TED Conversations

Steve Garguilo

Emerging Markets, Johnson & Johnson


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What can a sustainable telemedicine business model look like, and how do we get buy-in from those with the resources to make it happen?

In developing regions such as sub-Saharan Africa, the ratio of people-to-doctors is as high as 50,000:1. In the US, this ratio is 390:1. This means patients have to travel long distances at a considerable expense just to reach a doctor.

I worked with a team from Penn State University (http://www.mashavu.com/) on a unique, sustainable telemedicine solution comprised of highly low-cost, ruggedized biomedical devices designed specifically for the developing world. Devices will collect medical information including weight, body temperature, lung capacity, pulse rate, blood pressure, stethoscope rhythms, photographs and basic hygiene and nutrition information. These readings would be paired with a healthcare questionnaire, medical history, and pictures which describe their symptoms, and then sent to a doctor for remote triage. The doctor then provides feedback through the same device. The solution would enable doing the initial triage and would provide the patient with remote health advice.

Though there have been MANY telemedicine projects in the past, most of them were experiments - they were VERY expensive and lacked an entrepreneurial outlook to ensure economic sustainability. A major constraint is that 95% of the biomedical diagnostic equipment used in Africa is imported, extremely expensive, not ruggedized and not repairable when it fails. This will be a low-cost, ruggedized option for decentralized diagnosis and triage of patients.

Three years of work in Kenya and Tanzania shows that people are willing to pay for a service like this because it cuts down on travel time/costs, and a pay-per-use business model will make this a sustainable venture rather than philanthropic. What should the model look like to really make it work? What are the flaws with this concept? How can we manage/mitigate/be willing to embrace the complexity? I want to influence decision makers at J&J, but don't have all the answers. I look forward to responses from the TED community!


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    Feb 15 2011: Steve, I think this telemedicine concept is great in theory, but I can't see it working in poorer countries with very high patient to doctor ratios. Instead, I could see it being viable in a place like the US for people who live very rurally or are house bound due to disability or illness--but as a supplement to an in person visit, or for clinical visits that don't require touching (eg psychiatry). As a doctor who's worked in rural and urban areas in the West, and in rural and urban areas in low income countries, I can tell you that you gain a lot of information from being in the same room as someone. Telemedicine with video capability would be good for triage and follow-up visits, but nothing beats the laying on of hands for diagnosis. In a place like the US, telemedicine could work as a cash service (eg via PayPal until insurances cover it), based on time spent with a patient. In poorer countries for non-wealthy patients, doctors usally don't spent more than 2 minutes per patient, and in that case, telemedicine is no substitute for an in-person visit. And figuring out payment systems there would also be tricky. Of course it would be ideal to have more doctors and to have them better distributed to rural areas. But, in the absence of that, community health care workers and auxiliary health workers (rural midwives, nurses) are a better solution than offering a doctor by telemedicine. If you want me to give you a detailed view on this telemedicine device, I'd be happy to examine it and give you more feedback. Here's how I can imagine telemedicine working in a developing world context--as a support to the country's doctors, to allow them to communicate with experts outside their country (eg for diagnostic dilemmas or 2nd opinions or for clinical mentorship). Hope this is helpful to you. Best of luck.
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      Feb 15 2011: Nassim - thank you so much for the valuable feedback.

      Your point about community healthcare workers and auxiliary workers is especially true. In our work in Kenya and Tanzania, it proved valuable where these workers played a key role as the operator of the device, either in remote locations expanding the radius of the doctor's practice and using the device when necessary to communicate with the doctor, or at a doctor's office so that this triage could happen before a patient needed to see a doctor. This unburdened the doctor so that he/she is only seeing more critical matters.

      Great idea surrounding connecting doctors to other doctors, definitely an area I need to research more as I'm sure there may be some programs like this that I can look at.

      Perhaps a better question to be asking is one that is more broad and not device/solution-specific: What role can you see an organization like J&J playing in helping to solve this challenge? Given that a device alone certainly won't solve the challenges, what would be the best model of partnership with NGO/MOH or projects that we can execute that would help? So many organizations separately want to tackle this problem, but I wonder what truly is an effective way to contribute to the solution?

      Thank you again for providing your expertise and guidance.
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        Feb 15 2011: Ha, I'm grappling with this question myself. See my idea thread on effective, long-term global health interventions. One obvious action that a company like J&J can do is to make life saving drugs available at a fraction of their US cost to poorer countries. And even better, to help revitalize the generic drug factories in those countries. Working to strengthen local health efforts and government health infrastructure make more sense to me than starting a brand new, foreign-inspired venture. Solidarity should be the model, not charity. See Dr. Wendy Johnson's excellent talk on this subject from TEDxRainier: http://www.youtube.com/watch?v=CvVydQqJfWo
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      Mar 5 2011: Steve, you may be interested to see this TEDx talk which doesn't go into a lot of detail but appears to show a model that works in several developing nations and also in the USA - http://tedxmonga.com/en/videos-9-dec-2010/53-ting-shih-brings-telemedicine-to-the-world

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