Telemedicine and accessible health care in South Africa

A patient sits in the living room of her apartment during a telemedicine video conference. Picture: AP

A patient sits in the living room of her apartment during a telemedicine video conference. Picture: AP

Published Aug 8, 2022

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South Africa has a two-tiered and highly unequal healthcare system.

The recent Covid-19 pandemic clearly demonstrated that the health needs of South African citizens exceed capacity.

This is mainly due to the constant neglect and underfunding of the public sector and the fact that most South Africans can no longer afford the exorbitant cost of medical funds and private care.

This situation is worsened by a lack of a strong primary healthcare network with highly competent and well trained community health workers, as well as the efficiencies of hospitals. Many hospitals are falling apart and provide a low quality and inadequate health service. A major problem is also that access is based on distance to health services, resulting in people in remote areas enjoying less privileges.

In order to address the inequality, the government tabled the controversial National Health Insurance Scheme to provide universal healthcare by buying services from health professionals through a National Health Insurance Fund. These services would then be delivered at private and public facilities.

But despite many unanswered questions and doubts about the scheme, it would still not solve the problem of the huge lack of resources, poor management of medical facilities, and access, especially in remote areas.

Perhaps South Africa should look elsewhere for a solution to alleviate the problem of access to quality healthcare, such as modern information and communication technology.

Telemedicine

To increase access to healthcare of people living in remote areas, a major development in medicine has been that more and more patients are consulted, monitored, and treated remotely or at home via telemedicine technology.

Telemedicine generally refers to the use of modern information and communication technology to provide medical information, clinical care and other medical services remotely to persons whose access to medical services are restricted by geography or environment. Especially during the Covid-19 pandemic and lockdown, telemedicine became an alternative way to consult a health professional, similar to having virtual meetings or talking to friends via video technology.

Telemedicine is widely used all over the world in numerous medical fields to reach people in under-served areas that cannot easily be reached by medical staff. It is particularly useful for people from remote areas and people with mobility problems.

Telemedicine can thus provide equitable access to health services and reduce the disparities in health status in South Africa due to overwhelmed state hospitals, high patient-doctor ratios, lack of resources, and large distances. It can further increase the cost effectiveness and efficiency of the allocation of the current limited health resources.

Ultrasound imaging

One medical field in which telemedicine has made tremendous progress is ultrasound imaging, in particular through the use of artificial intelligence (AI) technology, deep learning and image recognition capabilities that recognises and analyses images based on specific patterns.

Enterprise imaging provides access to advanced visualisation technologies from any location for specialists such as oncologists, vascular surgeons, cardiologists, and liver surgeons.

Due to telemedicine, image sharing and collaboration via the cloud (Platform and Software as a Service) has become much easier.

The benefits of telemedicine are numerous, such as an improvement of the quality of care specifically in traumatology where image sharing is important for trauma centres and primary stroke centres and assist in making faster decisions, eliminate unnecessary transfers to hospitals with the necessary specialists and avoid the redundancy of rescanning.

In complex diseases and oncology, telemedicine allows greater access to scarce specialists focusing on specific types of cancer treatment. It increases collaboration among specialists and multidisciplinary teams and enable them to decide on the best treatment for the patient.

Wearable imaging

Ultrasound imaging is a powerful and commonplace medical tool that is widely used for the non-invasive imaging of tissues and organs inside the body. However, ultrasonography requires close contact between the transducer and the target area, highly trained sonographers to correctly position the transducer on the surface of the patient’s body, as well as a steady hand. This has limited the acquisition of images to short and static sessions. A further complicating factor is that there is a worldwide shortage of sonographers.

Therefore, researchers have been endeavouring to develop wearable ultrasound devices that are flexible, will remain stuck to human skin and can also provide long-term continuous high-resolution ultrasound imaging of diverse organs.

Now Professor Xuanhe Zhao and his colleagues from Zhao Lab at the Massachusetts Institute of Technology (MIT), The Mayo Clinic and Makihata Engineering in the US of America, found an answer to this challenge. They combined a rigid transducer component that produces and detects ultrasound waves with a soft, sticky patch the size of a postage stamp to provide continuous ultrasound imaging of internal organs for 48 hours.

The value of this bioadhesive ultrasound (BAUS) device is that it can expose details such as the stomach expanding and contracting when the person eats or drinks, or the heart, muscles, and lungs of the person changing shape during exercise. It can provide continuous imaging of several internal organs such as the blood vessels, abdomen, diaphragm and gastrointestinal tract.

A thin and rigid piezoelectric probe array is bonded to the patient’s skin with an acoustically transparent hydrogel (a polymer that can absorb a large volume of water while retaining its shape), sandwiched between two layers of flexible elastomer material. The hydrogel enables the ultrasound waves to be transmitted, while the elastomer prevents the hydrogel from dehydrating.

There is still much more work to do before the ultrasound patches could be used for medical monitoring. The current data acquisition device is a computer that is connected with wires to the patch. Since point-of-care ultrasound devices with data acquisition devices the size of a cellphone exists, the researchers believe they will be able to be miniaturise the computing component to such an extent that it can be integrated with the ultrasound patch. The addition of a wireless connection will make it a truly portable imaging system.

This breakthrough allows medical practitioners to see inside a body in motion and could provide critical diagnostic and monitoring information about the patient’s health and diseases.

It will furthermore bring diagnostic medicine closer to the patient. It will also enable hospitals and doctors to monitor patients over a period of time and without the mediation of sonography technicians, who are often in short supply in under-resourced communities. It will also allow ultrasound diagnostic access to people in remote areas.

Practically the ultrasound patches will help to monitor patients with cardiovascular disease or to monitor the lungs of a Covid-19 patient. It could also closely monitor the growing of a tumour in a cancer patient or the growing of a foetus in the womb of the mother.

Innovative inventions

Professor Zhao is no stranger to innovative inventions and is famous for his work with hydrogels and marrying engineering and medicine. His lab is producing synthetic hydrogel versions of body parts such as muscles, tendons, ligaments, and cartilage; a quick-sealing tape that replaces surgical sutures and staples; and a wound sealing glue for deep wounds.

Stroke are one of the leading causes of death. Until now physicians used a catheter, guided by X-ray fluoroscopy, to remove the blood clot with suction or a stent. Unfortunately, highly experienced physicians are not available in smaller hospitals or rural areas.

Professor Zhao thus developed a surgical robot to remove blood clots from affected areas of the brain. The elastomer (a stretchy polymer) catheter is magnetically sensitive and external magnets and X-ray imaging guide the catheter through the body. This is all done from a separate room or even from another city, thus providing remote patients access to advanced treatment.

Access to health services a human right

The universal declaration of human rights of December 1948 states that “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical and necessary social services.”

Today a lack of access to health services has become a major challenge and created wide disparities in South Africa. This is exacerbated by the poor quality of state health services and the worldwide increase in medical costs and technology.

Telemedicine is one possible way to broaden the access to proper healthcare to people living in remote rural areas. But the only way telemedicine will succeed in reaching vulnerable groups in South Africa is by close collaboration between state, non-profit organisations and the private sector.

Unfortunately, the alternative to telemedicine or remote medicine is no medicine. It is time that South Africa progresses from the current hospital-centric model to a more collaborative and remote care model.

Details of the bioadhesive ultrasound patch can be found in the journal Science, Volume 377 of July 28, 2022.

Professor Louis C H Fourie is an Extraordinary Professor at the University of the Western Cape.

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