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We welcome another blog by ESA-sponsored Dr Stijn Thoolen, currently spending 12 months at the Concordia research station in Antarctica conducting experiments. What an amazing experience - do take a look at his previous blogs (Part 1, Part 2, Part 3) to follow his great adventure to the world's southernmost continent.
Dr Stijn ThoolenMedical Research Doctor, Concordia Research Station, Antarctica
Concordia, February 7, 2020
Sunlight: 24 hours (but not for long) Windchill temperature: -45°C Mood: a little roller coaster At this moment I am just plain excited. Next to me the rest of the DC16 crew are having their own emotions. Our freshly inaugurated station leader Alberto, draped in the colours of our three national flags, came up with the idea to have our national anthems playing while the last Basler plane of the summer campaign leaves Dome C. So here I stand, hearing my own voice on maximum volume pronouncing a Dutch translation of too patriotic sentences from the station’s speakers, and with the Dutch ‘Wilhelmus’ screaming over the Antarctic plateau as an official start of our winter over. Haha, such an unrealistic scenario! And while those sounds are quickly overruled by the roaring engines of the plane, and with snow blowing in our faces, I can only smile. There goes our last connection to the rest of the earth, disappearing into the distant sky. Unbelievable! 
The last plane left us, wondering what to think… Credits: ESA/IPEV/PNRA–S. Thoolen
I guess I have already spilled all of my emotions at this point. In the past few days, more and more planes have been taking away more and more of the beautiful people we enjoyed our summertime with, and the station has become more and more empty. Funny: they were already leaving, and I have the idea we just started… It has been an exciting idea on the one hand, but the closer we came to being left alone, the more and more confronting that got on the other. When two days earlier another plane left with sixteen more people, the goodbyes were harsh, with everyone in tears again. You know, those healthy ones. And when it was gone, those left on the ice slowly returned back to the station, all silent, all caught in their own thoughts. It had been an intense few summer months, and this was the weird moment of realization that it had come to an end, with a big unknown lying ahead. I guess the blend of feelings has been a repetition of those during the days before my departure to the Antarctic. Perhaps a little lighter this time.
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Daniel E. Vigo, MD, PhD Independent Researcher: Institute for Biomedical Research (Catholic University of Argentina and National Scientific and Technical Research Council) & InnovaSpace Advisory Board Member Belgrano to MarsThe Antarctic continent is considered to be one of the most realistic analogues found on Earth of the situations of extreme isolation and confinement experienced in space. Since 2014, we have been conducting at the Belgrano II Argentine Antarctic Station the project "Chronobiology of Antarctic Isolation: the use of the Belgrano II Station as a model of biological desynchronization and spatial analogue", also known as “Belgrano to Mars”. The project aims to explore the impact of a year of isolation on different physiological, psychological and social variables. In particular, we are interested in studying how biological rhythms are affected by the lack of natural light during the four months of polar night typical of that latitude. The study of the chronobiological responses to extreme isolation increases our understanding of the physiological mechanisms underlying human biological rhythms, with applications in space exploration or other highly demanding professional settings, as well as in human health. The Belgrano II Antarctic station consists of a series of scientific research facilities located approximately 1,300 km away from the South Pole at 34°S, 77°W. It is the most southerly Argentinian station and one of the three southernmost permanent stations on the planet. The temperature ranges from 5°C to 48°C below zero. One feature of this station is that, due to its latitude, it has four months of continuous sunlight, four months of twilight and four months of polar night. The station crew is composed of around 20 men. To generate a light-dark cycle during the summer, windows with blinds closed are used, in accordance with a normal sleep routine, while using eye covers during the night if necessary. Exposure to ultraviolet light is also stronger and sunglasses for external work are mandatory. Conversely, in the wintertime, the light-dark cycle depends entirely on artificial light. Schedules with well-defined times for meals (breakfast, lunch and dinner) work and rest are paramount in Antarctic stations. “Belgrano to Mars” is a collaborative project in which researchers Camila Tortello and Santiago Plano (UCA-CONICET and UNQ) participate in the analysis and interpretation of the information and Juan Manuel Cuiuli (Joint Antarctic Command) in the scientific coordination between Buenos Aires and Antarctica. Other members of the project are Marta Barbarito (Argentine Antarctic Institute), Diego Golombek and Patricia Agostino (UNQ and CONICET), Agustín Folgueira and Juan Manuel López (Central Military Hospital), and Guido Simonelli (University of Montreal). Field work during isolation is carried out by physicians from the wintering crews at the station and staff members that volunteer for the study. Antarctic scientific activity is coordinated by the National Antarctic Directorate (DNA), which together with the Joint Antarctic Command, provides the logistics of the bases.  