Correspondent: Dr. Gregory Dever, Director, Pacific Basin Medical Officers Training Program, Pohnpei, Federated States of Micronesia, 104075.3004@compuserve.com

Pohnpei ("PO-ne-pay") is a 129 square-mile (441 km2) island with about 34,000 people, one of the four constituent states of the Federated States of Micronesia that include Chuuk (formerly Truk), Yap, and Kosrae. It lies more or less midway between Hawaii, three time zones to the East, and Manila, three time zones to the West. Its extreme isolation has important medical and economic implications. Fully 25% of all health care dollars are spent on off-island medical referral costs for the less than 1% of patients who have to be transferred thousands of miles to Guam, Oahu, or Manila. To make matters worse, the medical education infrastructure has languished until recently, a casualty of regional politics and colonial policies (Spain, Germany, Japan, and since WWII the U.S.) directed toward the occupiers’ economic and political interests rather than local self-sufficiency. This has led to an "aid economy," with a tripling of food imports between 1977 and 1990 and an absolute fall in subsistence food production. Even medical care has been largely an import item: in 1985, 75% of all physicians in the Federated States of Micronesia were non-native.

The Federated States of Micornesia (FSM), with a population of 105,000 spread over 3 million square kilometers of ocean, became politically independent in 1987 and joined the United Nations in 1991. The health legacy left to it by the United States was the chronic underdevelopment of primary and secondary health and education systems and an overreliance on off-island medical referral -- the cost overruns of which were continually for by the U.S. Department of Interior until independence. Despite its idyllic appearance, this new developing country has tuberculosis rates 10 times that of the U.S., the highest rate of leprosy in the Pacific (third in the world), and infant mortality rates 7 times that of the U.S. One of its most important public health objectives has been to improve access to quality health care while keeping costs down. This is important because the cost of off island medical referrals plunders the fixed budget of this independent nation frustrating the improvement of primary health care and hospital based services. However, to do this a new health workforce was needed. To this end, the Pacific Basin Medical Officers Training Program (PBMOTP) was established on Pohnpei in 1986, with the mission of training native Pacific Islanders from select U.S.-associated Pacific Islands (FSM, the Republics of Palau and the Marshall Islands, American Samoa). This program, championed by U.S. Senator Daniel Inouye of Hawaii, has been funded through the U.S. Public Health Service, and administered through the John A. Burns School of Medicine at the U. of Hawaii. In the ten years since its inception, five medical school classes have graduated a total of 68 physicians including the first ever indigenous female physicians from the FSM and the Republic of the Marshall Islands. The result: today, 75% of physicians are native to the FSM -- an exact inversion of the situation a decade ago. Now, these physicians are returning from their specialty training residencies at the Fiji School of Medicine, the new postgraduate training medical center for the Pacific.

The problems of access to care, of continuing medical education, and of overcoming professional isolation have been addressed creatively since 1994 through the use of simple telemedicine technology. The concept was introduced by personnel from the Telemedicine Clinic at Tripler Army Medical Center in Honolulu. Recognizing that the telecommunications infrastructure would not support interactive-video mediated telemedicine, the Tripler staff recommended the use of a still-image capture system that could reliably transmit over regular phone lines. The enabling technology was the Picasso Still-Image Phone, manufactured by AT&T. The size of a small briefcase, this product, which has been used successfully at programs in the U.S. (Mary Imogene Bassett Hospital, Cooperstown, NY; McKennan Hospital of Sioux Fall, SD; U. of KY), behaves like a still-image, full color, paperless FAX machine. Freeze-frame images captured at the sending end by a camcorder are transmitted to a remote receiver unit, where they can be displayed and stored. Each Picasso unit costs about $3,000. Through contacts at Tripler, AT&T donated four units to the Medical Officers Training Program in early 1995. These have since been used for about 30 patient consultations between Micronesia and Tripler, for delivering medical lectures (with concomitant voice transmission on the same line) throughout the Pacific Basin, and for weekly case conferences, and Grand Rounds. Soon the system will be used for postgraduate education.

The Picasso phones have performed flawlessly, and their ease of operation has made them very popular among users. Because the units were donated (total retail value approx. $12,000), the only significant costs incurred have been for transmission time. These can be significant. The satellite-mediated FSM Telecom phone system charges at least $2.50/minute. While images can be sent earlier, during lower-price off hours, they typically are transmitted during the day, in the course of a consultation. A typical medical consultation involves transmission of about 3 images, with each transmission over the 28.8 Kbps modem taking about one minutes. Thus, a 20-minute consultation might cost about $50 just for telephony charges. This is a fair amount of money in a region where the average per capita income is $2,000/year and the health care systems have difficulty paying for long distance phone calls. However, the expense appears to be more than offset by improved, and more timely, diagnosis and treatment and by the occasional averted transfer to Hawaii or Manila. The round trip airfare alone for these transfers is at minimum $1,500 - $2,000. At least two averted transfers have been documented in the past 18 months. The savings from these may have alone accounted for the telephony charges for the entire project since its inception.

Dr. Dever cautions that cost savings may not be, and perhaps should not be, the bottom line in deploying a system like this. The increased access to medical expertise could actually increase the number of off-island transfers, especially as expectations about health care increase -- expectations which the region cannot afford to fulfill. It is clear, however, that this technology promises to:

* reduce professional isolation

* help with physician recruitment and retention

*        increase regional medical self-reliance

* help retain medical care dollars at home

As planned, funding from U.S. Public Health Service for the PBMOTP ceases on the last day of 1996. Thereafter, the medical school will become the Micronesia Human Resource Development Center, which will promote the development of primary and secondary health care in the region, assist the new Pacific Basin Medical Association implement CME for the regional health workforce, and initiate a sustainable telemedicine network for distance medical consulting and CME. The Center will support itself through grants, regional contracts, and innovation. Judicious use of telemedicine technology will definitely play a significant role in assuring the improvement of medical care and education throughout the Pacific Basin.

Post Script:

Unfortunately, the Picasso Phone was discontinued in the fall of 1995 (cf. "Picasso’s Blue Period: AT&T Stops Manufacturing Still-Image Phone", TT vol. 3, no. 3). There is talk in the industry about it being manufactured again by another company, but Telemedicine Today was unable to confirm this at press time.

REFERENCE:

Malani J, Dever GJ. Telemedicine demonstration projects in the Western Pacific. TeleMed 96, Conference Proceedings (R Wootton, Ed.), The Queen’s University of Belfast, 1996