Expanding Health Access in Haiti through Telemedicine

Abstract

This chapter, per the author, describes the telemedicine technology, reviews relevant literature, analyzes the benefits and limitations, and highlights specific challenges and opportunities for its implementation in Haiti. It describes potential applications of telemedicine for attenuating workforce shortage, advancing healthcare access, equity, and inclusion, as well as improving clinical outcomes and education of medical providers in resource-poor settings. More specifically, the chapter proposes to leverage the pool of Haitian health professionals abroad for the development and sustainability of well-structured telemedicine programs while encouraging the continuous support of existing ventures. Stretching out limited healthcare dollars to optimize the well-being of Haitians represents the overarching goal of this endeavor. The author hopes to disseminate and replicate this model in other low- and middle-income countries.

1. Introduction

With the most worrisome health indicators in the Americas, inadequate healthcare budget, fragile infrastructure, alarming shortage of healthcare professionals, and limited access to primary and specialty medical services, Haiti stands very far from meeting the healthcare needs of its ever-growing population and achieving sustainable development [1]. Moreover, Haiti exports 85% of its physicians, the largest proportion in the world. But a few encouraging trends of progress had emerged recently, albeit underrecognized. Indeed, since 1990, infant and maternal mortality had halved (but the rates remain three and five times higher than the regional average), and life expectancy had increased by 6 years to 64.3 years, largely attributed to better control of infectious diseases. During the past 12 years, these small gains had been threatened by rampant violence, numerous accidents, and major disasters. Nonetheless, amidst these dark clouds, the watchful observer discerns few patches of blue sky. For instance, in partnership with private and international organizations, the Haitian Ministry of Health had deployed noteworthy efforts to eliminate the imported cholera epidemic for three and a half years, curb the scourge of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), expand vaccination coverage nationwide, and build capacity for tuberculosis (TB) control. Plenty of room for skepticism abounds as cholera is re-emerging and the incidence of tuberculosis in Haiti remains the highest in Americas. The accelerated deterioration of the social fabric, inaccessibility to clean water, and breakdown in hygiene probably contribute to the resurgence of cholera. Deeply entrenched TB risk factors, such as poverty, malnutrition, low educational attainment, and overcrowding, greatly explain this underperformance. Meanwhile, public health experts recognize the tremendous challenges posed by the climbing prevalence of cardiovascular diseases in Haiti, the excess morbidity and mortality from ischemic heart disease, stroke, lower respiratory infections, diabetes, the jump in cancer cases, and chronic renal failure, as well as the historic neglect of oral health and societal discrimination against behavioral disorders [1]. Given this heart-wrenching landscape, the exploration of telemedicine in Haiti as an innovative solution to mitigate the workforce shortage, increase healthcare access, and improve targeted health outcomes, clearly deserves the utmost consideration. This book chapter intends to stimulate in-depth thinking and open the forum for discussion on global equity and inclusion showcasing Haiti.

2. Background

The Haitian Institute of Statistics and Informatics estimates the population of Haiti at 11887456 inhabitants in 2021. However, only 19.28% of the population had accessed ambulatory healthcare services in 2021, as compared to 30.7% in 2017, a troubling downward trend contrasting with skyrocketing unmet needs. No other country in the Americas displays such a critical workforce shortage as illustrated in the following indicators. In 2021, Haiti disposed of 9.91 medical personnel (physicians, nurses, midwives, and nurses’ aides) per 10,000 population [2]. At 6.3 per 10,000 population, Haiti exhibits the lowest density of physicians in the Americas, nearly fourfold lower than the minimum recommended by the World Health Organization (WHO) [1], and with an operational and investment healthcare budget allocation of 4.2% and 2.6% of the national budget in 2021, far below the 15% benchmark recommended by WHO. For the past four decades, about 85% of Haiti medical graduates had been leaving the country to pursue better opportunities for themselves and their families. About 80% of Haiti’s public health workforce practice in urban areas, while over half of the population resides in rural localities. Nowadays, essential hypertension and diabetes account for the majority of outpatient visits in Haiti, while the incidence of cancer keeps rising [2]. On a hopeful note, Haiti had implemented a fruitful public-private partnership model to control the major epidemics of HIV/AIDS and tuberculosis, eradicate the imported cholera epidemic for three and a half years, and expand immunization coverage, notwithstanding the recurrent natural disasters, pervasive political instability, and collapsing economy.

