Bob Pyke Jr. (BP): Dr. Jim Katzenstein, thanks for your time, so tell me a little about your self and how HealthSpan International came about?
Jim Katzenstein (JK): Thanks Bob. I was born in New York City of entrepreneurial working class parents and was the first in my family to go to college. After graduation I served in the United States Air Force, and then returned to school to get an MBA. I pursued a long and productive career in business, filling senior level management positions in manufacturing operations and general management, and was CEO of several entrepreneurial companies. I returned to school in 1996 to find a new direction for my life and found Africa. People I met there had a need for skills and resources but nobody was listening. Instead, help is being offered using a development model - I know what you need and I have the resources so, if you want help, we'll do it my way. We began by organizing small groups and empowering them to articulate a need, develop a plan and implement the plan, their way. HealthSpan International developed from there. We currently have colleagues in the U.S., Canada, India, Tanzania.
BP: So how did you become involved in telemedicine human factors sig group in the ATA?
JK: It was shortly after I received my PhD that I was asked to speak at TATRC's international day, held prior to the ATA's annual meeting. The subject was Africa. At the end of my talk, Rufus Sessions, then the chair of the SIG got up and announced that the HF SIG "needed me!" I am a sucker for anyone who claims they need me so I joined. I subsequently discovered that the confluence of need in developing countries for health care, the capabilities of technology to deliver health care at a distance, and the socio technical systems approach inherent in human factors presented a unique opportunity to advance health care in developing countries by skipping over badly broken infrastructure. It seems a match made in heaven.
BP:What role does telehealth and e-health play in your program?
JK: Telehealth is necessary in developing countries in order to defeat the infrastructure problem. It is much more difficult to transmit information, in any form, in a developing country because roads and telephone lines function sporadically. Getting to where health care is delivered, whether in person or by phone is a hit or miss proposition for providers as well as for patients, depending on the weather or the condition of the phone lines at any given time. Political issues and cultural differences further complicate the problem. The technology that supports telemedicine provides a new more dependable and more ubiquitous infrastructure on which to communicate. We use the technology to build relationships, communicate ideas and move projects along in between face-to-face visits. We have discovered that the level of technology used is crucial to the success of the particular problem being addressed. Simplicity is frequently more important than flexibility or other benefits.
BP: Can you tell me about the countries you serve and the patients that you serve, and what are their numbers and locations?
JK: We are primarily in Tanzania and in Mizoram, India but have had preliminary discussions with people in Sudan and in Sri Lanka.
BP: Can you give me some examples of what you are doing?
JK: We are working on several exciting projects at the moment, an example of which is a Tanzanian program called Safe Motherhood. We are collaborating with nurses to provide prenatal and postnatal care as well as well-baby exams and vaccinations in a village of 23.000 people in Dar es Salaam. HealthSpan provides the tables, chairs and other equipment and pays the nurses' salaries for the one day a week the clinic meets. We also buy the gasoline to get them to the bar where the clinic meets. Yes Bob, there is a demand for additional days but we don't have the money yet to pay for more time.
In a separate project, we are using the power of radio to transmit public health information in a "Larry King Live" format. A doctor is interviewed about a health related subject such as HIV/AIDS or Malaria control, and takes call from the audience.
We are also collaborating with a hospital in Dar es Salaam to operate a pilot telemedicine project. The hub site is in the hospital on the outskirts of the city while the spoke is in a walk-in clinic in the downtown area.
BP: What technology are you using and how?
JK: Our technology tends to be quite primitive. Our telemedicine system uses 8X8 cameras at each end and television sets as monitors. We also use computers with web cams for higher quality still pictures and to transmit data. When the nurse at the clinic needs to consult with a doctor, she calls the doctor on a cell phone and the doctor places the patient-at-a-distance in her queue of face-to-face patients. When it's the remote patient's turn, the doctor calls the nurse on the cell phone, turns on the cameras and starts the consult. This eliminates the need for precise scheduling which is foreign to the local culture.
BP: What problems do you have when trying to implement technology in the developing world and in rural areas?
JK: The first problem is one of dependable infrastructure. Frequently, availability of telephone service and internet connectivity is inconsistent. When you need to talk to someone "come back tomorrow" doesn't cut it. This inconsistency contributes to an air of undependability which is globalized to the entire system, so that even when the phone and the internet are working, there is a basic mistrust.
There is also a cultural disconnect between the patient and the western oriented doctor and nurse. The patient, with a reality that is rooted in the village culture is not inclined to visit a western clinic and the doctor and nurse in the western clinic views health care from a radically different perspective than does the patient. When the two are connected via technology, they might as well be from different planets.
BP: How do you partner in the places you're working?
JK: People in organizations in developing countries know what their problems are and they frequently have a good idea of what is needed to solve them. We collaborate to create innovative practical solutions, develop implementation plans, and help identify resources that are needed. If asked, we provide help with implementation and fund raising, but frequently this is not necessary. Our model builds confidence and self sufficiency.
