Tuberculosis Worldwide

April 5, 2010

Tuberculosis kills more than 1.7 million people around the world each year, and this figure is growing as over-crowded conditions in poverty stricken areas can elevate transmission rates. The World Health Organization’s (WHO) recently published report, entitled “Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 Global Report on Surveillance and Response” outlines the prevalence of the disease and its potential global impact. In it, data from 114 countries around the world are examined to determine the extent of this “serious threat to global health.”

Mycobacterium tuberculosis, the organism that causes tuberculosis (TB), is an airborne bacteria exclusive to humans and can be transmitted through close personal contact, particularly coughing. According to the United States Centers for Disease Control and Prevention (CDC), the bacteria usually affect the lungs of an individual, but can also impact the kidneys, spine and brain. Nikoloz Sadradze, International Committee of the Red Cross (ICRC) medical delegate, explains that more than two billion people – approximately one in three – carry the microbes that cause TB, but only one in ten will actually experience symptoms. Effective treatment of TB depends on daily doses of courses of medication lasting six to eight months. Tuberculosis infection is defined as multidrug-resistant (MDR-TB) if it cannot be eradicated by the antibiotics commonly used to treat tuberculosis: isoniazid and rifampicin. It is classed as extensively drug-resistant (XDR-TB) if it is also resistant to fluoroquinolone antibiotics and the injectable drugs amikacin, kanamycin, and capreomycin. If an individual contracts a MDR-TB or XDR-TB strain, a combination of oral medications, injections, and other treatment may be required for 24 to 36 months or longer. Costs associated with treating MDR-TB are, on average, 10 times more than “standard” TB. The WHO reports that 60 percent of individuals who contract of TB have been cured.

The WHO also reports that drug-resistant forms of TB killed approximately 150,000 people in 2008, and that 50 percent of all cases of MDR and XDR-TB occurred in India and China. Further, 57 countries have had at least one case of XDR-TB since September 2009, according the WHO report. Programs to combat the spread of tuberculosis have been established by the WHO in 30 countries around the world, primarily those that are impacted most by the disease. Reports from the CDC indicate that reported TB cases in the United States are at an all time low, but that there were a total of 108 reported cases of MDR-TB in the U.S. in 2008. According to the WHO there were approximately 440,000 reported cases of MDR-TB worldwide in 2008. Many cases of MDR and XDR-TB are due to individuals lacking access to necessary medical attention and drug treatments. In addition to a lack of available treatment, reports indicate that only an estimated seven percent of patients with MDR-TB are diagnosed.

In regions where access to medical care and treatment may be limited, telemedicine can be used to improve the rate of diagnosis and treatment outcomes. Programs like iCons in Medicine allow healthcare providers in remote and medically underserved areas to connect with physicians who can provide knowledge and guidance for recognizing and treating tuberculosis.


Mobile Medical Apps

November 9, 2009

New technologies, both mobile and Internet-based, hold potential medical applications that may advance care. Through cellular telephones, netbooks, and laptops, physicians and healthcare providers are now able to utilize these technological improvements at the point of care. Non-profit organizations, research teams at universities, and other groups are working to develop applications for use on cell phones, often with integrated web-based features, to ensure that medical knowledge is fully accessible worldwide.
Image by Deborah Ervin
Web-based iConsult, the flagship program of the iCons in Medicine initiative, allows for collaboration between healthcare providers worldwide through a teleconsultation software and social networking website. The iConsult application, which functions like email, is easy-to-use, reliable, and designed for use in areas with limited or intermittent connectivity. The system facilitates knowledge transfer worldwide by pairing Volunteers, medical specialists who lend their expertise, with Requestors, medical professionals who work for non-profits in remote or medically underserved areas. Through the software and website, Volunteers and Requestors may collaborate on difficult medical cases from a distance, providing specialty advice that otherwise might not be available. Volunteers in the iCon Network who elect to take part in iConsult agree to provide at least three teleconsults per year. The iConsult software allows Requestors to upload a case consultation form, including digital images, and discuss potential diagnoses and treatments on a one-to-one basis with Volunteers in a secure environment. Other organizations, like InSTEDD (Innovative Support to Emergencies Diseases and Disasters), develop free and open source technologies to enable seamless and reliable collaboration between individuals working in the developing world and areas affected by conflict situations or natural disasters. GeoChat is a mobile communications service designed to allow for group communications via cellular telephones and online. The technology can be used in humanitarian crises to ensure that individuals who may be trapped, injured, sick, or in need of assistance can be reached quickly and their needs addressed. Unlike platforms that are only web-based, InSTEDD’s GeoChat allows healthcare providers and others to form a team and use SMS messaging, email, and/or a web browser to share information based on their location, providing an accurate documentation of conditions in a given region.

