Most people with mental disorders in low income countries receive no treatment at all for their mental illnesses. The new technologies, like the internet and mobile devices, can solve part of this so called treatment gap. In ’10 good reasons’ the benefits of ICT in this global health field are clarified. 1: ICT is booming business, 2: Saving costs, 3: Reaching people, 4: Anticipating on globalization, 5: Raising awareness and fighting stigma, 6: Empowerment and independence, 7: Capacity building, 8: Global knowledge sharing, 9: Bottom up and demand driven, 10: Standardized and easy access of info.
As one can read in the 2007 Lancet Series on Global Mental Health the World Health Organization (WHO) estimated that mental disorders contribute to 12% of the global burden of disease and make up 5 of the 10 leading causes of health disability. In the meantime 75-85% of people with mental or psychosocial disabilities have no access to any form of formal mental health treatment in developing countries, the so called mental health treatment gap. In order to join forces and turn the international and national policies, a couple of initiatives are launched since 2005, like the publication of these Lancet Series, the Global Movement of Mental Health , the mental health Gap Action Programme (mhGAP), and more recent the Great Push for Mental Health by the World Federation for Mental Health (WFMH). International Mental Health conferences, like the one in September 2009 in Athens and the next in October 2011 in South Africa, and WHO reports like Mental Health and Development and other big, small, local, regional actions, courses and research are all an effort to scale up the mental health services. But, as Vikram Patel from the London School of Hygiene & Tropical Medicine states: ‘Because of the scarce mental health resources, we will never be able to close the treatment gap in any significant way if business continues as usual. It’s time for innovative thinking’. He, amongst others like the World Organization of Family Doctors and the WHO , believes that non-specialist healthcare workers should become the front-line of mental health services in poor countries, in the so called community mental health. And that the vulnerability, stigma and ignorance of people with mental disabilities must be fought by media and events, by strengthening the voices of user movements and that the violations of their basic human rights must be addressed.
Although, this all sounds great and positive, for me it still smells too much like the old paperwork, academic corridors, agenda’s-meetings-thick reports and hierarchies. Not wrong, but we are gifted with the 21st century new technologies! In this era ‘everyone’ can be online and on the phone, everyone is equal and accessible, everyone can search and connect and everyone can contribute to plans and innovative thinking. Thus global mental health must not only engage with the new technologies; for a real demand driven, affordable and sustainable care, we must marry the new technologies: embrace and stay together for ever.
In this paper I will try to motivate this by addressing a couple of main complications and challenges in solving the mhGAP. With figures and examples I will try to specify the benefits of ICT and mobile devices and will end in a conclusion with some obstacles and recommendations.
The scope of this paper is mainly the less served people and the poorest area’s of the world. But what has been published and shared about the new technologies and mental health until now is mostly in and from the higher income countries. Examples are the recent published book The Use of Technology in Mental Health and the inspiring International e-Mental-Health Summit in 2009, and the next in April 2011, and online networks like the International Society for Mental Health Online (ISMHO) and the Online Therapy Institute. Up to date and high qualitative information, but not suitable for the chained man with a psychosis in rural Ethiopia, the mentally disabled child with daily seizures due to untreated epilepsy, high in the mountains of Papua New Guinea or the aggressive woman in her manic episode in a remote village in Guatemala.
I got all the information from the web (off course) and because of the limited publications (yet) on mental health in this regard, now and then I relied heavily on developments and publications of the more general eHealth and mHealth fields.
1: The new technologies are already there and a worldwide booming business
Although the new technology penetration in developing countries is the lowest worldwide, it’s catching up rapidly with the rest. According to the International Telecommunication Union (ITU) at the beginning of 2011 21% of the population in developing countries will be online and 68% will have access to a mobile phone network. Compared to the internet access of 71% in developed countries and 90% global penetration of the mobile phone. The ICT prices are falling, but high speed internet access remains very expensive in the low income countries, and is even nearly 7 times more expensive then in the developed countries. The mobile wireless services are much more available and affordable and in the developing countries even cheaper then in the developed world. So, there is a big change that people in developing countries start their activities in the new technology on a mobile device and skip the desktop and wire-line network phase altogether.
