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Telemedicine and neurosciences in developing countries
Technology
Telemedicine and Neurosciences in Developing Countries K. Ganapathy, M.Ch., Ph.D. Department of Neurosurgery and Department of Telemedicine Apollo Hospitals, Chennai, India
Ganapathy K. Telemedicine and neurosciences in developing countries. Surg Neurol 2002;58:388 –94.
It is a universally accepted fact that the number of neurosurgeons in developing countries is woefully inadequate. It is also unrealistic to expect this limited number to work in professional isolation, in suburban and rural areas, without adequate infrastructure. Therefore, this has resulted in concentration of neurosurgeons in developing countries, in metropolitan areas, even at the risk of being underemployed. The phenomenal advances in communications and information technology in India are resulting in a new look at how secondary and tertiary health care can be provided to the underprivileged masses. Following a proof of concept validation ISRO (Indian Space Research Organization) in conjunction with the Apollo Hospitals, is ready to use satellite technology to provide specialist care not only to suburban and rural India but to other countries as well, by using the large number of highly qualified and trained specialists in urban India. The implications of these developments for the delivery of neurosurgical care to suburban and rural India is briefly reviewed. © 2002 by Elsevier Science Inc. KEY WORDS
India, e-mail, satellite, telemedicine, neurosciences in developing countries. “The future ain’t what it used to be” . . . . . . Mark Twain “All men are equal but some are more equal than others”
hat distribution of neurosurgeons worldwide is lopsided is an accepted fact. That one-sixth of humanity (India) has fewer neurosurgeons than are available in a single state in the USA is also known. That increasing the number of neurosurgeons, providing them with the requisite infrastructure, and maintaining high standards to provide neurosurgical care to all those in developing countries, including the 600 million living in suburban
T
Address reprint requests to: Dr K. Ganapathy, Neurosurgeon, Apollo Specialty Hospitals, 320 Anna Salai, Chennai 600035, India. Received March 28, 2002; accepted August 20, 2002. 0090-3019/02/$–see front matter PII S0090-3019(02)00924-2
and rural India is just not possible, is also an accepted fact. 300 million Indians, like many, many more in other parts of the world, live below the poverty line. In India at present, access to neurosurgical care is available only to about 450 million of the 1,060 million Indians. About 750 neurosurgeons and 110 neurosurgical trainees provide this. Fewer than 110 neurosurgeons qualify per year from about 55 residency programs (5 national institutes, 4 deemed universities, 25 medical colleges, 21 corporate, private, and trust hospitals). Only 80 of the 160 medical colleges in India have neurosurgical departments. Neurosurgery units in 25 to 30 corporate hospitals supplement this. Small to medium nursing homes where basic neurosurgery is conducted, number less than 130. The 15 neurosurgical centers of excellence, of world standards, are too few for this vast country. The city-based neurosurgeons are not willing to relocate to suburban or rural India because of lack of infrastructure and fear of professional isolation. The 75 neurosurgeons in Chennai (Madras), with a population 4 million, outnumber the neurosurgeons in the whole of North Eastern India (population 250 million). Often patients from suburban India are sent to the limited number of tertiary neurosciences referral centers in the metros and state capitals, incurring considerable expense and time. This results in enormous (and sometimes avoidable) overwork at these centers. Suboptimal management of difficult neurosurgical cases may sometimes occur because of the limited neurosurgical resources being utilized for management of cases that could have been managed in smaller (nonexistent!) centers. However, India is a paradox. We now produce and launch our own satellites. Plans are under way to send an unmanned mission to the moon. Preliminary information is being gathered regarding the feasibility of launching a HEALTHSAT—a satellite exclusively for providing health care. There has been an unprecedented growth and development in © 2002 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010 –1710
Telemedicine and Neurosciences
1
VSAT satellite on the roof of Apollo Hospitals Chennai (top left) Doctor in village hospital at telemedicine console (top right). The village of Aragonda (bottom left). Note VSAT on the roof of the village hospital (bottom right).
information technology in India. Satellite transmission, fiber optic cables, increasing band width, fall in computer prices, licensing of private internet service providers, cable internet access, have become buzz words even in suburban and rural India. Theoretically, it is easier to set up an excellent
2
Surg Neurol 389 2002;58:388 –94
telecommunication infrastructure in suburban and rural India, to increase the reach of the limited number of urban neurosurgeons, than to place hundreds of neurosurgeons in these places. Telemedicine appears to be the answer. “Watson, come here; I want you” said Alexander
CT pictures transmitted from a village hospital. The doctor was reassured that the calcification has no clinical significance.