3. Overview of the literature on telemedicine in Haiti

A scant body of literature on the use of telemedicine in Haiti had primarily reported isolated projects for diabetic foot care, pediatric emergencies, dermatology, radiology, military operations, and disaster relief [3]. In a case study of hybrid telemedicine for diabetic foot care by Olayele et al., the investigators engaged a nurse practitioner (NP) from a Chicago wound care clinic to travel to Haiti twice a month [4]. During the 90 to 120-minute telemedicine sessions, the NP presented the clinical cases and transmitted related health documents to physicians in Chicago via CISCO WebEx platform. Then, the consulting physicians dispatched their recommendations for medical care and teaching points for staff education. The team followed 44 patients with diabetic foot ulcer in 1226 total visits between April 1, 2014 and March 31, 2015. The authors identified bidirectional language translation as the major barrier. Most of the participants reported improved knowledge of wound care, and 90% of them considered the acquired information as a helpful tool to better manage their patients with diabetic foot. Unfortunately, this study did not clearly mention the geographic location of the hospital in Haiti. More recently, Kamaratos-Sevdalis et al. published a qualitative review of 12 English-language studies of telehealth services for diabetic foot infection from around the world [5]. Based on pre-established criteria, they selected five randomized trials, three case reports, three cohort studies, and one survey for analysis. Sample sizes varied widely from one to 1199. In short, the study results suggest a good acceptance rate of telehealth for diabetic foot care and possibly similar or better outcomes. The interpretation of these findings calls for caution because they derive from short-term follow-up data and require validation in better designed long-term randomized controlled trials or large prospective cohort studies. On their side, Flaherty and colleagues from the University of Florida, Gainesville, USA, evaluated the cost-effectiveness of a nighttime telemedicine and medication delivery service for children ages zero to nine years living in the hilly town of Gressier, near Port-au-Prince, urban Jacmel and three surrounding rural areas in the southeast of Haiti, from July 2019 to June 2021 [6]. The National Bioethics Committee of Haiti and the University of Florida Institutional Review Board (IRB) approved the study protocol. The study participants gave IRB-authorized informed consent/assent prior to enrollment. As the main outcome measure, the clinical investigators chose disability-adjusted life years (DALY) averted by treating pre-emergency conditions such as acute respiratory, gastrointestinal, and cutaneous diseases. The study results showed potential benefits from these innovative interventions as compared with using the hospital emergency department. However, the authors themselves acknowledged three main study limitations: missing provider/institutional costs of hospital emergency in the analysis, exclusion of patients with nighttime symptoms evolving slowly enough not to warrant routine primary care in the morning, and the reliance on a particular methodology that could have introduced recall bias in data collection and lead to underestimation of the outcome measure. Furthermore, using Health Insurance Portability and Accountability Act (HIPAA) compliant platform and the approval of University of California, Los Angeles (UCLA) institutional review board (IRB)-approved English and Haitian creole informed consent, Cutler et al. carried out the first known teledermatology research project in Haiti [7]. The study setting occupied a philanthropic clinic in the town of Petit-Goave, serving local and neighboring rural communities, 42 miles from the capital of Haiti. The study enrolled 101 participants in March 2015, with a mean age of 26 years (range 0–92) and a male-to-female ratio of one to two. The clinical investigators selected the study format based upon prior trial runs. First, a Haitian primary care provider in Petit-Goave examined the participants at the local clinic, proposed a working diagnosis and treatment plan, photographed each subject with an iPhone 6, and formatted the picture with the application Photogene four to achieve a resolution of 1024 and a configuration of 300 × 300 DPI. Subsequently, the Haitian primary care provider uploaded the images to a smartphone via encrypted platform, scanned, and forwarded them along the consultation request forms, using unique patient codes, to six board-certified dermatologists in Los Angeles, California, for review, diagnosis, and recommended treatment plan. Whenever the consultants changed the treatment plan, the Haitian staff contacted the patients in concern to ensure they received the correct therapy. The concordance between the primary care provider and the dermatologist reached 68.9%. The elapsed time between initial case upload and reading of the dermatology consultation by the Haitian primary care provider and volunteer United States-based medical students averaged 1.67 days only. Atopic dermatitis, including prurigo nodularis and eczema, and fungal infections accounted for the majority of diagnoses, 39% and 18%, respectively. Acne, bacterial infections, and pigment disorders represented 10%, 9%, and 7% each, while other various pathologies constituted the remaining 16% of the total cases. However, atopic dermatitis also made up 46.7% of the discordant diagnoses. Although this study demonstrated the feasibility of teledermatology in rural areas, it did not adjust for confounders that might have biased the dermatologists’ impressions, for example, the clinical presentation and diagnosis formulated by the Haitian primary care provider. During Operation Uphold Democracy in 1995, the United States military troops deployed in Haiti experimented 30 asynchronous telemedicine consultations between Walter Reed Army Medical Center in Washington, D.C., and Haiti [8]. The most common consultations concerned dermatology, radiology, and surgery [8]. The results of this limited experience indicated that the consultations generated a significant change in treatment plan half of the time. In a retrospective study of telemedicine consultations conducted by the United States military in Haiti during this second troops occupation, Walters et al. found an effect of telemedicine on diagnosis, treatment, and overall patient health status of 30%, 32%, and 70%, respectively [9]. Not too long ago, in the aftermath of the 2010 earthquake, a few nongovernmental organizations and private health entities launched some, short-term, unstructured telemedicine initiatives for primary care, and mental health in Haiti. In general, the organizers reported very few of them in non-peer-reviewed publications, using rather a plain narrative format.

Yet, an embryo of telemedicine already exists in Haiti. It consists essentially in telestroke, telesurgery, teleradiology, and telepathology, representing less than 1% use. By comparison, in Latin America, 2015 data emanating from the World Health Organization (WHO) Global Survey on eHealth and the 2017 survey of hospitals across nine diverse countries discovered a range of telemedicine use from 25% of hospitals in Colombia to 65% in Chile before the COVID-19 pandemic [1]. In the context of rising costs of energy from crude oil and natural gas on the international market, soaring shortage of electricity, potable water, internet service, and transportation, compounded by galloping inflation, dismal gross domestic product (GDP) of $1176.8 per capita [10], harrowing national budget and trade deficit, and scarce investment in sustainable development, creative solutions for cost-effective, and outcome-driven healthcare delivery models become highly desirable in Haiti once the right conditions exist.