People round the world are spending a lot time online and on social networks. According to the Deloitte report on Social Networks and Healthcare, in June 2010 Facebook boasted 400 million users and Twitter 105 million, LinkedIn 60 million. Youtube reported 6.5 billion views and there are 112 million blogs posted worldwide. The social networks were initiated as a recreational tool, but they are increasingly getting important for business and organizations. For example: in the USA 700 out of 5,000 hospitals have a social media networking presence like for example the Mayo-Clinic and 55% of surveyed Americans get information about a therapy or a medical condition via a website like psychcentral.com.
Because mental health users, practitioners, caregivers and family members are online and are using there mobile devices abundantly, we must incorporate these technologies in our global mental health organizations and policies. Otherwise we will miss the connection with the daily reality of this new era.
2: Affordable mental health care; saving costs
One of the major problems in the global mental health care in low and middle income countries is the lack of funding (Lancet Series 2007). But even in high income countries costs for healthcare are spinning out of control, although partly for other reasons. See for instance the Medical News Today article about the situation in the US .
In this context i.com, the innovative centre of mental health and technology, states that ‘It would be a formidable step ahead when for instance evidence based treatments for mental health disorders could be offered on a broad scale and at low costs over the internet’. Trying to use the limited time and resources of mental health professionals more efficiently. Examples of internet based programs are: the international Stop Smoking Site, the UK Beating the Blues program and the Arabic Internet-based treatment of PTSD.
Another cost-saving example is tele-nursing, where the client can consult a nurse via the phone for information, advice, a referral or a drug subscription. The ITU reports that in the USA there is a 600% increase in tele-nursing in the last 5 years and a further worldwide growth is expected when there is more financial impetus for it. A mental health example is the telemedicine project in India after the 2004 tsunami from the Schizophrenia Research Foundation.
An additional advantage of this kind of distant care is relapse prevention. As the ITU addressed in their report ‘unfortunately, once finishing the inpatient treatment, most of the (psychiatric) patients never seek after-hospital help. GSM and internet offer easy and user-friendly ways to support these patients on their way back to everyday life’.
And last but not least: how much money would we save if we stop travelling around the world for conferences, research, study, consultancies etc. Count in the primary costs for hotels, meeting venues, the drinks and dinners, and the secondary costs in the loss of time. I know it’s marvelous to travel and meet and greet face to face, but anno 2010 it sometimes seems already an unnecessary waste of money and anno 2020, I think, it will be a shame. Or, as the software provider Virtually Face-2-Face states in an advertisement: ‘We deliver communication solutions for more effective collaborative events saving time and money, while being environmentally friendly’. Other (free) web conferencing software are for instance Dimdim.com and oovoo.com, and companies like Google offer ‘reliable, secure web-based office tools for your organization’.
3: Reaching people in need in the remote and underserved area’s of the world
Not only are resources for mental health care scarce, they are also inequitably distributed, between countries, regions and within communities (2007 Lancet Series). Low income countries have a median of 0-05 psychiatrists and 0-16 psychiatric nurses per 100,000 population. In high income countries this ratio is 200 times higher. In countries like Chad, Eritrea and Liberia for instance, there is only one psychiatrist for the whole country. Since most mental health care professionals live in and around the larger cities, rural populations are extra underserved.
If mental health care is offered in a community based model or integrated into primary care the local lay community workers or low educated health workers need extra training, knowledge, supervision and continuous support from elsewhere. The mHealth and Development report of the UN Foundation and the Vodafone Foundation, the eHealth Tools & Services report of the WHO, the Question 14-2/2 study of the ITU and the special mHealth dossier of the Dutch Royal Tropical Institute, offer all a broad array of applications for this remote control support in developing countries. For instance shared electronic records, computer assisted prescription of medicines and step by step diagnosis decision trees, wiki’s, video conferencing, tele-pharmacy, second opinion and distant consultations. A nice example is a project in the Caribbean with the PDA, portable digital assistance for nurses to empower diagnosis and decision making. Another the use of CommCare in Tanzania, with several pilots on social support for HIV+ and chronic care patients, general health promotion, safe pregnancies and vulnerable children.
