilitation organisation for a year and a half and CURE International Hospital for three-and-a-half years in Afghanistan.

Another case that benefited from the system was that of a young pregnant lady with a heart condition. She developed serious complications during the seventh month, says Dr Hill. "I needed specialist advice on how to stabilise the mother
and deliver the child. I contacted the Trust.

In a few hours I received three replies that helped me save
their lives." For doctors in remote areas, the system provides instant access to
more than 400 (419 till date) recognised and reliable specialists, thus boosting morale.
"When a specialist says, 'I would do the same in your situation', it gives me confidence. The exchange of opinions and advice helps me make informed choices," says Dr Hill.

The first time she heard of the Trust system was through a friend at the Royal College of Obstetricians and Gynaecologists, UK. At the time, she had moved from Medair to CURE International Hospital, while her husband Eric, country director, was still with Medair.

"Together we registered along with our respective organisations. We were dealing with high maternal and infant mortality rates, complicated cases and limited resources," says Dr Hill.
She hopes her experience with the Trust will benefit the Oasis Hospital, which is also supported by the American Charity CURE International, and that "the hospital is looking forward to use this telemedicine resource and develop their relationship with the Trust".

Several studies have proved that a telemedicine link is technically feasible and can be of significant benefit towards diagnosis, management and education in developing countries. Read on to know how its founders, Lord Roger and Lady Pat Swinfen set it up.

The Trust

For 10 years, the Trust has connected doctors with free medical advice.
Lord and Lady Swinfen, say the system is like a virtual hospital. "No patient is ever turned away or charged a fee. The system never runs out of beds. And all patients are treated regardless of religion, race or politics."
Since its inception, the Trust has facilitated the treatment of more than 1,800 cases and saved numerous lives. Some cases are common and not serious.

Others life-threatening like the case of a person injured in a terrorist attack in Iraq or unusual like the case of a child in Tibet who suffered painful swellings that discharged larvae.
Lord Swinfen, a retired
army officer, handles fundraising
and general administration; Lady Swinfen, a retired nurse, supervises systems operations.

They are grateful and "privileged to have the volunteer services of some of the most highly qualified medical personnel in the world". Specialists represent a range of disciplines: anaesthetics, neurology, surgery, nephrology, nursing, radiology, dentistry, paediatrics, pathology, plastic surgery, and obstetrics
and gynaecology.

The system links hospitals in 43 countries including Afghanistan, Pakistan, Kuwait, Cambodia, Nepal and Sierra Leone and even Antarctica. The Trust continues to expand its operations and one of the most recent to be linked is violence-wracked Iraq.

The Swinfens travelled to the country to establish links with one medical clinic and 12 hospitals in early 2004. Since then 28 hospitals in Iraq and many individual doctors have established telemedicine links with the Trust.

The Swinfens say telemedicine isn't a new idea. It has existed in various forms for years. In rural Colombia and Peru for instance, consultations between village health workers and a regional hospital were carried out via radio transmission.

Other systems operated between French-speaking regions of Africa and Geneva, Switzerland, and between hospitals in the developing world and specialists through an e-mail referral system.
These systems, however, weren't primarily for direct clinical use or for use between doctors and specialists in different countries, unlike that of the Trust.

It started with one hospital in Bangladesh

The Swinfens were told about a simple e-mail store and forward telemedicine system set up by three UK Defence Medical specialists during their voluntary work – since 1992 – with the Centre for Rehabilitation of the Paralysed (CRP), Bangladesh, in November 1998.

It was developed by Lieutenant Colonel David Vassallo of the Royal Army Medical Corps (RAMC), Surgeon Commander Peter Buxton
of the Royal Navy and Wing Commander John Kilbey of the Royal Air Force (RAF).

Lt Col Vassallo used a digital camera and tripod to take photos
of his patients. He sent these along with case histories through satellite to his colleagues for advice on diagnosis and treatment.
Back then, the Swinfens identified telemedicine as a bellwether for the health industry.

"They [the persons who set it up] generously suggested that we run a trial of their system in a civilian hospital in the developing world. This resulted in the first Swinfen telemedicine link at the Centre in 1999," says Lord Swinfen, mentioning the link is still in operation.