390 Surg Neurol 2002;58:388 –94
3
A case of meningocele evaluated through telemedicine
Graham Bell on March 20, 1876, when he inadvertently spilled battery acid on himself while making the world’s first telephone call. Little did Bell realize that this was indeed the world’s first telemedical consultation. We have come a long way since then. Telemedicine is a method by which patients can be examined, investigated, monitored, and treated, with the patient and the doctor located in different
4
Ganapathy
places. Using telemedicine one transfers the expertise, not the patient. Images are acquired, stored, and forwarded in a compressed format. Digital manipulation can be done by the teleconsultant at the remote end. Immediate electronic access to neurosurgeons saves time and costs and reduces the enormous physical effort normally required of a patient in traveling long distances. Text, reports, voice images, and video can be transferred. Through cost-effective video teleconferencing, expertise available in the cities can be transferred to suburban areas. Once the “virtual” presence of a neurosurgeon is acknowledged, a patient can access resources in a tertiary referral center without the constraints of distance. Telemedicine allows patients to stay at home, ensuring much needed family support. In a large telemedicine project in the USA, 83% of patients who would have been transferred to an urban hospital remained in their communities reducing the cost by at least 40 to 50%. Telemedicine also ensures maximal utilization of suburban hospitals. The general practitioner in the rural/suburban area often feels that he would lose his patient to the city consultant. With telemedicine, the community doctor continues to primarily treat the patient under a
The author with tribals (top left). Map showing remote location of the island (top right and bottom left). Vehicles being transported by barge as there are no bridges between the islands (bottom right)
Telemedicine and Neurosciences
5
CT images of an unconscious head-injured patient sent from a remote island through e-mail.
specialist’s umbrella. With modern software/hardware at either end 90% of the normal interaction can be accomplished through telemedicine.
Advantages of Telemedicine in India ● ● ● ● ● ● ●
Doctors licensed to practice all over India Maximum utilization of limited resources Saves travel, time, and money International grand rounds, Web casting of conferences Useful in designing credits for recertification of doctors Motivation for increasing computer literacy among doctors Reduction of unnecessary referrals to specialists
6
Surg Neurol 391 2002;58:388 –94
THE ARAGONDA STORY The Apollo Hospitals have been pioneers in putting up the first modern secondary care, rural hospital in India, using telemedicine to provide expert care. As a pilot project, a secondary level hospital was set up in a village called Aragonda (population 5,000, 180 km from Chennai), 16 km from a district headquarters called Chitoor in the southern state of Andhra Pradesh. This 40-bed hospital was equipped with a computed tomography (CT) scan, a modern ultrasound, ECHO, automated laboratory equipment, an incubator, automated ECG, an operation theater, and a telemedicine unit. A pediatrician, a general physician, and a general surgeon were available in addition to three general duty doctors. Starting with simple Web cameras and ISDN telephone lines (specially made available to this village) today this village hospital has a state-of-the
Digital photographs of an unconscious head injured patient sent from a remote island through e-mail.
392 Surg Neurol 2002;58:388 –94
7
Digital photograph of a newborn sent from a remote island through e-mail.
art video conferencing system and a VSAT (Very Small Aperture Terminal) satellite installed by ISRO (Indian Space Research Organization, Department of Space, Government of India). Specialists and super specialists from Chennai have given about 400 teleconsultations to this village alone. Specially designed software (E Mediscope) was used and the clinical history and physical findings transferred from the village of Aragonda. Images of X-rays and ultrasound were scanned, compressed, and sent through ISDN lines (64 ⫻ 6; 384 kbps) initially and later through VSAT. CT images and echocardiograms, being DICOM compatible, were directly electronically transferred to the telemedicine computer at Aragonda for onward transmission to Chennai initially through ISDN lines and now through VSAT. Most of the teleconsultations were initially offline—store and forward. The teleconsultant’s opinion was sent back to the primary physician. There were no fixed hours for teleconsultation, a medical officer being available at the telemedicine unit at
8
Ganapathy
Chennai from 9 am to 5 pm. Arrangements are now being made to provide emergency teleconsultation as well. When the teleconsultant wanted to directly interact with the primary physician and the patient, a “net meeting” was initially arranged. All such online interactions were recorded and stored. Detailed clinical “examination” of pseudo seizures, involuntary movements, Parkinsonism, myopathy, and so forth, was possible by viewing video clippings. Seven seriously ill head-injured patients were managed by the local general surgeon, including evacuation of an acute subdural hematoma and excision of compound depressed fractures of the skull, with the confidence that on line neurosurgical video teleconsultation was available. Fifty-five patients with neurologic afflictions (medical and surgical) have been evaluated through telemedicine; in all neurologic and neurosurgical cases the teleconsultant was able to give a definite opinion and guide the local physician. Some cases required management in a tertiary
Hydrocephalus (left) and brilliant transillumination of meningocele (right) detected through e-mail.