And in order to reach patients in remote area’s, or immobile patients, mental health practitioners can use mobile or internet care-at-home programs like video monitoring, online encrypted chats/mail via free providers like Skype and Hushmail and tele-nursing. An nice example of an application is a Doctor in your Pocket, a phone based primary care model, used successfully in a few developing countries. Another example is the use of SMS services to clients for drug adherence and relapse prevention, like the On Cue project in South Africa. Health workers were sending SMS out within a chosen time frame, to remind patients with tuberculoses for drug regime compliance. The costs for this SMS service was $16 patient/year and the they had a 99,3% compliance rate.
4: Anticipating on the globalization and movement of people
Immigration is a key part of globalization. According to Peter Koehn of the University of Montana-Missoula in 2000 185 million people live outside their country of origin and according to the ITU in 2007 there were 36 million expatriates worldwide and more then 898 million people crossed national boundaries, which number is expected to increase to 1.56 billion in 2020.
In a comment on the 2007 Lancet series Dinesh Bhugra and Iraklis Minas state that although globalization can promise universal and economic benefits, for a lot of the people on the move it can lead to increased marginalization, unemployment, increased poverty, facing violence and other adversities. The encounter between people and other cultures can result in acculturation problems, leading to extra distress and dysfunction in some individuals and tension between cultural groups.
Emergencies and violence produce large flows of asylum seekers and refugees, often in low and middle income neighboring countries which have little capacity to receive them and take care of them, even more overstretching local limited resources. According to the World Development Report 2011, there were 42.3 million people displaced globally in 2009. Of these 15.2 million were refugees outside their country.
With many countries having multiple local and regional languages, communicating with care givers in the language you know can be crucial for help and accurate advice. Personal health info and records can be accessed online (see point 6) and shared with a professional elsewhere. Free encrypted mail and chat sites (see point 3) make communication with far away mental health professionals possible and with 100% privacy (if used properly), and some of the online interventions mentioned above (point 2) can be accessed worldwide. So, with the new technologies people can ‘take their mental health care with them’, wherever they are.
5: Fighting stigma and raise awareness about mental health conditions
A lot of people with mental health problems are subject to stigma, exclusion and discrimination. That’s why the WHO stated in their report on Mental Health and Development that ‘people with mental health conditions meet the major criteria for vulnerability’. As Jagannath Lamichhane, journalist in Nepal, explains in Time to Heal and another article, people can have the notion that a mental illness is a loss of face for the family, a result of bad karma, or the individual’s fate and result of bad deeds in past lives. This stigma and lack of knowledge about mental disorders can result in a strong avoidance in seeking treatment, and efforts of family members to ignore or conceal the mental health problems of their family member. Often patients are still locked up or chained out of sight and the conditions in many mental hospitals are appalling and treatments abusive. See also the WHO´s framework on Mental Health, Human Rights and Legislation.
A strong advocacy is required to shift these attitudes and behavior, at all levels: the people with mental health problems, the family, the community, health workers, civil society, government, bilateral and multilateral agencies, donors etc. In this urge to advocate the WFMH for example launched ‘the great push for mental health’ initiative in order to push its vision ‘of a world in which mental health is a priority for all people’. Their major themes are: unity, visibility, rights and recovery. They stress, amongst other things, fighting the stigma by means of public events like grass-roots campaigns, national parades on the World Mental Health Day 10 October, petitions, conferences and the use of the social media.
Good examples of mental health stigma fighters with a extensive social media appearance are Time to Change in the UK, Mind Freedom in the US and Sane in Australia.
In the UN Foundation and Vodafone Foundation report is concluded that ‘formal studies and anecdotal evidence demonstrated that SMS alerts have a measurable impact on and a greater ability to influence behaviour than radio and television campaigns’. Example of a successful SMS awareness campaign is the HIV/AIDS Text To Change, a SMS-based quiz to 15,000 mobile phone subscribers during 3 months in Uganda. The quiz produced 40% more patients who came in for testing, from 1,000 to 1,400, during a 6-week period.
6: Empowerment and independence of users and caregivers
A vast amount of people with mental health problems are not meeting any mental health professional at all. Reasons can be the huge lack of services, or lack of understanding about the benefits of services, lack of money, stigma or other reasons. Others are meeting (mental) health professionals, but face insufficient or bad treatment or violations of basic human rights (see point 5). People from both groups, including their caretakers, will benefit from more information about conditions and treatment, more ownership, more possible choices, decisions and support.