In addition to web-based initiatives, many organizations have begun developing and distributing applications for smartphones, creating a new base of information for both physicians and the general public. An analysis published by Manhattan Research in February 2009 indicates that more than 10 million adults in the United States use mobile devices to access health information. This figure may include individuals who chose to purchase the Merck Manual Home Health Handbook (3rd Edition) in its iPhone application format. Users can reference a range of health topics on-the-go with this and other similar applications. The Merck Manual is available in both a home and professional edition, and features a search engine and the ability to bookmark and email subjects. Other organizations, such as health insurance company Medica, are making efforts to increase the public’s awareness about healthcare and its costs through iPhone applications like Main Street Medica. The application, which is available to all consumers, not only Medica members, offers users the chance to compare the cost of common procedures at hundreds of clinics and facilities.

Though some look for health information on their own, a recent Opinion Research Corporation survey found that 64 percent of consumers turn to their physicians for health advice and feel that they are their most trusted source of health information. In an effort to ensure that healthcare providers have up-to-date information, organizations like Emerging Solutions in Pain (ESP) have also begun releasing mobile applications intended for use by medical professionals. ESP has launched an application for healthcare professionals involved in pain management or addiction medicine called ESP Mobile, which provides multimedia information in a mobile format and also includes up-to-date information and educational programs in pain management, news articles, and clinical support resources for providers. Physicians at Houston-based Memorial Herman Healthcare System use this and a number of other iPhone applications, including Airstrip OB, which displays medical notes and real time vital statistics of women as they approach delivery. The thousands of doctors and nurses within the 11 hospitals that comprise the System also utilize apps in the emergency room to quickly identify medications – particularly useful “if an unconscious patient comes in with a pocketful of pills.”

Other applications may be of use to both physicians and patients including language translation applications and a number of websites and mobile applications developed to provide up to the minute disease outbreak tracking and evaluation. Primarily focused on the medical community, applications like the Arabic Language Buddy, which provides real time, two-way English-Arabic translation; and Jibbigo, which converts English to Spanish and vice versa, offer potential tools for doctors working in regions where they are not fluent in the native language. Websites developed by the United States government and a joint effort from Microsoft Corp. and Emory University are more focused on providing patients with information, and may help individuals determine if their symptoms indicate possible H1N1 virus infection and warrant a doctor visit. Outbreaks Near Me, a mobile application for the iPhone developed by researchers at the Children’s Hospital of Boston, provides real time tracking of the spread of H1N1 infection. IntuApps application Swine Flu Tracker provides similar information as well as maps and “threat level” indicators.

Both mobile applications and web-based tools provide a chance to share information and knowledge across borders and ensure that quality medical care is delivered worldwide. New innovations continue to flood the marketplace, and it remains to be seen what the next improvement in healthcare technology will bring.

Find Out More About iCons in Medicine Technology and Improving Global Health

On the Uses of Stem Cells

October 27, 2009

Though their use remains controversial, new research and innovative procedures indicate that stem cells may be applicable in more situations than previously thought. Stem cells are immature cells with the ability to grow into any type of tissue. Scientists have worked for years to perfect methods of extracting and directing these cells to grow into different tissue types to heal injuries and cure diseases. In addition to human embryonic stem cells (hESCs), methods of using patient specific cells in regenerative medicine are being refined. Like embryonic stem cells, induced pluripotent stem cells (iPS cells) have the potential to become any type of cell in the body. Because iPS cells are made by “rewinding” adult cells to their pluripotent state – a state from which they can grow into other types of tissue – they can be created from a patient’s own tissues, thus lessening or eliminating the risk of rejection. According to the Los Angeles Times, iPS cells could be used to grow insulin-producing beta cells for patients with diabetes or nerve cells for patients with spinal cord injuries.