Telemedicine and Neurosciences
9
Surg Neurol 393 2002;58:388 –94
The author offering neurosurgical diagnosis from home by telemedicine.
care hospital. Details of the treatment were discussed in detail with the patient and the family so that they were well informed and fully prepared (e.g., meningoceles, secondary deposits). Other
10
cases like tuberculoma or cysticercosis of the brain were managed by the family physician under the supervision of the specialist from Chennai. These teleconferences were of considerable help. Tele-
Neurosurgical teleconference between Chennai and UDMNJ.
394 Surg Neurol 2002;58:388 –94
consultation was particularly useful in the follow-up of already treated patients. Interestingly, the acceptance of teleconsultation by the rural patient, the suburban doctor, and the suburban community was much better than expected. None of them were really averse to a teleconsultation. The teleconsultants have also accepted this new method of interacting with a patient. Detailed evaluation of the socioeconomic benefits needs to be done. THE SRIHARIKOTA STORY Sriharikota Space Center, an island, is an important launch pad of the Indian Space Research Organization, located 130 kms from Chennai. About 2000 families live in the campus. The Health Center also provides medical assistance to the neighboring villages. A virtual OP is operational every Saturday from 10 am to 1 pm at Chennai. The medical officer at the remote center gets an opinion from the specialist in Chennai. Tele-examination of the patient is also done if necessary. Twenty-five different specialties are covered, some every week, others once a fortnight, and others once a month (neurology and neurosurgery). Emergency teleconsultations on other days are also available. EXPANSION PLANS Connectivity has already been established with centers at Guwahati, Kolkata, and Mysore. Telemedicine centers in very remote areas include Kohima in Nagaland, Burdwan in West Bengal and Silchar in Assam. Neurosurgical teleconsultation was provided to Port Blair the capital of the remote Andaman and Nicobar islands, 1900 km away from mainland India initially through the Internet. VSAT connectivity is now available. Seven military hospitals in South India have been interlinked with telemedicine. Neurosurgical teleconsultation is provided when required. The tertiary care Apollo
Ganapathy
hospitals at Hyderabad and Delhi are also capable of providing tertiary neurosurgical teleconsultation. Video conferencing is an inexpensive way of interacting with neurosurgeons worldwide. In August 2001, on behalf of the Department of Neurosurgery at Apollo Hospitals Chennai, the author organized a 2-hour teleconference with Prof. Tetsuo Kanno of the Department of Neurosurgery at Fujitha Health University, Nagoya, Japan. This international grand round went off without a hitch. A similar meeting followed, with Prof. Michael Schulder of the Department of Neurosurgery, UDMNJ New Jersey in December 2001. Such teleconferences will take place periodically with neurosurgery centers worldwide. This constant international exposure will change our perspectives and help us think globally. Geography is indeed becoming history! It is the author’s dream and hope that within the next few years there will be telemedicine units in most parts of suburban and rural India. Feasibility studies have been completed and the first phase of execution is starting. ISRO has announced that it will be providing 40 VSATs exclusively for telemedicine purposes. Eventually no one living in India will be deprived of a specialist consultation wherever he/she is. This is not impossible. What is required is not implementing better technology and getting funds, but changing the mindset of the people involved. Neurosurgical consultation in suburban and rural India will soon be only a mouse click away! The author is thankful to Dr Pratap C. Reddy, Founder and Chairman of the Apollo Group, Mrs. Sangeetha, and ISRO for making available the necessary infrastructure. Mr Kishore Reddy, Dr J. Thiruvengadam, Dr. Murugesan, Dr. Vilvanathan, and others of the Telemedicine Department have ensured successful teleconsultations. Mrs Jayalakshmi and Mrs Shobhana rendered secretarial assistance.
t is easy to understand why the law is used by the legislator to destroy in varying degrees among the rest of the people, their personal independence by slavery, their liberty by oppression, and their property by plunder. This is done for the benefit of the person who makes the law, and in proportion to the power that he holds.