Nowadays there is 7 x 24 access to online information, suicide-prevention and emergency sites/telephone numbers like Befrienders Worldwide and others. There are apps on mobile devices like the T2 MoodTracker application of the US army, Mobile Therapy, a cell phone application for ’emotional self-awareness’ and others. If you stroll for instance the Apple iPhone app store you can find apps to help with relaxation, anxiety, anger management, eating disorders, obsessive compulsive disorder, and substance use recovery. And there are internet services like Personal Health Records (PHR’s) like Microsoft HealthVault and others.
With these applications people can manage a part of their mental health care themselves, wherever they are or at what time of the day.
All these technologies can play an important part in the ‘self care’ level of the WHO Pyramid: ‘the optimal mix of mental health services’. In this pyramid self care refers to care without individual professional input and is the most frequent needed and cheapest care (the bottom of the pyramid). And in all other levels self care is essential and occurs simultaneously with the professional services.
According to Amita Dhanda and Thelma Narayan user and self-help groups can play a important rule in the everything that is ‘wider then the medical establishment’, like peer- and family support, rehabilitation, training. Addressing issues like livelihood, life skills, education, occupation, parenting skills, local healing traditions etc. Examples of user and self-help groups are the Alcohol Anonymous, the World Network of Users and Survivors of Psychiatry and others, and online communities like Intervoice and others. A lot of these group have a high internet presence and/or use the internet for contact, actions and news.
7: Capacity building in the mental health care
Because of the massive shortages of psychiatrists, psychologists, psychiatric nurses and social workers in low and middle income countries, capacity building is a priority. But according to the 2007 Lancet series, training facilities are generally inadequate and on top of that there is a large scale migration of mental health professionals to higher income countries, the so called brain-drain. As Vikram Patel argues: ‘mental health services in developing countries tend to imitate those in the West, where specialists in hospitals or clinics treat patients. But both hospitals and specialists are in short supply’. In the more innovative thinking an integration of mental health in the primary care is needed (see for references the introduction). In these models the specialists will have more roles then merely treating patients and they need other skills. There are already short courses addressing this leadership in mental health and universities have been launching academic courses in public health, mental health, research and human rights. A few of them are for most part based on elearning, like the Mental Health and Policy and Service International Master in Lisboa, Portugal. There are also special distance colleges who offer paid distance learning, online communities for free sharing of educational material (so called Open Course Ware) and a few websites on ‘how to…’ who offer instructions about mental health issues as well. But the community health workers will need extra education, supervision and on the job training too. An nice example is the Primary Healthcare Nursing Promotion Program in Guatamala, with a combination of mobile phones, land-line phones and tele-writers the nurses are trained on the spot in the far away rainforest community.
So, development of more, cheap and easy applicable distant- and elearning programs seem a ultimate solution here. Practitioners and students from low and middle income countries don’t need to leave their country or area for years, which is very expensive and bears the risk of not coming back. They can practice on the spot and even in the remote underserved rural places, in their own pace and time.
8: Global knowledge: together we know more
The field of mental health in low and middle income countries used to be a patchwork of hospitals, NGOs, local initiatives, donors and research institutions. There are a couple of worldwide operating NGO’s like for instance Basic Needs, GIP-Global and Reference Centre for Psychosocial Support, and Academic Institutions like the London School of Hygiene & Tropical Medicine and the Centre for International Mental Health of the University of Melbourne. But most of them still seem to have own projects, manuals and pilots. Maybe inventing the wheel over and over again.
In the last decade a few promising alliances are forged like the Global Movement of Mental Health, the WHO Mental Health and Poverty Project (MHaPP) and the Mental Health Gap Action Program (mhGAP) and others. But how to share the information and how to convey useful information to the people involved? And even more important: how to receive essential feedback from people in the field? How to build all these bridges?