Belgrano II crew on the ARA Almirante Irízar icebreaker TelemedicineThis year, we have traveled to Antarctica to supervise the implementation of the Belgrano to Mars project in the field, to test measurement instruments and to train the crew in the use of the equipment and software. The trip demanded six weeks of navigation in the ARA Almirante Iríza icebreaker. In addition, we started working with the European Space Agency (ESA) in the operational test of the Telemedecine Tempus Pro equipment, under the framework of an ESA-CONAE-DNA agreement. The project, led by Dr. Víctor Demaría-Pesce, from ESA's European Astronaut Center, involves conducting operational simulations in a situation of extreme isolation and confinement, which will contribute to the design of a definitive prototype to be used by astronauts and medical teams during future space missions to the Moon and Mars. The equipment will be tested at Belgrano II (Dr. Bruno Cauda and Enf. Luis Almaraz) and Carlini (Dra. Melina D'Angelo and Enf. Gustavo Cruz) stations, through six simulations that will recreate medical scenarios similar to those encountered by astronauts in space. Lessons to be learned from this kind of study We have recently published in the journal Scientific Reports (from the Nature Group) data regarding changes in the sleep-wake cycle during a winter campaign at Belgrano II. We observed that during the polar night the subjects tended to go to bed one hour later and sleep one hour less. A possible explanation is that this is due to the lack of exposure to natural light, since bright light acts as a synchronizer of our biological rhythms. This loss of sleep was somewhat compensated by naps, which were longer during that time of year.
These results show us how biological rhythms can be desynchronized in periods of prolonged confinement, such as the ones we have had to go through during the quarantine periods instituted in different countries. Moreover, it highlights the importance of exposure to natural light in the morning and darkness during the night and maintaining fixed activity and rest routines to avoid the desynchronization of our biological rhythms. Other sleep hygiene measures include the limiting of daytime naps to 30 minutes, regularly exercising (it may be necessary to avoid working out before bedtime), having a light dinner, avoiding stimulants like caffeine and nicotine close to bedtime, and making sure that the sleep environment is dark, silent and with a pleasant temperature. The beneficial effects of having good sleep relate to an increase in alertness during the day, the prevention of anxiety or depression, and the improvement of our general health, which in turn will reduce the chances of becoming ill. Authors: Prof Samira Bulcão Carvalho Domingues*, Prof Flávia Porto** and Prof Jonas Lírio Gurgel****Master's Degree student, Exercise and Sports Sciences/Institute of Physical Education & Sports/UERJ
 Image by Pete Linforth from Pixabay When faced with the COVID-19 global pandemic, a reduction in the numbers of people circulating is essential. It’s important to know there are differences between social distancing, isolation, quarantine and total lockdown, however, all of these strategies have one goal in common, which is to contain the speed at which the virus spreads and limit the collapse of health systems. In extended social distancing, those establishments considered to be non-essential are closed to avoid the gathering together of people, while in selective social distancing, people belonging to at-risk groups, especially the elderly, are encouraged to stay at home. In isolation, sick people (with suspected or confirmed disease) are separated from the non-sick, whether in a domestic or hospital environment. Quarantine is carried out by those people who have come into contact with or are suspected of having come into contact with the virus and, even if not presenting symptoms, they are isolated from others. When none of these measures work, a total lockdown is declared, like a community quarantine. Although essential, staying at home involves a radical change in the habits of a population, which may harm health in some way. Within the context of epidemiological normality, work, academic and leisure activities require a variety of effort that, taken together, maintain the minimum level of daily physical activity necessary for health, especially for sedentary individuals. An immediate interruption of these activities has a negative impact on the cardiorespiratory and muscle systems, responsible for maintaining functional capacity. This, in turn, is directly related to quality of life and the development of comorbidities. Similarly, and at the same time, physically active individuals are compelled to abruptly interrupt their exercise routines during this period. The damage caused by this halt in training includes losses in muscle strength and mass, aerobic capacity, and joint flexibility and mobility, in addition to alterations in body composition. The change from a physically active to sedentary life can affect important variables for health maintenance, including blood pressure, blood glucose and cholesterol levels. It is therefore advisable to use countermeasure strategies to combat the disuse. One of these is the practice of exercise - known to be the best non-drug health promotion strategy. The American College of Sports Medicine (ACSM) has already taken a position on the importance of staying physically active during isolation. The weekly recommendation for asymptomatic individuals is 150 to 300 minutes of aerobic exercise, plus two strength training sessions. One could, for example, do 5 workouts a week of 30 to 60 minutes, adding muscle strengthening exercises to two of them. The intensity should be moderate, as very light stimuli may not promote benefits, while very high intensities are associated with impaired immunity.