I
—Frederic Bastiat “The Law”
Telemedicine and Neurosciences in Developing Countries K. Ganapathy, M.Ch., Ph.D. Department of Neurosurgery and Department of Telemedicine Apollo Hospitals, Chennai, India
Ganapathy K. Telemedicine and neurosciences in developing countries. Surg Neurol 2002;58:388 –94.
It is a universally accepted fact that the number of neurosurgeons in developing countries is woefully inadequate. It is also unrealistic to expect this limited number to work in professional isolation, in suburban and rural areas, without adequate infrastructure. Therefore, this has resulted in concentration of neurosurgeons in developing countries, in metropolitan areas, even at the risk of being underemployed. The phenomenal advances in communications and information technology in India are resulting in a new look at how secondary and tertiary health care can be provided to the underprivileged masses. Following a proof of concept validation ISRO (Indian Space Research Organization) in conjunction with the Apollo Hospitals, is ready to use satellite technology to provide specialist care not only to suburban and rural India but to other countries as well, by using the large number of highly qualified and trained specialists in urban India. The implications of these developments for the delivery of neurosurgical care to suburban and rural India is briefly reviewed. © 2002 by Elsevier Science Inc. KEY WORDS
India, e-mail, satellite, telemedicine, neurosciences in developing countries. “The future ain’t what it used to be” . . . . . . Mark Twain “All men are equal but some are more equal than others”
hat distribution of neurosurgeons worldwide is lopsided is an accepted fact. That one-sixth of humanity (India) has fewer neurosurgeons than are available in a single state in the USA is also known. That increasing the number of neurosurgeons, providing them with the requisite infrastructure, and maintaining high standards to provide neurosurgical care to all those in developing countries, including the 600 million living in suburban
T
Address reprint requests to: Dr K. Ganapathy, Neurosurgeon, Apollo Specialty Hospitals, 320 Anna Salai, Chennai 600035, India. Received March 28, 2002; accepted August 20, 2002. 0090-3019/02/$–see front matter PII S0090-3019(02)00924-2
and rural India is just not possible, is also an accepted fact. 300 million Indians, like many, many more in other parts of the world, live below the poverty line. In India at present, access to neurosurgical care is available only to about 450 million of the 1,060 million Indians. About 750 neurosurgeons and 110 neurosurgical trainees provide this. Fewer than 110 neurosurgeons qualify per year from about 55 residency programs (5 national institutes, 4 deemed universities, 25 medical colleges, 21 corporate, private, and trust hospitals). Only 80 of the 160 medical colleges in India have neurosurgical departments. Neurosurgery units in 25 to 30 corporate hospitals supplement this. Small to medium nursing homes where basic neurosurgery is conducted, number less than 130. The 15 neurosurgical centers of excellence, of world standards, are too few for this vast country. The city-based neurosurgeons are not willing to relocate to suburban or rural India because of lack of infrastructure and fear of professional isolation. The 75 neurosurgeons in Chennai (Madras), with a population 4 million, outnumber the neurosurgeons in the whole of North Eastern India (population 250 million). Often patients from suburban India are sent to the limited number of tertiary neurosciences referral centers in the metros and state capitals, incurring considerable expense and time. This results in enormous (and sometimes avoidable) overwork at these centers. Suboptimal management of difficult neurosurgical cases may sometimes occur because of the limited neurosurgical resources being utilized for management of cases that could have been managed in smaller (nonexistent!) centers. However, India is a paradox. We now produce and launch our own satellites. Plans are under way to send an unmanned mission to the moon. Preliminary information is being gathered regarding the feasibility of launching a HEALTHSAT—a satellite exclusively for providing health care. There has been an unprecedented growth and development in © 2002 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010 –1710
Telemedicine and Neurosciences
1
VSAT satellite on the roof of Apollo Hospitals Chennai (top left) Doctor in village hospital at telemedicine console (top right). The village of Aragonda (bottom left). Note VSAT on the roof of the village hospital (bottom right).
information technology in India. Satellite transmission, fiber optic cables, increasing band width, fall in computer prices, licensing of private internet service providers, cable internet access, have become buzz words even in suburban and rural India. Theoretically, it is easier to set up an excellent
2
Surg Neurol 389 2002;58:388 –94
telecommunication infrastructure in suburban and rural India, to increase the reach of the limited number of urban neurosurgeons, than to place hundreds of neurosurgeons in these places. Telemedicine appears to be the answer. “Watson, come here; I want you” said Alexander
CT pictures transmitted from a village hospital. The doctor was reassured that the calcification has no clinical significance.
