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Telemedicine’s sight for sore eyes
Rural clinics in South India benefit from technology that could revolutionize health care in the developing world
By Rachele Kanigel
In a spare, one-room eye clinic in the rural South Indian village of Bodinayakannur, a 64-year-diabetes patient named V. Ramaswamy, and a medical technician sit facing a computer monitor. On the screen is a live video of an ophthalmologist at the Aravind Eye Hospital in Theni, nine miles away. Speaking into a microphone, the technician describes the patient’s condition to the remote physician, then hands the man the microphone. “For the last week, my eyes have been red and itching,” the patient, Ramaswamy tells the physician in Tamil, the local language. “There has been swelling and watering.” The physician prescribes five days of eye drops, explaining that Ramaswamy has an infection, and asks him to come to the hospital for a follow-up exam.
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In his Berkeley Intel Research Lab, Eric Brewer (left) and graduate student Sonesh Surana make adjustments on a prototype for models they have deployed in India. This low-cost wireless technology, part of a collaborative project between UC Berkeley, Intel and the Aravind Eye Hospital in South India, creates high-speed network links directly connecting patients in rural clinics to ophthalmologists in distant hospitals.
PEG SKORPINSKI PHOTO
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Later Ramaswamy, who had heard from a friend in town that he could go to a local eye clinic for a teleconference with a hospital doctor, said he might not have sought prompt treatment if he’d had to find a way to the hospital nine miles away. “They said I could talk straight to a doctor through the TV,” he says. “If I had to go to Theni, I would have put it off or maybe not gone at all. Because the clinic was here, I came right away.”
This virtual consultation and hundreds more conducted every week at the clinic are made possible through videoconferencing technology developed by a team of UC Berkeley computer scientists. The group has helped set up five clinics, or vision centers, with video conference links to the Aravind Eye Hospital in Theni, in the South Indian state of Tamil Nadu. The pilot project, less than two years old, has been so successful that hospital administrators plan to expand the program over the next few years to 50 clinics linked to Aravind’s five hospitals in South India. Together these centers will serve a population of roughly 2.5 million people.
“The information technology revolution holds tremendous potential for addressing problems in developing countries,” says Eric Brewer, Berkeley professor of computer science and director of the Berkeley Intel Research lab. “Historically though, most projects have been either too expensive or too technologically complex to use in poor, rural areas. What we’ve done here is develop a simple, inexpensive software and hardware system that can provide villages with a high-bandwidth connection to computer networks in cities as far as 50 miles away.”
Brewer has been a visionary in the field of computer science since 1996, when he co-founded Inktomi Corporation, a pioneering search engine venture, with a Berkeley grad student and helped lead it onto the NASDAQ 100. The company was bought by Yahoo! in 2003. But the modest, unassuming computer scientist isn’t looking for fame; his aim now is to apply his technological know-how to solving some of the developing world’s most intractable problems.
The Aravind Eye Hospital project is part of a larger initiative Brewer leads called Technology and Infrastructure for Emerging Regions (TIER), a collaborative project between UC Berkeley and Intel underwritten by the National Science Foundation and sponsored by CITRIS, the Center for Information Technology Research in the Interest of Society. Brewer has deployed student teams around the world, working on a variety of IT projects in Ghana, Rwanda, Mexico, Sri Lanka and Cambodia, as well as India. The emphasis is on tailoring technology to meet pressing community needs in practical ways.
“The only way to close the divide—not just the digital divide, but the general divide between the industrialized world and the developing world—is through technology,” Brewer says. “But technology can only make a difference if it’s useful. We’re trying to create new technology options that are less complicated, less expensive, require less power and that meet local needs.”
In 2004 Sonesh Surana, a native of India and a Berkeley computer science doctoral student working with Brewer, heard about the Aravind Eye Care System—a network of five eye hospitals, the first of which opened in 1976. Its founding mission: to eradicate preventable blindness in Tamil Nadu, a state of 62 million people. Employing a unique fee system, Aravind provides free eye care to two-thirds of its poorest patients with revenue generated by the other third of patients who can afford to pay.
Still, poverty, inadequate transportation and poor publicity have kept many locals from getting to eye hospitals to obtain the free care. In response, Aravind administrators came up with the idea of establishing village eye centers that could offer basic eye care and access to specialists through videoconferencing.
In August 2004, Surana visited the Aravind Hospital in Theni to see if a collaborative venture with Berkeley was possible. He surveyed the existing setup and did a preliminary topographical survey to determine if TIER’s technology was feasible, given the requirement for line-of-sight between communicating endpoints. “I realized that Theni’s current situation could be greatly improved by adding much higher bandwidth wireless links to dramatically improve the quality of videoconferencing, eventually allowing for services such as retinal image transfer and live remote examination of the eye itself,” says Surana. “They had a need and we had a solution.”
Telemedicine—using telecommunications technology for distant medical diagnosis and patient care—has been around for years. In many parts of the world, patients “meet” with doctors via teleconferencing technology. But such virtual consultations depend on a community having some basic technology, such as reliable Internet access and high bandwidth. These amenities are often not readily available in much of rural India, where some homes don’t have electricity and many people live on about $2 a day. Satellite technology, which is commonly used in telemedicine, is prohibitively expensive.