4. Telemedicine technology

The terms telemedicine and telehealth are not interchangeable. Telehealth encompasses a broad range of remote healthcare technology applications, including patient education, administration, and collaboration, as well as telemedicine. Depending on the backdrop, conditions, and populations, telemedicine comprises various modalities: real-time service via live video, voice, and data conferencing; store and forward, involving data capture in digital files on a computer or mobile device followed by secure transmission for later analysis, interpretation, and sharing. A third modality consists in remote monitoring via patient data collection from wearable sensors and other devices, and subsequent transmission to monitoring systems and health care professionals to track patient health [1]. Two distinguished peer-reviewed journal articles by Dorsey and Topol [11] and Tuckson et al. [12] had depicted a comprehensive synopsis of telemedicine modalities and challenges. A paper by Daniel and Sulmasy, elaborated policy recommendations for the use of telemedicine in primary care setting on behalf of the American College of Physicians (ACP) [13]. Two months later, ACP issued a full Position Paper in the Annals of Internal Medicine. The authors reviewed evidence-based advantages of telemedicine regarding access of health services, clinical outcomes, and costs of treating patients outside of traditional healthcare settings and at home, versus potential barriers, operational, regulatory, and licensing challenges. The paper described the ACP positions on the adoption and practice of telemedicine in great detail. This book chapter focuses on synchronous telemedicine, i.e., real-time interactive audio-video, supplemented as necessary, with asynchronous telemedicine, i.e., secure electronic transmission of patient’s medical information (medical history and physical exam findings, radiographs, laboratory, and pathology results) for expert evaluation and recommendations outside of real time. Network performance remains essential to any successful telemedicine program, especially when using real-time video and voice. Network reliability, resiliency, and diversity play a central role to ensuring the delivery of quality care in an increasingly connected environment. Selection of the right internet and wide area network (WAN) service provider, internet and WAN connections that offer high bandwidth and availability, as well as minimal latency turns out crucial. Expressed in Mbps or Gbps, bandwidth represents the measure of both the capacity of data connection and the amount of data delivered through it. Many cloud-based high-definition videoconference platforms function fully on a modest bandwidth of just 1.5 Mbps, 6% of the 25-Mbps federal commission communication (FCC) standard. In fact, zoom video software requires only 1.5 Mbps [14], as do other widely used videoconferencing platforms, such as Webex (Cisco Systems) and GoToMeeting (LogMeIn) [1]. One can realize effective high-definition communication by simply using smartphones and laptops over land and wireless connections and over a range of bandwidths. The U.S. Federal Communications Commission recommends a broadband connection of 10 Mbps for a small practice and 100 Mbps to one Gbps for a large one [1, 15]. Measured in milliseconds, latency describes the lag time for a data packet to travel to a destination either one way or round trip. High-quality videoconferencing usually requires a latency of 150 milliseconds. Additionally, high availability and robust security stand as critical elements for telemedicine applications to support compliance with security, privacy, and confidentiality [1, 16, 17, 18, 19]. About 60% of Haiti’s population subscribes to mobile phones [20]. According to the 2016–2017 “Enquête Mortalité, Morbidité et Utilisation des Services” (EMMUS VI), the daily utilization of internet service in urban and rural areas is nearly similar (25.0% vs. 29.2%) in spite of disparate access to electricity, 76% vs. 17% [1, 21].

5. Potential applications of telemedicine to advance global equity and inclusion in Haiti

Telemedicine could alleviate the physician workforce shortage and clinic overcrowding, enhance continuity care, and streamline health information management. In essence, program implementation should aim at overcoming major technical, operational, financial, procedural, and human barriers (Table 1) [1].

Technical	Scarce electric grid and power supply; Unreliable or non-existing internet service; Low broadband penetration
Operational	Suboptimal organization of patients’ charts; Space constraint for telemedicine session; Deficient roads and transportation service; Recurrent work stoppage due to a cascade of strikes and civil protests
Financial	Inadequate accessibility to funding for telemedicine equipment, software, maintenance, and sustainability; Frequent payment interruptions for salaries, intrants, and utilities
Procedural	Little to nonexistent telemedicine policies and legal framework; Restricted availability of mutually agreed standard operating procedures; Undefined credentialing process for licensures and privileges
Human	Locally-specific: Absence of telemedicine integration into the national health care plan; Lack of leadership engagement and stakeholders buy-in; Reluctance of patients and medical providers to adopt the new format; Increased burden on personnel at overcrowded and understaffed clinics; Low educational attainment and health literacy level of patients; Provider-specific: Lack of cultural competence of foreign telemedicine consultants; Conflicting schedules and competing priorities for the consultants; Absence of incentives for telemedicine providers; Patient-provider related: Limited patient-provider relationship and continuity of care; Cross-border language barriers

Table 1.

Major barriers to telemedicine in Haiti.

