For the past 46 years, Médecins Sans Frontières (MSF), or Doctors Without Borders, has been providing emergency medical and humanitarian aid around the world where the need is greatest, particularly to people afflicted by conflict, epidemics, disasters or exclusion from health care.
In 2016, Doctors Without Borders provided humanitarian assistance in 71 countries, providing 9.7 million outpatient consultations, performing 92,000 surgical interventions and the organization also has rescued and assisted more than 30,000 migrants and refugees at sea. Every day, the organization’s medical teams treat people displaced by conflict and extreme violence through field missions in countries such as Syria, Yemen, South Sudan, Nigeria and the Democratic Republic of Congo.
To support the medical work of doctors and nurses on-the-ground in remote areas, Doctors Without Borders leverages a telemedicine platform to provide clinicians in the field with access to medical specialists. I recently spoke with John Lawrence, M.D., a pediatric surgeon, and MSF-USA’s board of directors’ president, about the organization’s telemedicine platform and how it helps to bridge the gap between remote areas and large hospitals, linking patients with specialists around the globe. While telemedicine is not a cutting-edge technology, for doctors and nurses working in remote locations like Aweil, South Sudan with limited resources, that link to a specialist can literally help to save patients’ lives.
For the past 20 years, Lawrence has been a practicing pediatric surgeon, primarily in academic settings. He has completed eight surgical missions with MSF since 2009 in areas such as the Central African Republic, Ivory Coast, Haiti, Syria and the Democratic Republic of Congo. For the past nine months, he has been involved with the organization’s telemedicine program, providing his expertise as a specialist to doctors in the field.
The organization’s telemedicine service consists of three coordinators working 24/7 who receive alerts from field teams requesting assistance from a specialist. The coordinators then forward the request to one of the system’s 280 experts. Since 2010, more than 3,000 cases have been treated using the telemedicine service. The platform enables MSF staff to manage remote medical consultations and currently there is an average of five to ten cases received each day.
On the consulting side, Lawrence says he has found the process to be quick and seamless. “I have access to the patient’s clinical history, laboratory data, X-ray data, and sometimes, depending on the circumstances, a picture of the patient. There will also be a comment chain of other referral doctors that have been consulted on this case,” he says, noting that the general physician in the field may send a case to a pediatrician or pediatric infectious disease specialist, or send X-rays to a pediatric radiologist for input, and then request input from a pediatric surgeon.
Lawrence, who specializes in neo-natal surgery, notes one particular case he consulted on that involved an infant, whose family lived in Guinea, who was born with a severe birth defect. Based on the child’s clinical history and a photo provided, Lawrence was able to remotely diagnosis that the child was born with cloacal exstrophy, a birth defect in which much of the abdominal organs are exposed.
“It’s one of the most difficult conditions to reconstruct in all of pediatric surgery. Not every medical consultant is in the position where they’ve worked in the field and understand what the resources are like and the level of care in that setting. My response was that this was not something that could be cared for in a small, community hospital and that they needed to transfer the patient to the capital city to get the highest level of pediatric care,” Lawrence says.
In another case, physicians operating a MSF pediatric hospital in the eastern part of Lebanon, near the Syrian border, requested Lawrence’s expertise for a case involving a five-year old with a possible tumor. “The family were Syrian refugees who had just crossed the border from Lebanon and the child previously had surgery done to remove a pelvic tumor, but was experiencing symptoms that suggested it had reoccurred. The doctors in the field described the physical exam and sent X-rays and wanted my recommendation on how best to proceed,” Lawrence says. “The family had been trying in the last year or two to get care for the child, but they hadn’t been able to access care within Syria. Looking at the X-rays and knowing the capabilities of the facilities that we are running in East Lebanon, which is a good hospital, but it’s not a tertiary care hospital, it was my recommendation to refer the child to the main pediatric hospital in Beirut where the child could be treated by the appropriate oncology surgical team and receive a high standard of care.”
Lawrence believes that the telemedicine platform greatly enhances the care that physician and nurses on-the-ground can provide to patients in greatest need. “The teams we work with are exceptionally dedicated and skilled, but this allows for the full spectrum of medical or surgical specialists that you would typically have access to in a high-income setting. More often than not, our projects on-the-ground are straight-forward care, whether it’s pediatrics, gynecology or primary care, in each discipline, people are generalists with a good, broad knowledge base and can care for a wide range of common things. But, when you get into the uncommon, that’s the value of resourcing people," he says.
More broadly, Lawrence says his field work with Doctors Without Borders has been an eye-opening experience and has raised his awareness of the critical healthcare needs throughout much of the world.
“It’s been the most rewarding and most valuable part of my surgical medical career. From a patient perspective, the needs that exist for so much of the population of the world are not well addressed. In terms of how I view healthcare globally, I think it should be a basic human right, but it’s still largely a privilege. And, of course, there’s discrepancies in healthcare inside the U.S. as well, but it’s so different in the context that we work in,” he says.
Continuing he says, “Our focus is often in areas of conflict; a little over half of our projects are near or adjacent to conflict zones, so that instability often leads to deterioration of healthcare systems overall, systems that may or may not have been functioning in a pretty good state previous to the conflict or violence.” And, he adds, “From a surgical side, there is a gross maldistribution in terms of where surgical care is offered—the richest third of the population wind up getting 75 percent of the operative procedures, and the poorest third of the population only get about 3 percent of the operations. This is a void that I think we help to fill and I think what this organization offers in that regard is very valuable.”
As another takeaway, Lawrence says he has been impressed with the efficiency of the operating rooms of the Doctors Without Borders field hospitals. “They are the most efficient that I’ve ever been in. People in the U.S. are shocked to hear me say that, but there is so much more you can get done in a day there, than is possible here.”
Speaking with Lawrence about his experiences working in the field in areas like South Sudan and Syria, it brings to mind that while the U.S. healthcare system is in the midst of accelerating change and uncertainty—federal policy changes, possible cuts to Medicare, the ongoing transition from volume-based reimbursement to value-based care and payment, rapidly rising healthcare costs—there is much to appreciate and applaud about the U.S. healthcare system and the progress the industry is making to increase quality of care. And, healthcare professionals in the U.S. should perhaps appreciate that even with limited budgets they are operating with more financial resources and working in safer, more stable environments compared to many of their physician colleagues located in conflict areas throughout the world.
Moving ahead in 2018, technology and digital innovation will continue to play a large role in ongoing efforts to meet the “Triple Aim,” providing high-quality care and improving the health of populations at lower cost. And as healthcare IT leaders focus on leading-edge and next-generation technologies—whether artificial intelligence, machine learning, virtual reality, robotics and advanced analytics—it’s worth recognizing the benefits of more fundamental technologies, such as telemedicine, as highlighted by the work that Lawrence and other physicians are doing in their humanitarian and medical relief efforts around the world.