Brewer considered nearly 100 other prospective projects before deciding on Aravind. Their extensive network of facilities, efficient administration and commitment to serving the poor, he thought, would make them ideal collaborators.
What Brewer’s team has done is use inexpensive, off-the-shelf equipment—802.11 wireless cards and high-gain directional antennas—to create WiFi-based (wireless fidelity) long-distance networks. The wireless cards, also off-the-shelf, are used for short-distance communication, usually up to about 200 feet. But Brewer’s team, including graduate students Sergiu Nedevschi and Rabin Patra, modified the software, specifically the WiFi Media Access Control protocol. Now, combined with the antennas and routers that send, receive and relay signals, the network can handle high-speed communications over distances as great as 50 miles.
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Towers like this one set atop the Chinnamanur vision center’s roof (center of photo) ensure clearance over surrounding groves of tall coconut trees, some 60 feet in height, allowing clear line-of-sight transmission between distant antennae.
SONESH SURANA PHOTO
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The solution is not only innovative, says Brewer, it is truly cheap. The equipment costs a mere $600 to $800. “The monthly cost of satellite technology is typically higher than the one-time costs of our equipment,” Brewer says. “And no cellular or satellite network company is required, so the hospital can expand according to its own schedule.”
The Berkeley team traveled to South India many times over the past two years to install the equipment and work out the bugs for the first two vision centers, located in the villages of Bodinayakannur and Ambasamudram. The team replaced low-bandwidth links with high-speed links, dramatically improving the videoconferencing technology previously in place. They then trained local technicians to install the links themselves. For the third link, in Chinnamanur, local staff installed the equipment with only minimal assistance from the Berkeley team and created a high-speed link where none existed before. Last May, local crews installed two more links on their own, in Periyakulam and Aundipatti.
R.D. Thulasiraj, director of information technology and systems for the Aravind Eye Care System, says the collaboration has raised the technological competency of the Aravind IT group. “Working with the team sent by Professor Brewer is really easy and extremely pleasant,” he wrote in an e-mail interview. “It is a group of young professionals who are driven by the excitement of new technology and even more by the opportunity of employing the technologies to directly benefit humankind.”
Until the clinics opened, local people would walk as far as 12 miles to the Aravind Hospital in Theni to get eye care, forcing them to lose a day of work, Brewer says. Now many can walk to the local eye center and get their eye care needs met in an hour or two.
The clinics are run by ophthalmic technicians, usually local women without extensive education, trained in eye care by Aravind. Patients generally get a rudimentary exam from the technician and then have a brief consultation on a Web camera with a doctor at the distant hospital. Patients can buy glasses and medications at the vision centers. And if the doctor believes that an in-person examination or a medical procedure is warranted—most often cataract surgery—the patient is given an appointment at the hospital.
“The major impact is that we are now able to offer higher quality diagnostic care by using local people with less training,” Thulasiraj says. “It also gives confidence to the ophthalmic technicians in the rural setting who are independently handling the patients, knowing that there is a backup if they get into a decision-making problem or uncertainty about the mode of treatment. For the patients themselves, this has been significant benefit in terms of eliminating unnecessary visits to the hospitals, or in some critical conditions, reinforcing the urgency of coming to the hospital for treatment in the hospital.”
The first three clinics opened in 2004 and 2005; two more opened last spring, and all WiFi links became operational over the past two years. Together the five clinics examine about 1,700 patients a month and the numbers keep growing. “The goal,” says Brewer, “is to eventually expand to 50 clinics or vision centers, each serving a population of roughly 50,000 people.” The centers have had a tremendous influence on the health of the communities they serve, hospital officials say. In a recent study on the impact of the clinics, Aravind Eye Care System researchers found that 85 percent of the men and 58 percent of the women who had lost their jobs due to vision impairment were able to return to work after getting treatment.
“This is an exciting venture, and we believe it has the potential to effectively address the problem of eye care access in rural India,” says Dr. S. Aravind, administrator of the Aravind Eye Hospitals. “TIER’s partnership has been invaluable in enabling this approach to get off the ground with such speed and success.”
Surana, who has not only led the project’s fieldwork, but is also extensively involved in the design and experimentation of new laboratory protocols, says it’s been an extremely fulfilling effort. “Helping Aravind restore vision to poor people’s eyes and giving them the ability to work again is very gratifying,” says Sonesh. “Professor Brewer’s TIER group gives us the opportunity to transform people’s lives during the course of our education. Today, patients are already being examined on our network. It’s not every day that a computer science student can claim such benefits.”
Brewer hopes to apply the same teleconferencing technology used in India to other communities in the developing world and to rural settings in the United States, including remote Indian reservations, where access to health care is inadequate.
“Wherever there is a demand for eye care or other medical services, you can easily and inexpensively use one of our networks,” Brewer says. “This could revolutionize the delivery of health care services and greatly improve the quality of life in the rural developing world.”
RACHELE KANIGEL is a freelance writer who lives in Oakland. She teaches journalism at San Francisco State University. |