Technical barriers: One of the initial steps of telemedicine utilization involves the selection of appropriate space in a designated health center with dependable access to electricity and internet service for the establishment of secure broadband connection and storage of telemedicine equipment: high-resolution monitor, desktop computer, high-definition camera, and microphone, as well as digital stethoscopes, otoscopes, ophthalmoscopes, portable electrocardiographic machine, and handheld ultrasound, etc. Electricity and internet access constitute some of the greatest roadblocks [1]. However, one can partially overcome them by resorting to green technology such as wind turbines, solar panels (already in use by Partners in Health (PIH) and Zanmi Lasante in the Central Plateau of Haiti for over 8 years), and satellite communications (widely utilized by The Study Group on Kaposi’s Sarcoma and Opportunistic Infections, known under the French acronym as Les Centres GHESKIO, in Port-au-Prince). Access to the designated space for telemedicine and patients’ charts should be restricted to responsible personnel using door locks, proximity cards, keypads, or biometrics. Many Haitians in Haiti and abroad master the telemedicine technology. For instance, Eng. Samuel Pierre, PhD., internationally known as an award-winner expert in information technology, mobile communication, fiber optics, cloud computing, and department chair at Polytechnic Institute of Montreal, is leading an avant-gardist project, Pôle d Innovation et de Dévelopment du Grand Nord (PIGraN), to provide long-distance education from kindergarten to graduate studies, cutting-edge healthcare including telemedicine, along sustainable agricultural, and economic development in Northern Haiti.

Operational barriers: Complete medical history, medication lists, laboratory tests, and radiographic results should gradually integrate patients’ electronic health records (EHR). Telemedicine offers the opportunity to develop and implement a robust and user-friendly EHR system. As a matter-of-fact, in the Central Plateau of Haiti, Partners in Health (PIH) and Zanmi Lasante are utilizing a web-based medical record system linking remote areas in rural Haiti and University Hospital of Mirebalais. Through this system, PIH and Zanmi Lasante provide a wide array of medical, educational, social, and economic services aiming at health equity and social justice, while promoting scientific advancement. Sharing similar goals, The Study Group on Kaposi’s Sarcoma and Opportunistic Infections, known as Les Centres GHESKIO, in Port-au-Prince, had implemented a solid electronic database for healthcare delivery, education, and training, research and social services nationwide, focusing on marginalized populations. GHESKIO focuses on promoting scientific independence through multilateral collaboration. Under the sponsorship of the United States Centers for Diseases Control and Prevention (CDC) and the Haitian Ministry of Health, The President’s Emergency Plan for AIDS Relief (PEPFAR) program is operating a national network of HIV electronic database for healthcare delivery, monitoring, evaluation, and reports. The CDC had brought a significant contribution in the formation of epidemiologists, field workers, HIV providers, and health administrators, as well as uplifting laboratory capacity and infectious diseases surveillance in Haiti. As telemedicine is moving from hospitals and ambulatory health centers to homes and mobile devices, the nature of the telemedicine visit will keep changing. Broadband expansion could stimulate this ongoing technological transformation. Telemedicine visits may become shorter and more frequent by using diverse communication methods with different providers. Any chosen space for telemedicine in Haiti and abroad should ensure the protection of patients’ privacy and confidentiality and safeguard the telemedicine equipment. However, frequent strikes and civil unrest may continue impeding not only telemedicine operations but also the general provision of healthcare services, with grave consequences on people with acute and chronic illnesses.

Financial barriers: Contingent upon the technology adopted and the intervention used, the cost of a telemedicine program varies substantially. Quite often the initial costs of space retrofitting, acquiring the necessary medical equipment, telemedicine hardware, software, and medical equipment for telemedicine, and setting up a robust electronic health records (EHR) system, and establishing communication modalities could reach substantial amounts and become unaffordable for resource-poor countries. Further, maintenance and continuous upgrade of the telemedicine system, as well as staff training, will add up to the operating budget. In Haiti, the unstable political climate and persistent insecurity make it hard to attract potential donors and generate confidence in volunteer telemedicine consultants. Moreover, for a country with uncertain future, strapped for cash, entangled in foreign debt, and overwhelmed by high priorities, the public and private sectors would probably take a cautious approach to investing in new healthcare projects, such as telemedicine. Hence, the prior demonstration of clear clinical advantages of telemedicine usage may help sway stakeholders. In that regard, what does the published peer-reviewed literature indicate?