International conferences, including the travelling and accommodations, are not affordable for most practitioners in low and middle income countries. The same with paper text books and journals. The new technologies can tackle most of this money related obstacles and give ample possibilities to a 2 way information stream. In the mental health field there is for instance the initiative of the Movement for Global Mental Health with packages and programs of care and other upload possibilities, and the site of the Mental Health First Aid. The US National Institute of Health (NIH) invites applications to establish Collaborative Hubs for International Research on Mental Health. This program aims to ‘establish three regional hubs to increase the research base for mental health interventions in low- and middle-income countries through integration of findings from translational, clinical, epidemiological and/or policy research’. But these sites and initiatives are (yet) not so lively and interactive as examples from other health fields like for instance the IBP Knowledge Gateway for Reproductive Health. This is a virtual knowledge network, or a online Community of best Practice (CoP), of over 15,000 people from 195 countries who share knowledge and network about reproductive health issues. An example in the field of technology is the Open Mobile Consortium. This is a thriving community of mobile technologists and practitioners working to drive open source mobile solutions for more effective and efficient humanitarian relief and global social development.
Other web2.0 applications are blogs like this one, micro blogging like Twitter, podcasts like the MSF Voice and MSF Frontline Reports, video sharing like You Tube, slide sharing, social networks like Facebook and wiki’s like the MentalHealthWiki and it’s mobile version. The Frontier Psychiatrist, Stephen Ginn, wrote a clear blog about all these applications. He also find out that, although all major international journals have a web presence, most still shun reader contributions and peer reviews to their sites and still ask subscription or payments before access to articles. For example the British Journal of Psychiatry and the ‘International Journal of Mental Health, Psychosocial Work and Counselling in Areas of Armed Conflict’, Intervention, offer papers free to access after 12 months. But you can download all issues of the Journal of the World Psychiatric Association (WPA) and the International Journal of Mental Health Systems from the first day of issue.
‘Open Data, Open Knowledge, Open Solutions’ is a World Bank initiative. The World Bank Group started offering free access to more than 2,000 financial, business, health, economic and human development statistics that had mostly been available only to paying subscribers, on their Open Data Catalog. Or as the World Bank president Robert Zoellick stated:’Software has brought new tools- the internet has brought new communications and rising economies have brought new experiences. We need to listen and democratize development economics’.
In emergency situations the new technologies can play a crucial role in the coordination and tuning of relief efforts, including psycho-social support and crisis psychiatry. The Mental Health and Psycho-Social Support Network for example opened a special Haiti 2010 Earthquake Response Group on their online community, with more then 100 uploaded files and 79 members. Other general crisis coordination websites are Reliefweb and Ushahidi. They aggregate all kind of relevant information from the authorities, the public and organizations for use in crisis response, and accessible for everyone involved.
A last point about knowledge sharing is the fight against counterfeit medicines. According to the pharmaceutical-technology.com: ‘concerning the extent of the problem suggest that up to 10% of global pharmaceutical sales may be counterfeit, a figure that rises to 30% in certain developing countries’. An example of a ehealth solution here is the Sproxil’s SMS-based Mobile Authentication Service. Sproxil’s technology relies on the inclusion of a unique PIN on scratch cards in the drug’s packaging. The consumer reveals the PIN on the card and sends an encrypted text message (using a free shortcode) to a cloud computing server. This server then generates an immediate response indicating whether the drug is real or fake. Another is the mPedigree Network, they work on creating a global standard to address counterfeiting, by influencing industry leaders. The firm is working with the industry on a way to make mobile certification standard practice.
9: Bottom up and demand driven programs
Before the so called web2.0 era, the information stream was mostly one way, top down, from institutes and plan makers in developed countries, to their recipients in developing countries. In recent reports of the WHO and in the 2007 Lancet series you can see more grass root contributors and now and then reluctant recommendations to consult users and their movements. For example in the WHO report Mental Health and Development: ‘Improve development outcomes by increasing outreach to and consultation with people with mental health conditions, supporting the establishment and development of service user groups, and funding these groups to participate in public affairs and advocacy work’ etc.
Indeed the web2.0 offers great opportunities here. Some quotes from one Online Marketplace for Development Projects, the 1% club from their ‘International co-operation 2.0 paper’ are: ‘2.0 is about participants becoming the owners of the process, instead of being directed from the top. 2.0 is not about the plan; it’s about the people. Participating in the conversation that is about them (people in developing countries), for the first time in history. There are many unique, specific situations that don’t benefit from common large- scale solutions. Searches instead of planners’. Other inspiring web2.0 bottom up solutions in the field of poverty reduction and development aid are Kiva, Nabuur and Pifworld.
