Despite all the astonishing advancements in medicine in the U.S. in recent years, policymakers and health care providers have yet to come up with a comprehensive solution for addressing rural health care—and as a result, millions of Americans across vast stretches of the country continue to be underserved. The reasons rural medicine has consistently lagged behind the rest of the U.S. health care system are complex, owing to an array of factors spanning socioeconomics, access to technology and connectivity, availability of qualified personnel, properly aligned financial incentives, and finally, stifling over-regulation and bureaucracy.
But other countries—some of them with even far more challenging rural or remote populations—are proving that with the proper mix of innovation, technology and the ability to cut through red tape, a lot more can be done.
In global energy circles, there is no hotter market than Guyana, a tiny, English-speaking nation of less than a million inhabitants nestled between Venezuela, Brazil and Suriname on the north coast of South America. In 2015, ExxonMobil hit pay dirt in the country with one of the world’s biggest oil finds in decades, and now Guyana’s newfound riches are transforming the country into what some call the “Dubai of the Caribbean.” By 2027, Guyana will be the highest producer of crude per capita in the world.
Perhaps even more impressive than Guyana’s rags-to-riches story is its government’s commitment to deploying a significant slice of its oil profits towards an array of much-needed social programs, chief among them the improvement of the country’s tenuous health care delivery system. However, delivering quality health care services across the entirety of the Guyanese population is particularly thorny; over 90 percent of the country is covered by a blanket of dense primeval forests—an area larger than Washington State. Known locally as The Hinterland, this area is dotted by small indigenous communities—the majority with fewer than 400 inhabitants each. Many are only accessible by several days of river travel on small boats from regional population centers. The government estimates that 100,000 people – perhaps as much as 12 percent of the country’s entire population—live in these micro-settlements amid these rainforests.
Frank Anthony, Guyana’s Health Minister, knew that the solution for unknotting the complex challenge of delivering health care to hundreds of small, inaccessible villages would require an agile and unconventional approach heavily reliant on a strong technological backbone. “We needed a partner that wasn’t afraid to think out of the box—sometimes way out of the box,” Anthony told Observer. “There wasn’t a playbook for how to do this just lying around somewhere. A lot of what we were going to do had never been done before—at least certainly not against a backdrop like Guyana’s Hinterland.”
For help, the Minister turned to 19Labs, a Menlo Park, Calif.-based technology company that specializes in delivering remote health care in particularly tough environments. Led by Ram Fish, an Israeli-born former head of digital health for Samsung, 19Labs (the ‘19’ is a riff off of Florence Nightingale, the British nurse widely recognized as the founder of modern nursing) deploys sui generis health technology solutions across the developing world and the rural U.S. “We have worked in remote locations in places like Jamaica, Mexico, Kenya and even here in the U.S. in states like Missouri, Utah and Idaho,” Fish told Observer. “But nothing prepared us for what we were walking into in Guyana.”
“The first thing that needed to be deployed was some basic infrastructure for power and connectivity,” recalled Dr. Kofi Dalrymple, a Guyanese-born, U.S.-educated civil engineer who was also involved in the project from the get-go. “Even in the most challenging rural health care situations in the U.S., you can generally count on there being a nearby source of power. And even if it’s not high-speed internet, there’s usually at least some way to get online—or at least make a phone call. In Guyana we didn’t have any of those ‘luxuries’ for the vast majority of places we needed to bring health care. But the Minister wasn’t interested in any solution that had us waiting for infrastructure to be built out. We were not only building the car as we drove it, but we were building the road underneath the car at the same time.”
The other major structural challenge in Guyana—and it mirrors the contours of the U.S. rural health care theater as well—is a lack of qualified health care personnel. Fish, along with a team of 10 dedicated professionals from 19Labs, designed a networked telemedicine platform that could connect doctors, nurses, specialists and other qualified health care personnel, no matter where they lived, from any place in the country to these remote villages in the Hinterland. Dr. Dalrymple and his company, OnCall Health, went about deploying SpaceX’s Starlink satellite terminals and the remote solar panel systems needed to power them across a handful of villages selected as part of the first phase of the deployment.
