“Telemedicina in Alta Amazzonia - Una Prospettiva di Sviluppo Sanitario fra Diverse Pratiche di Cura” [“Telemedicine in the Upper Amazon – A Case Study of Health Development between Diverse Healing Practices”]

Abstract:

This research is based on the case of implementation of telemedicine services within the public health care system of a North-eastern area of Peru, in the Amazon (Ch. 1). Three years before this study started, a consortium comprising of Spanish and Peruvian universities –supported by a non-governmental organization- established radio connections for voice and data communication between the local hospital and health facilities of the area, in order to provide telemedicine services. This initiative was aimed at the improvement of the health care system organization, therefore of the local health conditions. It was not secondary the intention to define a model for ICT-based health development interventions in rural areas of Latin America (Ch. 2). My study, centered on the telemedicine system, is based on the participant observation within the consortium in Spain and Peru, both in the partner universities and in the Amazonian part of the public health care system (Ch. 3, with a special attention for reflexive issues). The focus of the research has been on the organizational relevance of the interplay between designers’ perspectives and expectations, on one side (Ch. 4), and local process of telemedicine system accommodation in the context of implementation, on the other. Particular attention is given to telemedicine system use, and to the mutual interrelation with local constructions of health and illness (Ch. 5). It has been found a divergence between planned and observed use of the system, the former being accountable to the context of origin of the project and to the funding agencies, the latter being indirectly affected by unexpected health-seeking behaviors of the target population (“Telemedicine And Knowledge Between Medical And Development Discourses” CMS4). A rationalist conception of telemedicine -and of organizational changes it is expected to produce- sees local healing practices as obstacles to health development, and this hinders organizational learning ("Organizational Learning in Health Care - Situating Information Technologies in the Amazon" under review process for Social Theory & Health). I noted how people’s perception and construction of their health (also outside formal health organization and scientific definitions of health and sickness) plays an important role as social regulator, as far as they are embedded in normal patterns of action (“Telemedicine in the Upper Amazon: Interplay with Local Health Care Practices” MISQ). This needs to be understood and considered in evaluation, design and implementation of future initiatives of ICT-based health development efforts (Ch 6 and “Policies on Health Development and Information and Communication Technologies - A Bottom-up Perspective on Policy Making about Telemedicine Services in Cross-cultural Settings” eHDC). MAIN CONTRIBUTIONS: - Focus on telemedicine through a micro-level lens of Neoinstitutionalism (in ethnomethodological terms), which is not well-developed in IS studies - Critique of diffusionism and of reified conceptions of medical knowledge, which cannot be made easily available though IT solutions, mostly across diverse social settings - Empirical granularity on practices, which highlights interplays that more traditional empirical units (actors, places, issues) may not account for - Reflexivity awareness in ICT in development contexts TABLE OF CONTENTS Telemedicine in the Upper Amazon - A Perspective on Health Development between Different Healing Practices 1 Abstract 3 Acknowledgements 5 Introduction 13 Chapter I – Telemedicine between Knowledge and “Development” 17 1. Research Field 18 1.1. Telemedicine and “Development” 19 2. Boundaries of the Empirical Field 25 3. Organizations, ICT and Knowledge 28 3.1. Telemedicine and Knowledge Transfer 32 3.2. A Boundary of the Knowledge Society 33 4. Development and Organization 35 4.1. Contemporary Trends 38 5. Research Focal Points 41 5.1. Research Questions 43 Chapter II – Introduction to the Telemedicine in the Upper Amazon case 45 1. Red Ibero-Suramericana de Salud Project 45 2. The Amazon area where the Telemedicine System is Implemented 50 3. Health Care System in the Upper Amazon 54 3.1. Public Health Insurance 57 4. Technical Aspects of the Telemedicine System 58 5. Planned Uses of the Telemedicine System 64 Chapter III – Methodological Aspects 67 1. Documentary Study and Participant Observation 68 2. My Perspectives on the Case 76 2.1. Self Interview 77 2.2. Access the Empirical Field and Construction of my Role 79 2.3. Telemedicine as Knowledge Instrument: Contiguity of Viewpoints 82 3. Research Trajectory 92 4. Notes about Data Analysis and Presentation 115 Chapter IV – Interorganizational Network of the Telemedicine Project 119 1. The Evaluation Conducted by Organizers 119 2. Interorganizational Aspects 130 2.1. Documentary Analysis of Mailing Lists and Chat Sessions 130 2.2. Academic Position of the RISS Project Coordinators 134 2.3. Discursive Alignments 137 3. Final Notes 142 Chapter V – Telemedicine and “Development”, the Case Of the Upper Amazon 145 1. RISS – Peru’s Perspectives 148 2. Arrival to the Amazon 158 2.1. First Impressions at the Hospital 163 2.2. Following the Prevention Programme 166 3. Re-starting from the Telemedicine System 172 3.1. Knowledge Sharing 185 3.2. Conference about Malaria 188 3.3. Epidemiologic Surveillance 192 3.4. Reports Transmission and Logistical Support 195 3.5. Maintenance and Responsibilities 199 4. Aspects of the Telemedicine Context 206 4.1. Use of Medical Plants 216 4.2. “A Physician is Someone who Studies Medicine through the University” 221 4.3. Local Healers 234 5. Trajectories through Medicines 243 Chapter VI – Discussion 251 1. Planned and Observed Uses 251 1.1. Problematizing an Approach to Telemedicine 256 2. Multiple Accountabilities 258 3. Expectations from the System 268 Conclusions 275 List of References 279