390 Surg Neurol 2002;58:388 –94
3
A case of meningocele evaluated through telemedicine
Graham Bell on March 20, 1876, when he inadvertently spilled battery acid on himself while making the world’s first telephone call. Little did Bell realize that this was indeed the world’s first telemedical consultation. We have come a long way since then. Telemedicine is a method by which patients can be examined, investigated, monitored, and treated, with the patient and the doctor located in different
4
Ganapathy
places. Using telemedicine one transfers the expertise, not the patient. Images are acquired, stored, and forwarded in a compressed format. Digital manipulation can be done by the teleconsultant at the remote end. Immediate electronic access to neurosurgeons saves time and costs and reduces the enormous physical effort normally required of a patient in traveling long distances. Text, reports, voice images, and video can be transferred. Through cost-effective video teleconferencing, expertise available in the cities can be transferred to suburban areas. Once the “virtual” presence of a neurosurgeon is acknowledged, a patient can access resources in a tertiary referral center without the constraints of distance. Telemedicine allows patients to stay at home, ensuring much needed family support. In a large telemedicine project in the USA, 83% of patients who would have been transferred to an urban hospital remained in their communities reducing the cost by at least 40 to 50%. Telemedicine also ensures maximal utilization of suburban hospitals. The general practitioner in the rural/suburban area often feels that he would lose his patient to the city consultant. With telemedicine, the community doctor continues to primarily treat the patient under a
The author with tribals (top left). Map showing remote location of the island (top right and bottom left). Vehicles being transported by barge as there are no bridges between the islands (bottom right)
Telemedicine and Neurosciences
5
CT images of an unconscious head-injured patient sent from a remote island through e-mail.
specialist’s umbrella. With modern software/hardware at either end 90% of the normal interaction can be accomplished through telemedicine.
Advantages of Telemedicine in India ● ● ● ● ● ● ●
Doctors licensed to practice all over India Maximum utilization of limited resources Saves travel, time, and money International grand rounds, Web casting of conferences Useful in designing credits for recertification of doctors Motivation for increasing computer literacy among doctors Reduction of unnecessary referrals to specialists
6
Surg Neurol 391 2002;58:388 –94
THE ARAGONDA STORY The Apollo Hospitals have been pioneers in putting up the first modern secondary care, rural hospital in India, using telemedicine to provide expert care. As a pilot project, a secondary level hospital was set up in a village called Aragonda (population 5,000, 180 km from Chennai), 16 km from a district headquarters called Chitoor in the southern state of Andhra Pradesh. This 40-bed hospital was equipped with a computed tomography (CT) scan, a modern ultrasound, ECHO, automated laboratory equipment, an incubator, automated ECG, an operation theater, and a telemedicine unit. A pediatrician, a general physician, and a general surgeon were available in addition to three general duty doctors. Starting with simple Web cameras and ISDN telephone lines (specially made available to this village) today this village hospital has a state-of-the
Digital photographs of an unconscious head injured patient sent from a remote island through e-mail.
392 Surg Neurol 2002;58:388 –94
7
Digital photograph of a newborn sent from a remote island through e-mail.
art video conferencing system and a VSAT (Very Small Aperture Terminal) satellite installed by ISRO (Indian Space Research Organization, Department of Space, Government of India). Specialists and super specialists from Chennai have given about 400 teleconsultations to this village alone. Specially designed software (E Mediscope) was used and the clinical history and physical findings transferred from the village of Aragonda. Images of X-rays and ultrasound were scanned, compressed, and sent through ISDN lines (64 ⫻ 6; 384 kbps) initially and later through VSAT. CT images and echocardiograms, being DICOM compatible, were directly electronically transferred to the telemedicine computer at Aragonda for onward transmission to Chennai initially through ISDN lines and now through VSAT. Most of the teleconsultations were initially offline—store and forward. The teleconsultant’s opinion was sent back to the primary physician. There were no fixed hours for teleconsultation, a medical officer being available at the telemedicine unit at
8
Ganapathy
Chennai from 9 am to 5 pm. Arrangements are now being made to provide emergency teleconsultation as well. When the teleconsultant wanted to directly interact with the primary physician and the patient, a “net meeting” was initially arranged. All such online interactions were recorded and stored. Detailed clinical “examination” of pseudo seizures, involuntary movements, Parkinsonism, myopathy, and so forth, was possible by viewing video clippings. Seven seriously ill head-injured patients were managed by the local general surgeon, including evacuation of an acute subdural hematoma and excision of compound depressed fractures of the skull, with the confidence that on line neurosurgical video teleconsultation was available. Fifty-five patients with neurologic afflictions (medical and surgical) have been evaluated through telemedicine; in all neurologic and neurosurgical cases the teleconsultant was able to give a definite opinion and guide the local physician. Some cases required management in a tertiary
Hydrocephalus (left) and brilliant transillumination of meningocele (right) detected through e-mail.