Amazing Image by Deborah Ervin

Using this type of “adult stem cells,” researchers at the Wayne State University School of Medicine have developed a procedure to increase mobility and quality of life for patients with spinal cord injuries. The process involves the use of progenitor cells from a patient’s own nasal tissue, thus lessening the chances of rejection, tumor formation, and disease transmission sometimes experienced when using donated tissue. Twenty patients with severe chronic spinal cord injuries took part in the Wayne State University study, led by Associate Professor Jean Peduzzi-Nelson. Each received a treatment of partial scar removal in combination with transplantation of nasal tissue and physical rehabilitation. Results from participants, including one paraplegic individual who is now able to ambulate with two crutches and knee braces, indicate that the transplantation of nasal tissue (an “olfactory mucosal autograft”) is an effective and safe treatment for individuals with chronic spinal cord injuries.

Other types of adult cells have also been used for transplantation to damaged tissues. At the Cincinnati Children’s Hospital Medical Center, fat stem cells from a 14-year-old boy were used to form cheekbones that the young patient lacked. This new technique has the potential to benefit approximately seven million people in the United States, including individuals with various forms of cancer, and those injured in conflict situations. A section of bone from a donated cadaver was shaped to resemble zygomatic bones and act as a support structure for the growth of new tissue. Mesenchymal stem cells from the patient’s fat and a growth-encouraging protein were injected into holes in this bone base. Before implantation, the research team wrapped the grafts in periosteum tissue, which helps encourage stem cells to produce bone tissue. Stem cells were harvested from fat tissue as they exist in similar proportions as in bone marrow tissue, but do not require invasive procedures to gather them.

Using embryonic stem cells from mice, researchers have been able to successfully create a “heart patch” to repair damage caused by heart disease. Bioengineers at Duke University created a 3D mold and used it to grow heart muscle cells or cardiomyocytes. In addition to the mold used to ensure that the cells would not grow as a disorganized mass, cardiac fibroblasts, which comprise up to 60 percent of the heart, were added. These cells helped to guide the growth of the patches and properly align the cells so that they would have properties similar to heart tissue. The heart patches created displayed critical features of heart muscle – the ability to contract and to conduct electrical impulses.

Studies indicate that transplants using pigment-containing visual cells derived from hESCs have also had some success. In individuals who underwent these procedures, structure and function of the light-sensitive lining and the eye (retina) were preserved. For millions who lose their sight or experience low-vision, this type of cell-replacement procedure could prove beneficial. Jennifer Elisseeff, associate professor in biomedical engineering at Johns Hopkins University, and her team have also utilized stem cells to repair damaged and deteriorating knee cartilage. In addition, Elisseeff’s team is working to enable stem cells to reconstruct muscle and fat lost during surgery or trauma and developing an eye patch constructed of special biomaterial derived from collagen to help repair damage to a patient’s cornea.

The use of hESCs remains controversial, though the Obama administration has lifted Bush-era restrictions on federal funding for research based on their use. iPS cells offer an alternative that may prove as beneficial or more so as there is no risk of rejection of the transplanted tissue. For patients with spinal cord injuries, deteriorating vision, compromised heart function, and many other health concerns, treatments using stem cells may offer an opportunity to heal that would otherwise not be available.

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The Flu Vaccine

October 12, 2009

As new cases and concerns about seasonal flu and swine flu (H1N1) continue to spread worldwide, two vaccines have recently been made available. Both the nasal spray vaccine and injectable vaccine for seasonal flu have proven effective for specific portions of the population, however distribution is still slow. For the H1N1 (swine flu) virus, The Baltimore Sun reports, availability is still an issue and many areas have not yet received enough doses to meet the demand. While many in the developed world do not yet have access to the H1N1 vaccine, Dr. Bernadine Healy notes that the problem is even greater in the developing world. To help these nations fight the pandemic, the United States has agreed to donate 10 percent of its vaccination supply to the World Health Organization (WHO) – eight other nations will make similar donations.

Fantastic Image by Deborah Ervin

Inoculating individuals for both viruses is complicated by the time frame in which the vaccinations can occur. If one chooses nasal spray for both seasonal and swine flu, they must wait four weeks between doses, while if one is injected for one virus and uses nasal spray for the other, they can be administered together. Discovery Health reports that doctors recommend annual flu shots to lessen the chances of becoming ill. Individuals as young as six months can be inoculated, according to the Centers for Disease Control and Prevention (CDC) and side effects are reported to be minor. Because the virus used to make the seasonal flu vaccine is dead, it is not possible to contract flu from a flu shot, however one may expect a low-grade fever 8 to 24 hours following injection, a swollen or tender area around the injection site, a slight headache or chills within 24 hours.