As new hospitals registered, they found it necessary to automate. In 2002 they did so with the help of professor Richard Wootton who
at that time worked at the Centre
for Online Health at the University of Queensland.

Despite the groundswell of support, one of the problems they encountered was the lack of telemedicine knowledge in developing countries. "This was entirely understandable," says Lord Swinfen, adding, "The news of telemedicine spread by word of mouth."

Medical help is an e-mail away
Lord and Lady Swinfen work from their home located about 75 miles southeast of London.
They ensure the system operates round-the-clock, 365 days a year. The monitoring is mostly done by four volunteers – two in England, one in Scotland and one in Tasmania.

"There is one part-time, paid administrator in the UK who mostly devotes her time to fundraising," says Lady Swinfen.
The first step is to establish a link between interested hospitals and the Trust. Then equipment – digital camera and tripod – is provided and appropriate training is arranged.

Referring doctors e-mail clinical photos, patient history and any other relevant material – test results, X-rays and case notes – to the Trust. These emails are handled by a secure web-based messaging system.

The systems operators then allocate cases to specialists who review case history and e-mail
the referring doctor with diagnosis and treatment.
"The requests vary from none to eight per day," says Lady Swinfen explaining the cases differ from region to region due to factors like climate, culture and relative wealth. "Very often the local situations dictate what is available in hospitals. Tropical countries will have more parasitology cases and childhood diseases for example," she says.
The average length of time between receipt of original message and the first reply by a specialist is 1.8 days.

If a specialist doesn't respond within 48 hours, a systems operator re-allocates a case to another appropriate specialist on the database, Lady Swinfen explains.

She also mentions the system archives all messages and operators can keep a check on traffic to ensure referrer and specialists are in touch.
Though telemedicine isn't an emergency response route, it has been in several cases like the recent case of a 36-year-old man in Iraq who survived a serious bullet wound.

Lord Swinfen says, "Cases are sometimes answered quite rapidly;
10 minutes was the fastest response. However we do our best to get a response within 48 hours. If necessary, the systems operator will allocate a case, and re-allocate quite rapidly, and in special circumstances even telephone specialists."

Telemedicine benefits

As a unique means of consultation, telemedicine has also proved to be an invaluable educational resource for otherwise isolated doctors. When a specialist doctor responds, he provides updated, detailed and instructive notes. And as such
the educational value goes beyond
the information transmitted by
the specialist.

The telemedicine system set up by the Swinfen Charitable Trust (SCT) leads to patient benefit and increased medical knowledge that a referring doctor can pass to his peer group. It can lead to improved management of cases, and earlier discharge from hospital.
The system also makes it possible for a patient to stay in his own country and be treated by his own doctor instead of incurring high expenses to travel to another country for treatment, often unsuccessfully.

The Swinfens say, "In Bangladesh, many people sell their land to pay for medical treatment, making themselves and their families landless. What the Trust provides avoids this tragedy. When a patient is kept in his own environment, it obviates the need for a specialist visit thus reducing their combined carbon footprint. The Trust is proud of its role in this."

Successful endeavour

The principal achievement of the
Trust is the demonstration of how cost-effective telemedicine is in developing countries. The Trust also takes pride in its ability to locate an appropriate specialist.
The Swinfens speak of their success with marked modesty. "Suffice to say that SCT has been running for 10 years and the initial specialists are still using the system. It is said that ours is the longest running, and is an example of the widespread use of simple telemedicine. We don't make extravagant claims, but certainly feel the system will run and run," says Lord Swinfen.

Doctors working in developing countries where medical specialists are most needed, but least available, have benefited from the system the most. The Trust works towards identifying such countries.

The Swinfens are happy with their endeavour, especially in Iraq where strict international sanctions and war have destroyed and depleted the infrastructure and affected healthcare services, making it extremely difficult for doctors to keep up with developments in their specialities. (The most modern hospital was built and equipped in 1984. However a new children's cancer hospital is under construction in Basra.)

The Swinfens emphasise the continuing need for funding as
the system expands. "Even with the best will in the world, it cannot run without increasing funding," they say.

Carolina D'Souza is Lifestyle Features Coordinator, Friday

For more info, log on to
www.swinfencharitabletrust.org