Depending on the clinical setting, randomized and observational studies of the clinical impact of telemedicine had yielded conflicting results. For example, the observational study by Nassar et al., including 3355 intensive care units (ICU) patients in a network of seven Veterans Administration (VA) hospitals failed to demonstrate shortened hospital length of stay or decreased mortality rates when applying telemedicine for critically ill patients [22]. In a different hospital setting, a retrospective cohort study, Monkowski et al. analyzed the impact of inpatient infectious disease telemedicine consultation service on hospital and patient outcomes [23]. The study reviewed data on 244 patients, 73 in the pre-infectious disease telemedicine group, year 2012, and 171 in the infectious disease telemedicine group, year 2014. Mean age was 65 for the pre-tele group and 58 for the tele group. More immunosuppressed patients belonged to the tele group (23% vs. 12%). Study results showed that infectious disease telemedicine significantly reduced hospital length of stay, the median number of days patients received antibiotics, and the average antibiotic cost per hospitalized patient day, $14.53 in 2012 vs. $11.25 in 2014, all important performance indicators of antimicrobial stewardship. Cantor et al. reviewed 28 randomized controlled trials and 14 observational studies to evaluate the effectiveness and harms of various telehealth interventions supplementing in-person maternal health care of 44,894 women [24]. The telemedicine interventions included phone, web, and mobile applications. Maternal health areas involved general maternal care, postpartum depression, gestational diabetes, gestational hypertension, breastfeeding, and other conditions, such as smoking cessation and weight gain. This qualitative review found essentially similar clinical outcomes and patient satisfaction between in-person care and maternal telehealth. Berthaud et al. implemented a stepwise hybrid model of telemedicine provided by board-certified infectious diseases physicians to improve clinic attendance and viral suppression for 516 HIV-positive inmates in Tennessee prisons as follows: in-person clinic only, 2004–2010, at the central prison in Nashville; hybrid 1, 2011–2013: 50% in-person clinic followed by 50% telemedicine at the same central prison and on the same day; hybrid 2, 2014–2016: 50% live clinic at the central prison and 50% telemedicine at the Meharry Medical College campus in Nashville, on alternate week; telemedicine only clinic sessions, 2017–2018: at the Meharry Medical College campus [25]. For the in-person clinic, the inmates were all seen at a central penitentiary clinic in Nashville. Clinic attendance increased from 50% in 2004 to 90% in 2017–2018, while HIV viral suppression rose from 30% to 90%. The telemedicine program improved all channels of communication, patient-provider relationship and continuity of care, linkage, and engagement of inmates in transition, and offered opportunity to train medical students and residents, as well as inmates and prison staff [25]. Salgia et al. examined the educational impact of Veterans Administration distance learning case-based and didactic program for treatment of chronic hepatitis C in Michigan, Indiana, east-central Illinois, and northwestern Ohio, from June 2011 to September 2012 [26]. The Specialty Care Access Network-Extension of Community Healthcare Outcomes (SCAN-ECHO) program was developed to transfer subspecialty knowledge to physicians, nurse practitioners, and physician assistants, modeled after the Project ECHO created at the University of New Mexico for treatment of chronic hepatitis C. The investigators surveyed 51 providers anonymously using an electronic instrument. They achieved a response rate of only 47% with 96% completion [27]. The results demonstrated that primary care providers considered case-based and didactic sessions as equally important and that the distance videoconferencing learning program improved healthcare delivery.

In summary, this body of research contributes to advancing our knowledge on the feasibility, favorable clinical advantages and cost-effectiveness of telemedicine in diverse clinical settings, and the potential to reduce barriers to accessing specialty care for underserved populations. Therefore, the author of this book chapter hypothesizes that telemedicine could reduce emergency department visits, hospital admissions, and enhance the management of chronic comorbidities in Haiti, leading to more productive lives, sizeable return on investment, and reduced financial barriers.

Procedural barriers: To the best of the author’s knowledge, no legislative framework exists to regulate the practice of telemedicine in Haiti. This shortcoming underscores the importance of memoranda of agreement (MOA) between international providers or healthcare organizations and local Haitian healthcare entities. Prior to starting a telemedicine program, the partners involved should develop mutually agreed upon standard operating protocols. The quality of care should reflect evidence-based guidelines adapted to the local context. Policies should address medical negligence and malpractice, as well as liability insurance to protect vulnerable populations. Two-way channels of communication should remain widely open. Providers should have ample opportunity to review patients’ charts within a reasonable time period prior to the telemedicine session. Encrypted e-mail with two-level authentication factors is preferred for the transmission of patients private and confidential health information. Patients would need to sign approved informed consent, and the medical providers would have to sign confidentiality agreement in order to confirm their engagement into a professionally responsible patient-provider relationship. At the local clinic, a physician or a mid-level provider should present the clinical case and perform a brief physical exam as necessary. The telemedicine consultants should use the opportunity to educate patients, medical teams, and stakeholders. They should forward their final consultation reports, including teaching points, in a timely manner, utilizing clear, concise language, and relevant references [1]. Finally, this author strongly encourages the telemedicine consultants to deploy their best effort to follow the same patients at subsequent sessions, thereby ensuring continuity of care and reinforcing patient-provider relationship.

Human barriers: Leadership engagement is paramount for the application of telemedicine. It requires basic knowledge of operations and identification of top-priority domains of application. The leadership vision should preferably align with the national and local strategic healthcare plan, but sometimes it could outpace them. Leadership should promote community awareness and convince national and international stakeholders of the potential benefits of telemedicine for the appropriate populations and locations. Prior to inception, this author strongly recommends identifying a telemedicine champion to spearhead an outreach campaign and build up partnerships. Patient education, confidence, engagement, and satisfaction remain indispensable for ultimate program success. Outcome-driven incentives may serve as acceptable enablers. Key performance indicators should measure specific clinical outcomes, patient’s health improvement and satisfaction, providers satisfaction, and cost-effectiveness. The national HIV care model in Haiti teaches us that successful engagement (99%), retention (80%), and treatment adherence (73% viral suppression) stand in the realm of possibility for a disease-specific, organized, accountable, and supportive healthcare delivery system [2]. Lessons learned from the Haitian national HIV program inform prospective telemedicine volunteers about the importance of education, respect, condemnation of stigma and discrimination, and promotion of self-centered care.