The seasonal flu shot is an inactivated vaccine, and contains three influenza viruses – one A(H3N2) virus, one regular seasonal A(H1N1) virus (which differs from the 2009 H1N1 virus), and one B virus. The viruses used change annually based on international surveillance which track infection trends and scientists estimations about which strains will circulate during the year. In contrast to the flu shot, the nasal-spray flu vaccine contains a weakened but still living flu virus, sometimes called LAIV (live attenuated influenza vaccine). These nasal mists are approved for use in healthy individuals ages two to 49 who are not pregnant. In addition to nasal sprays, Discovery Health reports that researchers at Stanford University and the University of Alabama at Birmingham have been working with naked DNA in an effort to develop a vaccine that could be delivered via shampoo or dermal patch.

Three recent large-scale studies, including a study led by Dr. Arnold S. Monto of the University of Michigan, indicate that while the seasonal flu shot is more effective for adults and safe for women who are pregnant, the intranasal vaccine (nasal spray) is more effective at preventing flu in children. These studies showed 35 to 53 percent fewer cases of flu in children who were given the nasal spray vaccine than those who received injected vaccines. The Los Angeles Times reports that injectable vaccines prevent roughly 50 percent more seasonal flu in healthy adults than the nasal spray vaccines.

Due to the relative newness of the H1N1 vaccine, health authorities have implemented a number of tracking measures to ensure its safety. The Associated Press reports that Harvard Medical School scientists are working to link insurance databases covering 50 million people with vaccination registries to allow them to determine if people visit a doctor after being vaccination as well as the reason for the visit. Johns Hopkins University and the CDC are also working to ensure that any side effects are noted and addressed quickly. These efforts include emailing individuals who have been vaccinated recently to see how they are feeling (Johns Hopkins), and preparing take-home cards asking vaccine recipients to report any side effects to the nation’s Vaccine Adverse Event Reporting system (CDC). These measures are being undertaken as in the Internet-age, the Associated Press notes, one person updating their Facebook status to say that they got a flu shot and feel sick could cause a wave of similar reports.

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Associated Press on the Nasal Spray Flu VaccineThe New York Times on CDC Side Effect Tracking Measures

The Price of a Soda

September 28, 2009

Obesity-related illnesses account for nearly 10 percent of all medical spending in the United States – an estimated $147 billion each year. Recent reports and study findings indicate that excess consumption of soda and other sugary beverages may be contributing to America’s increasing weight. New York City Health Commissioner, Thomas A. Farley told the Epoch Times that “Drinking beverages loaded with sugars increases the risk of obesity and associated problems, particularly diabetes but also heart disease, stroke, arthritis and cancer.” Initiatives have been launched to help cap consumption, including a public awareness advertising campaign in New York City and proposed taxation on sugary beverages, but their success has yet to be documented.

Soda: A Weighty Issue

CNN reports that sugary soft drinks contribute about 10 percent of the calories in the American diet. An “Extra Large” 32-ounce Coke contains 400 calories, nearly a quarter of the caloric total required by an average adult woman each day. Researchers at the University of North Carolina at Chapel Hill analyzed the national beverage consumption patterns of over 73,000 individuals over two years of age and found that between 1977 and 2001, overall calories from sweetened beverages had increased 135 percent. Findings from the UCLA Center for Health Policy Research and the California Center for Public Health Advocacy indicated that 62 percent of children ages 12 to 17 and 41 percent between 2 and 11 consume at least one sugar-sweetened beverage daily. The same UCLA study also found that adults who consumed one or more sweetened beverage each day were 27 percent more lightly to be overweight or obese.

Wayne Campbell, professor in the Department of Foods and Nutrition at Purdue University, explained that the human body does not react in the same way to solid and liquid calories, making these “sugar bombs” particularly problematic. A mix of hormones control appetite, ghrelin being the one that signals that it is time to eat again. When a large meal is consumed, ghrelin levels drop for several hours, however this does not occur when a large quantity of a sugary beverage is taken in. According to Harvard endocrinologist Dr. David Ludwig, the sugars in soda are rapidly absorbed, “which raises blood sugar and in effect causes the body to go into panic.” Insulin is released to break down the sugar, “but the body overcompensates, and blood sugar drops below the fasting level.” In response to low blood sugar levels, ghrelin and other hormones are secreted, triggering hunger and causing an individual to consume more.