Back in Georgetown, the country’s capital, Fish and Dalrymple designed a ‘Situation Room’ inside the Ministry of Health—just steps away from the Minister’s chambers—as sort of a master control to monitor all the networked distance medical consultations and interventions happening across the country. The Ministry of Health dispatched qualified health personnel to these remote villages to train local community members, such as nurses and midwives, to be able to use the telehealth platform. Today hundreds of remote exams and consultations—even ultrasounds—are being performed every week by local community members under the watchful eye of trained professionals hundreds or even thousands of miles away.
In the next phase set to kick off later this year, Fish, Dalrymple and their teams will be integrating a fleet of vertical-take-off-and-landing (VTOL) drones that can shuttle blood samples to and from a central diagnostic center as well as deliver medications to patients in these remote regions. “A lot of what we are doing here in Guyana isn’t necessarily groundbreaking, but in the U.S., a lot of these technologies and methodologies would never see the light of day, stifled by over-protective bureaucrats more vested in the process than anything else,” Fish said. “But in a place like Guyana, the need is so great that when we need to push through bureaucratic obstacles, we generally get very little resistance. Everyone understands that the mission is saving lives and improving quality of life.”
Back in the U.S., as Fish alluded, it’s a very different story. Despite access to the same if not better technologies, a complex web of state and federal regulations stand in the way of putting them to good use.
Eric Bricker, an internal medicine physician and renowned expert on health care finance, says that the project unfolding in Guyana is a testament to what can happen when new technologies and financial incentives are aligned towards solving pressing health care challenges.
“A lot of what 19Labs and the health ministry are doing down in Guyana makes perfect sense—and in an alternate reality, many of these are exactly the types of solutions which would really create a much more accessible health care system for large swaths of rural America,” Bricker told Observer. “But the U.S. system, unfortunately, is a complex patchwork of federal and state regulations, public and private payers, and other factors that really stifle innovation and problem-solving.”
Take, for example, how Guyana is using drones to deliver medications. In Guyana, there is no other tenable solution for getting medication to those who need it quickly in remote areas. “In some states, only a pharmacy can dispense medication, so the doctor would essentially have to delegate the drone delivering the meds to a pharmacy. In other states, both doctors and pharmacies can dispense medication, so the doctor could send the medication via drone,” Bricker said. “But of course with some exceptions. Generally these drones wouldn’t be able to cross state lines because doctors can generally only prescribe medications in the states in which they are licensed. And then there is the question of who would administer the medication once it arrives at its destination—again, highly regulated in the U.S.”
Sara Ratner, the president of government programs for Nomi Health, sees a completely different set of issues that would never fly in the U.S., such as minimum bandwidth levels set by the Federal Communications Commission (FCC). “Telemedicine typically involves video consultations, which require a stable and relatively fast internet connection to ensure clear audio and video transmission,” Ratner told Observer. “However, many rural areas in the U.S. do not have access to these required speeds. And Starlink doesn’t necessarily guarantee the constant connectivity required to meet these standards.”
“In many ways, the U.S. let’s perfect get in the way of good. While in Guyana they were smart to realize that ‘good’ is a heck of a lot better than nothing at all. But in the U.S., we can’t get out of our own way,” surmised Bricker. “While some of these new technologies will thrive in other parts of the world, they just won’t be able to form part of the solution here in the U.S. unless some swashbuckling elected leader is willing to stick his or her neck out and say, ‘look what they’re doing down in Guyana—we’re gonna do that too!’”
Frank Anthony, Guyana’s Health Minister, might just be the type of leader that Dr. Bricker has in mind; he sees the Ministry’s network for delivering quality health care as equally important to the development of Guyana as any road or bridge project. “Health care, along with education and nutritional security, are the foundational hallmarks of what we are building here in Guyana,” remarked the Minister. “I have a mandate to stick my neck out and make sure this gets done. And that it gets done well.”