6. Modalities and domains

6.1 Consolidation and expansion

6.1.1 Evolving medical and surgical specialties

As described in the background section, since the mid-1990s, few peer-reviewed papers about various telemedicine experiences in Haiti had been published in scientific journals. They relate particularly to dermatology, pediatric emergency, diabetic foot care, military deployment, and disaster relief. While most of these short-term experiments dwindled, new and more enduring projects emerged and strove to dispense invaluable services in different regions of Haiti. Therefore, the fundamental goal should emphasize consolidation and expansion of these impactful telemedicine services such as telestroke, telesurgery, teleradiology, and telepathology [1]. For example, telestroke can help quickly determine a patient eligibility for lifesaving thrombolytic treatment or neurosurgery. Telesurgery enables a surgeon in Haiti to perform robotic surgery remotely and can eliminate the barriers of distance in the delivery of high-quality surgical care. Teleradiology allows physicians to share digital imaging and interpretation remotely. Telepathology consists in the transfer of high-resolution microscopic pictures for reading and diagnosis [1]. Among illustrations of telesurgery/teleradiology programs in Haiti, one can mention the following: Bernard Mevs Hospital in partnership with University of Miami and Project MediShare, Mirebalais University Hospital in collaboration with Harvard University, and the longstanding partnership between Bienfaisance Hospital in Pignon and various academic medical centers in the United States. Teleradiology and telepathology open the prospect for applying machine learning (ML) and artificial intelligence (AI) to refine clinical decision-making capacity. However, before the application of AI and ML one should install proper oversight measures to protect the rights and well-being of patients, including a code of ethics and regulations, determination of data ownership, and processes for transparency, accountability, and elimination of algorithm bias. Then, the telemedicine clinic or hospital should pilot and validate the data output prior to dissemination and final application. These variants of telemedicine can upgrade the training of Haitian physicians and nurses in Haiti, as well as enriching the experience of international consultants. They can incorporate graduate residency training programs, reduce technological gaps, health inequities, and open doors for collaborative research, information sharing, and propagation of best practices.

6.2 Implementation and upscaling: chronic infections and comorbidities of public health importance

6.2.1 The use of telemedicine in infectious diseases

In general, randomized clinical trials of telemedicine use in infectious disease have demonstrated positive health outcomes for patients with HIV, chronic hepatitis C, and tuberculosis, as well as patient satisfaction and successful longitudinal mentorship. Experience with acute skin and soft tissue infections, respiratory, and urinary tract infections have shown favorable results. Thus, in a narrative appraisal of 29 peer-reviewed publications, Parmar et al. summarized the use of telemedicine technologies in the management of acute infectious diseases (14 papers), human immunodeficiency virus/HIV (2 papers), chronic hepatitis C/HCV (9 papers), and active pulmonary tuberculosis (4 papers) [28, 29]. Total sample size reached 3990, ranging from one to 1201. Study designs included case reports, cross-sectional and observational studies, randomized trials, and prospective and retrospective cohorts. Telemedicine facilitated the acute treatment and follow-up of patients with bacteremia, acute respiratory, urinary tract, soft tissue, and skin infections after hospital discharge. Published literature consistently demonstrates positive clinical outcomes for the treatment of HIV, chronic hepatitis C, and tuberculosis using telemedicine. In general, patients constantly report high levels of satisfaction. In a prospective study conducted from February 2012 to August 2015, Wood et al. analyzed the impact of teleconsultation and longitudinal mentorship to community HIV providers on medical care and education [30]. The University of Washington and Mountain West Education and Training Center (MW AETC) developed and implemented this program with the goal of reinforcing community provider capacity to deliver the latest, evidence-based HIV treatment. The program used cloud-based technology adapted to mobile device and computer to connect the participants with a multidisciplinary specialist panel in real time. It enrolled a cohort of 40 community HIV providers at 11 clinical sites, followed the Extension of Community Healthcare Outcomes (ECHO) model, and administered 172 ECHO sessions through 553 case presentations. The University of Washington tracked and evaluated program performance through periodic self-assessment of HIV care knowledge. The study results revealed significant increase in the knowledge and confidence of the participants and showed potential to promote workforce development and expand access to high-quality HIV care. In different geographic regions, Zolfo et al. described a hybrid telemedicine model sponsored by the Institute of Tropical Medicine, Antwerp (ITMA), Belgium, combining E-mail and web support to assist more than 170 healthcare professionals in 40 low- and middle-income countries in the provision of HIV care and continuing medical education [31]. Participants included alumni physicians of ITMA and their colleagues working in HIV clinics. During the initial 24 months (April 2003-March 2005), the participants requested 342 telemedicine consultations from 17 different countries. The majority of them originated from Uganda, Mozambique, Rwanda, and Cambodia. Diagnosis and treatment of opportunistic infections, antiretroviral side effects, and antiretroviral resistance represented the most common topics addressed in teleconsultations. This collaborative activity showed how telemedicine can provide effective clinical support in low-resource settings at an affordable cost. In Barcelona, Spain, León et al. performed a two-year prospective, randomized study to compare standard HIV care with an internet-based model encompassing the entire spectrum of management of chronic HIV infection, designated virtual hospital, and comprising virtual consultations, telepharmacy, virtual library, and virtual community [32]. They randomized subjects with computer and broadband access to either virtual hospital (Arm 1) or standard of care (Arm 2). After 1 year of monitoring, participants crossed-over to the other arm. In the first year, the study enrolled 83 subjects, 42 in Arm 1 and 41 in Arm 2. The study investigators did not detect any significant statistical difference between virtual hospital and standard of care in treatment adherence, viral load suppression, CD4+ T-cell count, quality of life, or psychological questionnaires. In 219, the Infectious Diseases Society of America (IDSA), the world’s largest organization of infectious diseases specialists had published an authoritative position statement on telehealth and telemedicine as they apply to the practice of infectious diseases [33]. The paper laid out an informative telehealth toolkit for consideration when developing and executing a telehealth program. In its position statement, the IDSA supports the use of telehealth in HIV and tuberculosis management, antimicrobial stewardship, outpatient antimicrobial therapy, and infection prevention and control. IDSA reiterates the special challenges to confront in telemedicine practice (patient satisfaction, reimbursement, licensure, and liability). Finally, the consensus paper recommends proper application of telehealth in clinical care, education, and research in an ethical manner.