According to Dr. Harold Goldstein, over the last 30 years, Americans consume at least 278 more calories daily, though physical activity levels have remained the same. Dr. Goldstein explained that during that period, soda and other sugary beverages accounted for as much as 43 percent of the new caloric intake. An American Heart Association survey indicated soft drinks comprised the top source of “discretionary sugar calories.” According to their findings, women should consume no more than 100 calories of added processed sugar per day (6 teaspoons), and men should limit their intake to 150 calories (nine teaspoons). Just one 12-ounce soda can contain as much as 13 teaspoons of sugar, often in the form of high fructose corn syrup, compounds of which researchers at Rutgers University say may start a chemical chain reaction leading to diabetes.

In an effort to raise awareness about the potential health concerns of drinking too much soda, the Fund for Public Health in New York has provided funding for an advertising campaign. The ads, which will run on 1,500 subway cars for three months, feature images of soda and other drinks becoming human fat as they are poured from bottles. “Are you pouring on the pounds?” the ads inquire, urging consumers to consider water or milk as alternatives to soda in order to not “drink [themselves] fat.” In the same vein, public health officials and U.S. health experts are calling for increased taxes on sweetened soft drinks. A study appearing in the New England Journal of Medicine cited research on the price elasticity of soda, indicating that for every 10 percent rise in price consumption declines 8 to 10 percent. Thirty-three states currently have sales taxes on soft drinks, but these existing taxes are viewed as too minor to affect consumption levels, and unlike the proposed tax initiatives, are not earmarked for health-related programs.
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Reuters on Soda and Obesity And Soft Drink TaxesCBS on Soda’s Impact on AmericaNBC New York on Soda and Obesity – New York Times on New York’s Anti-Soda Ads And Proposed Taxes

Physicians Using Twitter

September 15, 2009

A recent report from Forrester Research indicates that the use of social networking websites among people aged 35 to 54 increased by 60 percent in the last year. Twitter and Facebook have become popular among federal centers like the Centers for Disease Control and Prevention (@CDCemergency), hospitals like the University of Maryland Medical System (University of Maryland Medical Center – @UMMC), and even individual doctors.

Tweeting Doctors Can Change Healthcare Delivery

Through Twitter, doctors are able to post updates about the events of their day, connect with other healthcare workers, communicate with and inform patients, and even document surgeries and procedures. Results of a recent study by the American Telemedicine Association indicate that doctors and patients have seen beneficial outcomes from using Twitter to connect. Some healthcare providers, like pediatric gastroenterologist Bryan Vartabedian, MD (@Doctor_V), chose to use Twitter as a means to extend their web presence and communicate with existing and potential patients. Clinical nurse Phil Baumann notes additional medical uses for Twitter, including:

  1. Disaster alerting and response,
  2. Diabetes management including blood glucose tracking,
  3. Drug safety alerts from the FDA,
  4. Biomedical device data capture and reporting,
  5. Shift-bidding for healthcare professionals,
  6. Diagnostic brainstorming,
  7. Rare disease tracking and resource connection,
  8. Smoking cessation assistance,
  9. Broadcasting infant care tips for new patients, and
  10. Post-discharge patient follow-up and consultation.

Dr. Joseph Kvedar (@jkvedar), the Director of the Center for Connected Health and iCons in Medicine Member, describes Twitter as “a method of mass communication” that is real-time and “designed for mobility.” The ability to constantly update information also makes Twitter particularly appealing to government health organizations such as the United States Centers for Disease Control and Prevention (@CDCemergency) and the UK’s NHS (@NHSChoices). Using Twitter, these agencies are able to provide up-to-the-minute information regarding disease outbreaks, contact numbers to call for assistance, and other pertinent information. Medical associations such as the Radiological Society of North America (@RSNA), Healthcare Information and Management Systems Society (@HIMSS), and the Biotechnology Industry Organization (@BIOConvention) also use Twitter to keep their members informed about current news, promote events and meetings, and provide a sense of community.