Telemedicine and Neurosciences
9
Surg Neurol 393 2002;58:388 –94
The author offering neurosurgical diagnosis from home by telemedicine.
care hospital. Details of the treatment were discussed in detail with the patient and the family so that they were well informed and fully prepared (e.g., meningoceles, secondary deposits). Other
10
cases like tuberculoma or cysticercosis of the brain were managed by the family physician under the supervision of the specialist from Chennai. These teleconferences were of considerable help. Tele-
Neurosurgical teleconference between Chennai and UDMNJ.
394 Surg Neurol 2002;58:388 –94
consultation was particularly useful in the follow-up of already treated patients. Interestingly, the acceptance of teleconsultation by the rural patient, the suburban doctor, and the suburban community was much better than expected. None of them were really averse to a teleconsultation. The teleconsultants have also accepted this new method of interacting with a patient. Detailed evaluation of the socioeconomic benefits needs to be done. THE SRIHARIKOTA STORY Sriharikota Space Center, an island, is an important launch pad of the Indian Space Research Organization, located 130 kms from Chennai. About 2000 families live in the campus. The Health Center also provides medical assistance to the neighboring villages. A virtual OP is operational every Saturday from 10 am to 1 pm at Chennai. The medical officer at the remote center gets an opinion from the specialist in Chennai. Tele-examination of the patient is also done if necessary. Twenty-five different specialties are covered, some every week, others once a fortnight, and others once a month (neurology and neurosurgery). Emergency teleconsultations on other days are also available. EXPANSION PLANS Connectivity has already been established with centers at Guwahati, Kolkata, and Mysore. Telemedicine centers in very remote areas include Kohima in Nagaland, Burdwan in West Bengal and Silchar in Assam. Neurosurgical teleconsultation was provided to Port Blair the capital of the remote Andaman and Nicobar islands, 1900 km away from mainland India initially through the Internet. VSAT connectivity is now available. Seven military hospitals in South India have been interlinked with telemedicine. Neurosurgical teleconsultation is provided when required. The tertiary care Apollo
Ganapathy
hospitals at Hyderabad and Delhi are also capable of providing tertiary neurosurgical teleconsultation. Video conferencing is an inexpensive way of interacting with neurosurgeons worldwide. In August 2001, on behalf of the Department of Neurosurgery at Apollo Hospitals Chennai, the author organized a 2-hour teleconference with Prof. Tetsuo Kanno of the Department of Neurosurgery at Fujitha Health University, Nagoya, Japan. This international grand round went off without a hitch. A similar meeting followed, with Prof. Michael Schulder of the Department of Neurosurgery, UDMNJ New Jersey in December 2001. Such teleconferences will take place periodically with neurosurgery centers worldwide. This constant international exposure will change our perspectives and help us think globally. Geography is indeed becoming history! It is the author’s dream and hope that within the next few years there will be telemedicine units in most parts of suburban and rural India. Feasibility studies have been completed and the first phase of execution is starting. ISRO has announced that it will be providing 40 VSATs exclusively for telemedicine purposes. Eventually no one living in India will be deprived of a specialist consultation wherever he/she is. This is not impossible. What is required is not implementing better technology and getting funds, but changing the mindset of the people involved. Neurosurgical consultation in suburban and rural India will soon be only a mouse click away! The author is thankful to Dr Pratap C. Reddy, Founder and Chairman of the Apollo Group, Mrs. Sangeetha, and ISRO for making available the necessary infrastructure. Mr Kishore Reddy, Dr J. Thiruvengadam, Dr. Murugesan, Dr. Vilvanathan, and others of the Telemedicine Department have ensured successful teleconsultations. Mrs Jayalakshmi and Mrs Shobhana rendered secretarial assistance.
t is easy to understand why the law is used by the legislator to destroy in varying degrees among the rest of the people, their personal independence by slavery, their liberty by oppression, and their property by plunder. This is done for the benefit of the person who makes the law, and in proportion to the power that he holds.
I
—Frederic Bastiat “The Law”