6.2.2 Telemedicine opportunities for chronic infections and comorbidities in Haiti

For several decades, Haiti had adopted an exemplary model of public-private-international and academic cooperation for the prevention and treatment of HIV. The author would encourage the perpetuation of this successful model that had brought down the HIV prevalence from 3.2% in the mid-1990s to 1.9% in 2021, in spite of chronic political strife and social upheaval. Nonetheless, telemedicine could boost the success of PEPFAR and other HIV programs in Haiti. Given the current epidemiological picture of chronic diseases in Haiti, the implementation and upscaling of telemedicine in Haiti should focus on the management of chronic comorbidities: asthma/chronic obstructive pulmonary disease (COPD), essential hypertension, hyperlipidemia, diabetes mellitus, and behavioral disorders. The author of this chapter discusses the latter in the next section. During the past 40 years, Haiti had become dependent on import to feed its population. Consequently, cheaper high-fat, high-calorie, high-salt nutriments had become more accessible and affordable than healthy locally grown organic foods, raising the risks of cardiovascular diseases, and diabetes. Stress due to worsening food insecurity, growing food desert, political and gang violence, unemployment, precarity of life, and hopelessness further exacerbate these chronic conditions and the burden of behavioral disorders. The relentless deterioration of the environment and sanitary conditions, coupled with tobacco and alcohol abuse, and provide a fertile ground for the rising prevalence of chronic respiratory diseases. In term of implementation, first of all, the telemedicine programs should prioritize promotion of healthy lifestyles and disease prevention: good nutritional habits and weight management, environmental and personal hygiene, accident/injury prevention (especially for the widespread motorcycle riders), smoking and drinking cessation, adoption of responsible sexual behavior, and appropriate contraceptive methods. Although the incidence of cancer is escalating in Haiti and considering the limited access to expensive diagnostic and treatment tools (chemotherapy, biologics, and radiation), special telemedicine programs on the prevention of some of the more prevalent types of malignancies such as cervical, breast, and prostate cancer, deserve considerable attention. Nonetheless, a multidisciplinary oncology telemedicine consultation team can still play a role in alleviating the sufferings of people with cancer if they support a patient assistance program (laboratory and pharmaceuticals). Such a program could also embrace artificial intelligence and machine learning for diagnostic pathology and radiographic interpretation once they fulfill the necessary requirements.

6.3 Mental health

6.3.1 Applications of telemedicine in mental health

Mental health affects people worldwide. The COVID-19 pandemic had driven the use of telemedicine for mental health care and demonstrated promising results, but long-term outcomes remain undetermined. In general, the COVID-19 pandemic proves that tele mental health can substitute in-person care for assessment and treatment of diverse behavioral disorders, especially attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, major depression and anxiety disorders, and post-traumatic disorder (PTSD). However, tele mental health existed before COVID-19. A paper by Garcia-Lizana et al. summarized the results of earlier studies of the evaluation of telepsychiatry (1997–May 2008) [34]. After excluding studies with sample sizes lower than 10, the authors analyzed 620 articles, including 10 randomized controlled trials. They found inadequate evidence of the effectiveness of telepsychiatry in the management of mental illnesses. Later, an extensive review comprising 30 randomized controlled trials on the intermediate outcomes and health outcomes of tele mental health and four cost analysis studies by Bashshur et al. examined the empirical evidence of telemedicine interventions in mental disorders [35]. The review found empirical evidence of the potential for tele mental health to accomplish long-term management of mental illnesses through monitoring, surveillance, promotion, prevention, and biopsychosocial treatment programs. According to the study findings, basic telephone appears the preferred technology. Tele mental health found acceptance across lifespan, improved medication adherence, mental healthcare in primary care setting, and clinical outcomes for patients with comorbid medical conditions. Notably, it delivered effective treatment for depression and anxiety disorders, especially cognitive behavioral therapy. Cost-effectiveness analysis revealed that tele mental health programs need a threshold of 250 consultations to achieve cost-effectiveness. Lau et al. conducted a systematic review and meta-analysis to evaluate the efficacy of therapist-supported internet-based cognitive behavior therapy for stress, anxiety, and depressive symptoms among postpartum women [36]. The study found that therapist-supported internet-based cognitive behavior therapy significantly improves stress, anxiety, and depressive symptoms among postpartum women with small to large effects. Rightly so, the authors underlined five major shortcomings of their study: sampling bias as most of the participants self-selected, the use of self-reported outcomes, the inclusion of a small number of trials affecting subgroup analyses, the report of different effect sizes by diverse sessions of internet-based cognitive behavioral therapy, and the evaluation of only short-term benefits.