In the field of the global mental health there are a couple of communities online like the Mental Health Community, the Society for Emotional Well-being Worldwide, and numerous blogs, pages and accounts. A lot of them are individual initiatives and opinions. For instance psychiatrist Panneerselvan from India, with a website and Facebook appearance, Jagannath Lamichhane from Nepal, who is writing on mental health issues regularly (see point 5) and is active on Facebook as well, and Kanyi Gikonyo from Kenya, a user himself, active on Facebook and in the ‘Users and Survivors of Psychiatry’ Kenya. A nice bottom up mental health activism example is the online petition ‘Mental Health is a Global Urgent Issue’. My blog, which you are actually reading, my in2mentalhealth Facebook page and in2mh Twitter account, are other small web2.0 examples; just a person somewhere in the world, circulating information for whoever wants to read it……. So, global mental health organizations, institutes and policymakers, if you really want to get in touch with the grass root practitioners and the users ‘in the field’, just jump in the web2.0, join, ask, discuss; listen and contribute.
10: Useful data for research, planning and evaluation: standardizing and easy access
In the UN Foundation and Vodafone Foundation report about mHealth and Development is stated that ‘policymakers and health providers at a national, district and community level need accurate data in order to gauge the effectiveness of existing policies and programs and to shape new ones’. But when for instance the World Psychiatric Organization (WPA) reviewed systematically the development of community mental health care in Africa, they find a diversity of data and methods, which gave some insight in the matter, but not reliable figures or clear comparable outcomes. Patricia Mechael and her team of the Center for Global Health and Economic Development Earth Institute concluded in their Barriers and Gaps Affecting mHealth in Low and Middle Income Countries report, that ‘a proactive cycle of strategy, implementation and evaluation to in turn inform strategy at the global, national, regional, district, and community levels will generate the platform needed for implementation of more and better mHealth systems that generate health benefits for citizens and health workers in Low and Middle Income Countries’. After reviewing nearly 2,994 peer-reviewed publications and secondary sources, the consensus was that there are a lot of very small scale studies and ‘that you can make almost anything good in pilot. The challenge is how to conduct research at a significant enough scale to figure out what works and what doesn’t work’.
An answer on this challenge are the new technologies. First hand data about patients, tools, treatments and costs, obtained on the spot, can be transported quick and cheap via the internet to everywhere. With mobile devices and standardized apps/programs, a lot of paper work can be skipped and information can be processed immediately at the other side of the world. An example of such application is theTB prevention/vaccine program from Cmed and Aeras. They captured electronically data from three clinical sites in South Africa, while managing and analyzing the data from its headquarters in Rockville, Maryland USA in near real time. Another example of software is EpiSurveyor of DataDyne. This software allows anyone to set up a worldwide, mobile-phone-based data collection system in minutes, for free. The Vodafone Foundation and the UN Foundation used this software app for example to equip health workers in more than 20 sub-Saharan countries.
Conclusions and recommendations
A main challenge in this marriage between the new technologies and global mental health is the need of a broad multi-sector collaboration. As A. Iluyemi and J.S. Briggs of the University of Porthsmouth analyzed : ‘Project failure in ehealth and mhealth has been partly due to a lack of coherence between social and technological aspects of the system design and practice. To much focus on the ‘soft’ side of information systems to the detriment of the ‘hard’ ones’. Or, from the mHealth and Development report, ‘to accelerate this momentum and fully unleash the potential of mHealth applications, dynamic multi-sector collaboration between groups as diverse as governments, multilateral organizations, and the private sector is needed’. According to the ITU, in their Tele-Health in India report, special additional attention needs the billing systems for services. They can become multi-tier and very complicated as the ehealth system matures. It will save time and costs if from the start proven money transaction techniques are incorporated in the plans. Or as Tony Burkson noted in his blog about the mHealth Africa Summit: ‘Mobile phones could also play a significant role in health financing systems, including authentication of health insurance subscribers, monitoring of health benefits and paying for health services and products’. For example systems like M-PESA, that enables customers to transfer money with their mobile phones, show how this kind of innovative solutions can be successful.