While some providers use Twitter to connect with their patients and peers, others use it to provide information and updates during medical procedures. Recently surgeons in Iowa used Twitter to allow a woman’s family to follow the progress of her surgery in real-time. The Children’s Medical Center in Dallas provided updates when a father’s kidney was transplanted into his son, and the Henry Ford Medical Center (Henry Ford Health System – @henryfordnews) has tweeted during several procedures since January. These updates provide individuals who might not be comfortable watching a surgical procedure to still gain an understanding of the process and a chance to ask questions.

For the 61 percent of Americans who search online for medical advice, Twitter may not provide enough information. The social networking website Facebook allows healthcare workers or medical associations to connect with colleagues and patients. For the reported 55 percent of patients who want to be able to communicate with their doctors via email (according to a Manhattan Research study) it can offer another means of communication. Dr. William Cooper, a cardiothoracic surgeon, says that Facebook presents a way to always be available to his patients. According to Pauline Chen, MD (@paulinechen), it is unclear if engagement via Facebook and Twitter helps or hinders a patient-doctor relationship.

This concern is echoed by other physicians, including Dr. Sachin Jain, a resident physician at Bringham and Woman’s Hospital, who has accepted Facebook friend requests from patients, but “wondered about the appropriateness of the interaction.” In addition to the expectation that a physician would be “instantly available 24/7,” some doctors worry about the security of Facebook and other social networking websites, as well as potential HIPAA violations and litigation concerns. For many physicians, Facebook, Twitter, and other forms of social media are seen as “blurring the line between work and private life” – something that may cause some hesitation and discomfort.

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The New York Times on Twitter UsersUSA Today/Science Fair on the Medical Uses of TwitterAssociated Press on Tweeting During OperationsOn Medical Associations Using TwitterDr. Pauline Chen on TwitterCNN on Physicians on Facebook – More on Physicians and Medical Professionals Using Twitter

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Global Healthcare Worker Shortage

June 9, 2009

The World Health Organization (WHO) reports a shortage of healthcare workers worldwide, especially in rural areas. Healthcare workers are defined as those whose main activities are aimed at enhancing health – including doctors, nurses, and laboratory technicians, as well as management and support staff. Of the estimated 59.3 million healthcare workers worldwide, approximately two-thirds (39.5 million) provide health services. Rural areas of the United States are facing a shortage of healthcare personnel, and 57 countries throughout Africa and Asia are facing a severe healthcare workforce crisis. The WHO estimates that in order to fill the gap, at least 2.36 million service providers and 1.89 million support staff are needed. Between developing and developed nations, a large imbalance can be seen in the healthcare staff available. For example, in sub-Saharan Africa, an area with 11 percent of the global population, there are only three percent of the world’s healthcare providers.

Healthcare Workers

According to the Grosse Pointe News, Institute of Medicine figures indicate that by 2030 77 million Americans will be 65 or older. For the nearly 20 percent of these individuals who have five or more chronic health conditions, access to healthcare workers able to provide elder care is essential. Further, a report from Minnesota Public Radio indicates that though 13 percent of the state’s population lives in rural areas, only five percent of the physicians practice there. This shortage of doctors and other healthcare providers in rural areas is a national trend, and ultimately causes patients to experience longer non-emergency wait times, providers who are fully booked and/or not accepting new patients, and more care provision by mid-level practitioners. CNN reports that the findings of Barbara Starfield at the Johns Hopkins University Bloomberg School of Public Health indicate that an increase of one primary care physician per 10,000 people would result in a 34.6 fewer deaths per 100,000 people at the state level.

Increasing the availability of healthcare and health services is a major aim of the Millennium Development Goals (MDGs). The Goals also seek to reduce child mortality, improve maternal health outcomes, combat HIV/AIDS and diseases like malaria and tuberculosis, and ensure the availability of medications. In order to increase the availability of healthcare in rural areas, the WHO suggests a number of measures, including reassignment of needed healthcare workers during conflict situations. While this may increase the health outcomes for the population in the region, it also poses a risk to the providers – one that could be avoided through the use of telemedicine and teleconsultation programs like iConsult. Through teleconsultation, specialty care physicians can remotely provide advice and support to doctors within a region.

Find out more about how iConsult can help

WHO Information on Healthcare Worker ShortageGrosse Pointe NewsMinnesota Public Radio CNN Report