March 2007

Telemental Health Support After Disasters : Dr. S.B. Gogia

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Many e-Health experts have emphasized that IT will and can help disaster management, but much preparatory work is required. However, whenever IT in healthcare, and specifically for disasters is being talked about, the discussion has concentrated on the technology rather than how it should be used to help the people

Telemedicine literally meaning medicine from a distance is a means of improving access to healthcare for far  flung and remote communities, by providing a virtual doctor at their doorstep. It is expected to be the next big leap in Indian healthcare, for telemedicine has a force multiplier effect in widening the reach and access of medical specialists. This would be the single most factor to allow India to reach the status of ‘Healthcare for All’ by 2020.

After any natural or man made disaster, supplies, food, etc. can be moved to the affected area, but disease and healthcare needs require specialized care, which in most cases mean a reverse transfer. In disaster situations, health problems and their management can broadly be classified into three phases. These are:

1. Immediate phase – first 2-3 days, requiring evacuation and care for the injured, disposal of dead bodies, etc.

2. Intermediate phase where the emphasis is on sanitation, shelter and disease prevention.

3. Late or rehabilitation phase where the shattered lives and livelihoods have to be rebuilt.

Use of IT can improve the outcome in all three. While the beneficial use of IT in the first and second phases are better known, they require a huge infrastructure to be in place even before the disaster has occurred. Since most funds are released after the disaster, we believe that IT and telemedicine technology can and should be used to improve the outcomes.

Telemedicine has been found to be an effective method of helping the healthcare aspects of disasters, by providing healthcare specialists virtually to the affected area, thereby overcoming geographical barriers. The process can be sustained over a long time – a critical and often overlooked aspect especially for the rehabilitation phase- as most relief agencies tend to pack up and leave after the acute phase is over.

Many e-Health experts have emphasized that IT will and can help disaster management, but much preparatory work is required. However, whenever IT in healthcare, and specifically for disasters is being talked about, the discussion has concentrated on the technology rather than how it should be used to help the people. Most of the budgets literally crores have been spent entirely on the technology along with grandiose inaugurations. Most have seen little turnover after the initial hype was over, with an average turnover of less than one patient a day.

However, despite the odds, telemedicine remains the panacea for addressing healthcare issues during disaster, and there are some organizations in India who are doing commendable work in the field of telemedicine to alleviate the sufferings of disaster affected people. One such name is SATHI. SATHI, an acronym for Society for Administration of Telemedicine and Healthcare Informatics, is a resource organization for Healthcare information technology (HIT), consisting of IT savvy doctors, community health specialists, IT personnel, telecommunications experts and sociologists. SATHI has been involved in implementing the Healing Touch Project, which was sponsored by OXFAM Trust India. As project consultants our role was to pilot a sustainable telemedicine system which could also provide a roadmap for the future.

This project was started after the Tsunami disaster in Tamil Nadu, to benefit the surviving victims. Telemedicine being a new and yet untested field, many problems were faced. However, despite a delayed start, the project has managed to provide mental health support to the victims, while they were at home, virtually, through specialists working in their hospitals in Chennai.

The project was based directly on the needs at the grassroots level. We had a limited budget in hand and to maximize returns, we followed the approach of proper planning and implemen-tation, based on the actual needs at the grassroots level. Search for proper locations, appropriate partners, capacity building, orientation, social marketing, etc. were part of the elaborate planning process.

Our first step was to initiate a visit to the affected area and to do a needs assessment of the various health problems which were to be tackled in the affected areas in Nagapattinam district. When we visited the area in late January 2005, we found that the immediate and intermediate phases were over and were well managed, thanks to the prompt action by the state government and supporting NGOs.

However there was a need for mental health support due to high incidence of a sense of loss and bewilderment and alcoholism, with the survivors still in grip of fear and shock due to the loss of family members and loved ones. They were anxious, depressed, still displaced and unemployed with an unwillingness to venture back into the sea for fishing and other means of livelihood. Most were largely ignorant about tsunami and were unable to cope with the after effects and didn’t know how to be prepared for another similar eventuality. We ourselves experienced mass panic reactions wherein a high tide was thought to be another tsunami wave.

The occurrence of this problem was articulated by WHO at around the same time. We felt that the steps taken by the government for upgradation of mental health of the victims were inadequate, as well as wrongly directed. There also were no proper guidelines for its management, in the existing protocol available with the government offices. Though social workers as well as psychiatrists from NIMHANS Bangalore had visited the area, the visits were too early (PTSD takes a few weeks to be established as a clinical disorder), too short and sparse, and could not leave a lasting benefit. There was also a mismatch between the needs and available services around the affected areas, with a severe dearth of mental health specialists.

Though social workers as well as psychiatrists from NIMHANS Bangalore had visited the area, the visits were too early (PTSD takes a few weeks to be established as a clinical disorder), too short and sparse, and could not leave a lasting benefit

We could also see the increasing trend of psychosocial effects depression and alcoholism with stress and fatigue among relief workers. There was no community participation in the rehabilitation efforts. Information available from the experts in WHO told us that 80 90 percent of the population would be expected to have a lowered mental health status after such disasters. Though that situation of lowered mental health would improve in most but would sink to the level of requiring a specialist help in around 4 5 percent. Here it deserves a mention that PTSD and other serious mental problems manifest a few weeks after the disaster and the effects can last for up to 1 2 years in some cases.