6.3.2 Opportunities for Haiti

Mental health remains taboo in Haiti and among Haitian expatriates as the country suffers a dearth of mental health professionals (23 psychiatrists and 124 psychologists for the entire country of 11,887,456 inhabitants, practicing almost exclusively in the metropolitan area of Port-au-Prince). Meanwhile, a certainly much greater but unknown number of North American-trained mental health professionals of Haitian descent live in the United States and Canada. Many of them, previously educated in Haiti, very familiar with the nuances and distinctive features of Haitian culture, could significantly contribute to a culturally and linguistically-appropriate tele mental health program earning rapidly the trust of mental health patients and Haitian providers. The Haitian American Psychiatric Association, born in 1984, and quite active in community outreach and education programs stands out well-suited to accomplish this mission. Telemedicine can facilitate mental health service utilization, reduce stigmatization, promote patient privacy and confidentiality, and ease their discomfort with the mental health service delivery system in Haiti.

7. Conclusion

Telemedicine presents important limitations. First and foremost, it does not constitute a panacea for a weak healthcare infrastructure nor does it replace traditional in-person visits provided by well-trained personnel in a well-rounded healthcare system. The substantial absence of direct physical examination and the diminished patient-provider relationship may jeopardize the clinical acumen of the telemedicine consultant and erode patient trust. Nonetheless, telemedicine offers an interesting alternative to advance global equity in healthcare. Second, patients’ rights and privacy concerns always require strict protection still a work in progress for telemedicine. Third, preventive medicine, including community awareness, workforce education, and technical assistance, should form the backbone of telemedicine in low- and middle-income countries. Meanwhile, the expansion of smartphones and telemedicine throughout the world in the COVID-19 era opens new perspectives to attenuate the geographic and social digital divide and reduce global health equities. The spotlight on Haiti exemplifies how low- and middle-income countries can customize telemedicine to improve healthcare access. So far, whether or not upscaling of telemedicine will affect the expatriation of medical graduates to rich countries remains unanswered. Paradoxically, the emigration of physicians from resource-poor nations could also serve as a stepping stone to reconnect with and give back to their homeland. In fact, many of them had organized their own national networks of health professionals abroad. By twinning with their affiliated healthcare institutions, medical and nursing schools, and nongovernmental organizations, they can develop and implement long-term telemedicine programs to benefit their native countries.

The Association of Haitian Physicians Abroad, better known under its French acronym, AMHE or Association Médicale Haïtienne à l’Etranger (Haitian Medical Association Abroad), founded in 1972, defined by its obligation to the homeland, and composed essentially of health professionals of Haitian origin, could play a major role in telemedicine initiatives between North America and Haiti. To accomplish this endeavor, AMHE would leverage its rich experience in Haiti, including medical and surgical services, HIV and tuberculosis programs, medical education, and residency training. The initial step would consist in identifying a pool of potential volunteers among retirees and active professionals. Next, they would form a steering committee to spearhead one or two pilot projects funded by AMHE members and possibly sponsored by United States Agency for International Development (USAID), other US/Canada government agencies, international, or philanthropic organizations, and individual donors. Subsequent to performance evaluation and quality improvement, the telemedicine program would expand to advance global health equity and inclusion. In the aftermath of the 2010 earthquake in Haiti, a group of eminent professionals of Haitian descent living primarily in North America and Europe created the Groupe de Reflexion et d’Action pour une Haiti Nouvelle (GRAHN), or Think Tank and Action Group for a New Haiti. This worldwide organization appeals to Haitian citizenry and friendship in the construction of a new Haiti grounded in science, technology, equity, and social justice. In fact, GRAHN’s Institut des Sciences, des Technologies, et des Etudes Avancées (ISTEAH) or Institute of Sciences, Technologies, and Advanced Studies shows a proven track record in preparing local Haitians and government and private employees to earn fully accredited masters and doctors degrees using long-distance learning and the free expertise of foreign and Haitian academicians. As healthcare and education constitute the pillars of GRAHN and AMHE, the two organizations had joined forces to build the AMHE-GRAHN community health care center of excellence, a component of Pole d ‘Innovation du Grand Nord (PIGraN), or Innovation Pole of the Greater North. The center will provide free or low-cost, high-quality care in primary and reproductive health, preventive medicine, infectious diseases, mental health, and ophthalmology. The use of information technology, communication, and telemedicine will represent the cornerstone of the AMHE-GRAHN community health center. Thus, fiber optic cable for high-speed internet access and videoconferencing will wire all the offices. This will facilitate the implementation of telemedicine consultations to support medical providers at the health center and throughout Haiti under the auspices of health professionals from AMHE and GRAHN. Toward that end, the Montreal Nurses and Nurse’s Aides Association, a GRAHN affiliate, will shoulder this effort. Based on previous experience at similar centers, telemedicine may offer a wider spectrum of medical expertise, surveillance, and assistance. In the near future, smartphone technology will bring health counseling and medical care to disenfranchised populations wherever they might live in Haiti. Bridging the technological gap will enable children born in remote villages of Haiti to pursue undergraduate and graduate studies while accessing excellent healthcare without living their villages. Moving forward, the AMHE-GRAHN collaborative enterprise may attenuate poverty by fostering education, healthcare, creating wealth, sustainable, and equitable development. As a tenet of social justice and recognizing healthcare as a basic human right, the allocation of global healthcare resources should prioritize the sickest and neediest people around the world rather than the wealthiest ones.