Unlike many other medical conditions, treating tobacco addiction and diagnosing its sequelae, like oral cancers, can often be done remotely
The Coronavirus pandemic has prompted billions to seek shelter in their homes as countries across the world have gone into lockdowns at different times and in many phases. Although doing so has checked the spread of the virus to a certain extent, it has not slowed the progression of other diseases. Therefore, the need to find innovative ways to stem and treat such diseases grows daily and for many countries, telemedicine has provided a cheap and practical way to meet this need.
It is a quintessential example of the Fourth Industrial Revolution in action and is an area in which India has already demonstrated its ability to lead. Few interventions are as conducive to piloting ambitious telemedicine in India than tobacco cessation and there are three reasons for this.
First, as the Foundation for a Smoke-Free World’s India Report shows, tobacco use is widely prevalent in the country and its results are devastating. There are nearly 270 million adult users of tobacco in India. Experts estimate that tobacco use is responsible for nearly 10 per cent of all deaths in the country and the resulting economic burden amounts to more than one per cent of the Gross Domestic Product (GDP). This figure rises when we consider the economic toll of tobacco-related disability and other indirect costs. Ultimately, the burden of tobacco use constrains healthcare, particularly for the poor.
Second, many of those most affected by tobacco use live in places with few specialists to provide cessation services. The shortage of healthcare providers is acute in these regions where brick-and-mortar clinics are few and far in between. India already suffers from a shortage of healthcare providers, with only one doctor for every 1,400 people and only one hospital bed for every 2,000 people (well below the World Health Organisation’s recommended norms).
Third, unlike many other medical conditions, treating tobacco addiction and diagnosing its sequelae, such as oral cancers, can often be done remotely. Tobacco cessation is predicated on counselling for behaviour, which can be effectively delivered via telemedicine platforms. India has more cases of oral cancer than anywhere else in the world due to the popularity of smokeless tobacco products in the country.
The scale of tobacco use and its resulting harms, its disproportionate toll on those in rural areas and the ability to effectively treat it and diagnose many of its sequelae make it a natural contender for telemedicine. However, some structural changes are required to successfully integrate telemedicine in the healthcare sector’s arsenal. Specifically, the three “Ds” — doctors, diagnostics and data — require redoubled focus in this context. The Ministry of Health and Family Welfare’s recently-notified Telemedicine Practice Guidelines provide a scope for registered medical professionals (RMPs) to familiarise themselves with telemedicine. The guidelines include instructions for RMPs to maintain digital records of patients, including evaluation and management reports.
Doctors may still require guidance to select appropriate software and technology that can help streamline these tasks. Though specialised digital applications to facilitate cessation are available, doctor awareness is the key to unfetter their use-case. Additionally, issues of medical ethics and liabilities need to be addressed, to build patient trust.
The second critical area is investments in diagnostics. Recent experiments with tele-diagnostic services in Maharashtra have enabled the use of photos to detect early cases of oral cancer and identify at-risk patients. This ensures that RMPs can make clinical evaluations to identify early onset of diseases to reduce the time between diagnosis and treatment.
The country requires similar interventions that leverage the combination of widespread smartphone access and state-of-the art diagnostics. But scale requires private sector investments, based on a profitable business model.
Diagnostics capabilities can likely be bolstered through hub-and-spoke telemedicine models to ensure access to larger markets at reduced rates of service distribution. Moreover, the use of Artificial Intelligence (AI) and Machine Learning (ML) to augment diagnostic capabilities of physicians can also reduce healthcare costs. Studies estimated that the use of this model to treat stroke patients can reduce costs by 10 per cent.
India’s fragmented healthcare ecosystem has multiple public, private, and individual healthcare providers. Therefore, it is often a challenge for healthcare professionals to maintain robust medical records. Even when they do, such records are not easily portable, and patients rarely get timely access. Digitisation of health records can help doctors administer appropriate treatment and create a knowledge bank that will help officials understand trends in public health, such as the burden of tobacco use.
It is important that such solutions are designed as open data ecosystems, subject to user audits and not as vulnerable single points of failure. Studies indicate that high, out-of-pocket expenditure on healthcare pushes around 32-39 million citizens below the poverty line every year.
Telemedicine services offer an opportunity to leapfrog traditional constraints to quality healthcare. The three “Ds” offer the means to unlock such potential and reduce the healthcare burden that is a consequence of widespread tobacco use.
(Shah is research manager at the Foundation for a Smoke-Free World and Sharan is, partner, Koan Advisory Group. The views expressed are personal.)