In contrast, NGOs are the go-betweens, linking donors in the developed world with recipients in developing countries. They frequently have their own agenda which is presented to the recipient, along with the donor's money, as the solution to a problem the recipient needs to have fixed. The recipient's input is minimal. The mantra is "We have the money and we know what is best for you. Relax and let us do our job." This approach is demeaning and breeds dependence.
BP: What are your results in what you're doing? And can you give me some examples?
JK: We are making a difference in people's lives by giving them tools to make their lives better. Here is a simple example. During one of my trips, I organized a series of workshops which the Africans called project work. After a short discussion of how team work is done and a bit about project development, we organized the Tanzanians into small groups of doctors and nurses. Each group then selected a small project to accomplish and worked to make it a reality.
One group selected as its project the task of getting all doctors to wash their hands in between patients. Since there was no water in the patient's rooms, the group figured out how to build a cart with soap, water and towels. The nurse pushed the cart into the room and assumed responsibility for getting the doctor to wash after each patient. She held the pitcher of water and gave the doctor the soap and the towel - and would not take no for an answer. So what did we do? We gave them the framework and the "permission" to accomplish something and they did the rest.
Some of the other projects we have done include a major telemedicine conference in Mizoram, India. The government of Mizoram is using the conference as a springboard to implementing a state wide telemedicine system.
BP: What else are you doing in telemedicine as far as distance education and grand rounds?
JK: We have been contacted by an individual in Sudan who wants to develop a tele-education system connecting his university with those in other countries. We are using a store and forward technology to deliver a basic set of information and then following it up with an interactive SKYPE conference. We are at the very beginning of this but I think the methodology is new.
BP: How is your program funded?
JK: Our projects have, thus far, been funded by private donations. Donations, up to $5 million can be made through our web site http://www.healthspaninternational.org Click on the donations tab. For donations in excess of this amount, call and I will come pick it up.
BP: What do you want to do, and in what direction would you like to see your program go in the future?
JK: Most of our work so far has been what I would call learning and piloting. We have developed a way of being and operating that I think is truly unique. I think we can make an impact on a large scale because of the relationships we have built, and I am itching to proceed. Safe Motherhood clinics all over the developing world, telemedicine centers of excellence linking people from all parts of the world together in a powerful network of learning and sharing are some of my dreams for the future.
BP: What can be done to continue to promote telemedicine in Africa, India, Eurasia, and other parts of the world?
JK: The real question is what can be done to promote quality health care in developing countries throughout the world, using ICT as the enabling technology. First, make the technology and the systems that support the technology simpler, easier to use and more dependable. Second, make the system more cost effective with the technology than it is without it, and third make telemedicine compatible with the social and cultural contexts in which it is expected to operate.
BP: David Balch, who,retired from the Advanced Telemedicine Training Center at Eastern Carolina University told me that he thought telemedicine as we know it would disappear, that would be so common on our desk top, that we will take telemedicine for granted. What do you think?
JK: That's an interesting observation, Bob. When I was a boy, medical care was delivered to the home by physicians who made house calls. The process has evolved away from that, partly because it is more cost efficient for all the patients to come to the doctor than for the doctor to go to all the patients. This model is ubiquitous through out the world. As telemedicine becomes more cost efficient, I see no reason why the pendulum shouldn't swing back - even in developed countries. We are busy and so don't have time to sit in a doctor's office for an afternoon and then get stuck in traffic on the way back to our office for a dinner meeting. Far more efficient to have a quick teleconference between meetings and have the prescription delivered.
BP: What do you want to say or add to your colleagues out there? And what words of advice can you offer?
JK: I don't feel wise enough to be offering advice but I have an observation. We, as a generation, have enormous resources that we can use to make the world in which we live a better place for the ordinary people in it who struggle every day to stay alive. And with those resources come the responsibility to act. To those of you out there who think the world is too big and you are too little to make a difference in it, I am reminded of what Bobby Kennedy said in 1967. "Few will have the greatness to bend history itself, but each of us can work to change a small portion of events, and in the total of all those acts will be written the history of this generation. It is from numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance." If each of us reaches out to people in need, we can make a difference.
BP: If people want to donate or help with your mission how can they help and what do you need to continue your work, ie. a dream list?
JK: Our needs can be divided into two main categories - what we need to maintain HealthSpan International, and what our clients need to build on what we have started.
HealthSpan International's most urgent needs are for funds for travel expenses, (air fare, lodging and meals), part time clerical support and part time fund raising support. There are good people out there but we need money to pay them for part time work. There is a huge pent up demand for our services, but we are hampered by an inability to travel.
Our clients need nurses' salaries and gasoline to expand the Safe Motherhood program and the school program. They need air time to maintain the radio program, teleconferencing equipment to expand the telemedicine pilot, and travel expenses to maintain and expand Adopt-a-Doc.
BP: How can people contact you?
BP: Jim thank you for your time and I wish you continued success.
To find out about Dr. Jim Katzenstien and Health Span International, go to his web site at Health Span International.
Interviewer Bob Pyke Jr. is Co-administrator Telehealth List Serve and E-health List Serve and roving editor at large. You can reach him at email@example.com