The problem was in identifying the exact persons, who would require specialized medical help. This meant a virtual door-to-door search on a repeated basis. Telemedicine was felt as the right solution to the problems as it would allow the specialist to train the health workers, who being in the community could organize such searches better on a continual basis and identify the 4-5 percent of the population who require help. This would ensure access to specialists’ services for the victims and would also ensure quality. However, it was important to look for problems among the health workers themselves too who might themselves be affected.

A continual dialogue was possible through video conferencing, allowing people to articulate their needs and participate in interactive sessions with experts. This enabled the service provider to be need specific and strengthen the healthcare delivery system. It increased the efficiency of the service provider who could cover more areas.

A teleconsultation time-table was made and a tele-conference based training module was developed, which was based on assessed needs and considered human rights perspective. It provided on the job and continual training, using an innovative, interactive and participatory training methodology, supported by audiovisuals.

The Project Cycle

The project was conceptualized in January 2006. All initial processes such as identification of stakeholders, operators, locations, etc. were ready by mid February. 6 -7 units were planned in the periphery and one in the center. SCARF (Schizophrenia Research Foundation) was identified as the central unit, which would provide mental health support. This selection was based on willingness to do voluntary work and familiarity with language, as well as proximity to the affected areas, so that in case of need, actual transfer and care should be possible.

Units in the periphery were to be located in various places, depending on how much affected the population was and the willingness of local NGOs to run the system and to pay for the running costs. Proximity to the exchange (to allow ISDN connectivity) and access to government channels were two other important factors influencing location of periphery units.

The units were to be located in the PHCs or government hospitals and run by the health workers, with the supervision and support of local NGOs. OXFAM had promised funding support for the machines as well as for maintenance and connectivity, for the first six months. Currently there are three systems, two in the periphery managed by ISED (Dharmakulam in North Nagapattinam district) and PEDA (Karaikal) and one in the center (SCARF short for Schizophrenia Research Foundation) in Chennai.

The project however could not start till the middle of May due to various reasons. First of all the funding was slow and it was never fully released; so the scope of the project had to be shortened.  Lack of connectivity proved to be another impediment. Satellite connectivity was promised (from the French Govt) in three locations but the antenna did not work and ISRO connectivity was beyond the budget.

Furthermore, ISDN lines, which were promised within two days of application, took a minimum of two months. Moreover, in some areas the exchanges are too old so the project had to be shelved after extensive preparation.

ISDN connectivity was a problem, leading us to drop the initial choice of location from the Taluk Hospital in Tharangammbaddi, which incidentaly housed a large rehabilitation colony in the premises of the hospital. In fact this hospital had been flooded by the tsunami. Delayed release of connectivity elsewhere also delayed implementation. After this experience, we decided to look for locations only if the connectivity could be easily established. Besides, this being a new type of technology, there were doubts about the project and delays meant that continuous retraining of volunteers was required.

However, once the connectivity was established and the system was up and running, the results have been gratifying. There have been thrice weekly sessions where in patients were asked to come to the local telemedicine center.  They were seen online by doctors from SCARF, and counseling was done. The medicines which were prescribed by the doctors at Chennai, were provided to the patients by the attending volunteers a separate stock of medicines used was kept locally as no chemists were available in the periphery where the patients were undergoing treatment. This solution was provided by SCARF and the local agencies.

There was a need for mental health support due to high incidence of a sense of loss and bewilderment and alcoholism, with the survivors still in grip of fear and shock due to the loss of family members and loved ones

Currently, the patients in these and surrounding areas requiring mental health support have been largely treated. OXFAM has been happy to hand over the project along with the installed equipment to SATHI to manage and use further as they please, now that the basic functions of the project are over. The volunteers from Dharmakulam are now asking for online treatment for other specialties like general medicine, cardiology, etc.

In retrospect, much more would have been possible if we had a freer hand and got more support. Mobile units and easy satellite connectivity would have allowed us to provide help for a large segment of the affected population. Early release of all the funds was another constraint, which induced us to cut down from ten planned units to three. Thus the psychiatrist sitting on his computer screen in Chennai would have seen and managed many more persons online if there were enough centres in the periphery.

This project has been different form other telemedicine projects in the sense that it was:

(i) Sponsored and managed by NGOs;

(ii) the local community NGOs were directly trained to manage their own health problems after the natural disaster;

(iii) intensive pre and post ution work was done.

An independent uation was conducted in May 2006 and this report has pointed the project in a highly positive light. Overall the conclusion of the report was ‘Telemental health is economically viable.’ We as a nation and society should wake up to this possibility.

Ultimately, technology should be used to solve the problems of the people. Unfortunately most telemedicine projects have not succeeded because they focus too much on the technology and less about the needs of the people who have to utilize those technologies.

A paradigm shift in the management of such new technologies in healthcare is the need of the hour. Much ground work and a road map for future disaster management needs to be created in this regard.

Note : I  acknowledge the contribution of my SATHI members and partners: Dr. M. R. Surwade, Project Co-ordinator and Ms. Gurinder Kaur, the  then Director of OXFAM. 

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