Since the awareness and knowledge of the medical staff in developing countries about ehealth and computers is low, the International Telecommunication Union recommends more training and capacity building in this field. They developed a special training course for participants from developing countries which was successfully launched in 2008. For the ITU, in their report on Tele-Health in India ‘video conferencing, including, if necessary, a real time human translator to counter linguistic barriers, seems to be the pivotal application in education and acceptance of eHealth by doctors and patients alike’. The WHO Global Observatory for eHealth advocates strongly for inclusion of eHealth courses within university curricula as well. And Patricia Mechael and colleagues argue that: ‘Additional efforts in educating health professionals about the potential role of ICT in healthcare delivery will be critical for mass adoption. These must be focused on the benefits to the professionals themselves.’
According to the UN Foundation and Vodafone Foundation and A. Iluyemi and J.S. Briggs in their article ‘Technology matters’, during the design and implementation of the new technologies the end user must be kept in mind. Using the simplest available technology and adapting the plans to the ICT trends in developing countries like the use of mobile/wireless ICT devices in stead of the more traditional wire-line networks and desktop computers. Low cost laptops like the One Laptop Per Child (OLCP) XOI device, which can withstand the harshest environmental conditions, have a long battery life and a wireless connectivity, are very useful in this context.
There are a few important hazards with the use of internet and mobile services. For instance: ‘All info lays on the street’ and commercial companies try to profit from the information and data available. Although most of the security problems encountered on the Internet are due to human mistakes, I think these privacy concerns must be addressed in all parts of the program designs and be a part in the education and supervision of health workers as well. There are solutions like encrypted data transport and codes/passwords, but this means extra technical knowledge and a consequent use in practice by all people involved. In addressing this security issue, the ITU pleads for ‘voice/video/image records endorsed by biometric signatures as a method of authentication, in stead of the type written and handwritten records and handwritten signatures’. But, according to the IDRC, International Development Research Centre Canada, restrictive policies on protection of personal information like the EU 1998 directive, create functional barriers. ‘These inter-jurisdictional issues need to be concerted. Inappropriate or not concerted policy in one jurisdiction could hamper the ability of eHealth to fulfill its potential’. Again a plea for a multi-sector and international collaboration in early stages of development of plans and policies.
Extra caution is also needed in the use of the information derived from the web like articles/blogs, research data/figures and advices and conclusions. As the Frontier Psychiatrist argues: ‘There is no guarantee of authoritative control over the content and content can be false, changed or malicious due to commercial influence. Overall it would be wise to double check any information gleaned from a blog, wiki or tweet, since the content of any information on internet is no more reliable then its administrator’.
Another concern comes again from the IDRC. They think that the developing countries have both the most to gain and the most to lose from e-applications like eHealth. Because of the digital divide, there is a risk that the least developed countries will be excluded from the potential gains. And because a lot of funding, time and effort is needed to raise their health and eHealth infrastructure to the required levels, their debts can be increased or potentially diverting funding away from already stressed traditional health care delivery and support. Bill Gates, one of the keynote speakers at the mHealth Summit in November 2010, believes too that ‘the greatest mHealth innovations will come not in the poor countries and not in the rich countries, but in middle income countries like Brazil, China and India’. So we must try to get the poorest countries on board. The 2005 WHO WHA58.28 e-Health resolution may be a turning point; drawing the attention of domestic governments of member countries to the potential of, and the need for, e-health in each of their countries. Other initiatives like the healthcare divisions of a few big telecom companies like Telefónica, Orange and Vodafone, and global alliances like the ITU, the Global Observatory for eHealth, mHealth Alliance, the Database of European eHealth Priorities and Strategies and I.com etc., are also promising, although only the last one is specialized in eMental-Health. And this makes a small bridge to my last worry: although the eHealth and eMental-Health fields are at least overlapping, eMental-Health has own features and challenges. Although a few colleagues are real ambassadors of e-Mental-Health in the poorest and remote area’s of the world, I think it is yet a bit too quiet.
I hope this paper is convincing enough. That, despite the hazards and obstacles, the new technologies are part of the solution of the mhGAP and can’t be ignored or left to the few internet freaks in the field (like me).
In the context of millions of people who are struggling with untreated treatable mental health conditions, neglecting the eMental-Health applications in policies and plans is, I think, even a immoral deed.
Thus, time for the wedding.
Roos Korste, psychologist, trainer, founder of in2mentalhealth