Although many people doubt the feasibility and efficiency of home training, the literature shows that results similar to those obtained in traditional gyms can be achieved by using one's own bodyweight as a load. Routines can include exercises based on calisthenics, both in aerobic (stationary running, climbing stairs, jumping jacks) and strength (squats, push-ups, planks) training. Accessible materials can help: elastic bands, skipping ropes, and even household items to increase the workload (water bottles, backpacks with books, bags with groceries). Authors: Prof Samira Bulcão Carvalho Domingues*, Prof Flávia Porto** and Prof Jonas Lírio Gurgel****Master's Degree student, Exercise and Sports Sciences/Institute of Physical Education & Sports/UERJ
 Image by Pete Linforth from Pixabay Diante da pandemia mundial de COVID-19, diminuir a circulação das pessoas é algo essencial. É importante saber que existe diferença entre distanciamento, isolamento social, quarentena e bloqueio total, porém, todas essas estratégias têm o objetivo comum de conter a velocidade de propagação do vírus e evitar o colapso dos sistemas de saúde. No distanciamento social ampliado, estabelecimentos considerados não essenciais são fechados para evitar aglomerações, enquanto que, no distanciamento social seletivo, pessoas pertencentes a grupos de risco, em especial, idosos, são estimuladas a ficar em casa. Já no isolamento, pessoas doentes (com suspeita ou confirmação da doença) são separadas das não doentes, seja em ambiente doméstico ou hospitalar. A quarentena é realizada por pessoas que tiveram contato ou suspeito de contato com o vírus e, mesmo não apresentando sintomas, ficam isoladas das demais. Quando nenhuma dessas medidas funciona, finalmente, é decretado o bloqueio total, como uma quarentena comunitária.
Apesar de imprescindível, a permanência em casa implica em uma mudança radical nos hábitos da população, o que pode prejudicar, de alguma forma, a saúde. Em um contexto de normalidade epidemiológica, atividades laborais, acadêmicas e de lazer solicitam esforços variados que, somados, mantêm o nível mínimo de atividade física diária necessário para a saúde, especialmente de indivíduos sedentários. A interrupção imediata dessas atividades impacta negativamente os sistemas cardiorrespiratório e muscular, responsáveis pela manutenção da capacidade funcional. Esta, por sua vez, está diretamente relacionada à qualidade de vida e ao desenvolvimento de comorbidades. Da mesma maneira, no momento, indivíduos fisicamente ativos precisaram interromper bruscamente suas rotinas de exercícios neste período. Os prejuízos do destreinamento incluem perdas sobre força e massa musculares, capacidade aeróbia, flexibilidade e mobilidade articular, além de alterações na composição corporal. A mudança de uma vida fisicamente ativa para o sedentarismo pode impactar variáveis importantes para a manutenção da saúde, entre elas, pressão arterial, glicose sanguínea e taxas de colesterol. Assim, é oportuno lançar mão de estratégias de contramedida ao desuso. Uma delas é a prática de exercícios - sabidamente a melhor estratégia não-medicamentosa de promoção da saúde. O Colégio Americano de Medicina Esportiva (ACSM) já se posicionou quanto à importância de se manter fisicamente ativo durante o isolamento. A recomendação semanal, para indivíduos assintomáticos, é de 150 a 300 minutos de exercícios aeróbios, além de duas sessões de treinamento de força. Pode-se, por exemplo, realizar 5 treinos semanais de 30 a 60 minutos e, em dois deles, acrescentar exercícios de fortalecimento muscular. A intensidade deve ser moderada, pois estímulos muito leves podem não promover benefícios, e intensidades muito altas estão associadas a prejuízos à imunidade. Authors: Prof Flávia Porto*, Prof Nádia Souza Lima da Silva* and Prof Jonas Lírio Gurgel***Institute of Physical Education and Sports, State University of Rio de Janeiro (UERJ)
 There are few known coping strategies for dealing with the coronavirus pandemic (COVID-19), but social isolation stands out. While this provides an effective way to reduce the spread of the virus, it also brings a range of problems for individuals and families, especially the elderly, such as limiting their in-person participation in health promotion programs. In a society highly connected through the Internet, a large number of seniors form part of the group that is digitally excluded, showing greater resistance to the use of digital technology tools. The current situation has imposed changes in our behaviour, serving as a catalyst for alterations in everyone's habits and leading to increased use of digital tools in order to mitigate social distancing. In this context, it is essential for health maintenance that physical exercise programs are continued during social isolation, particularly so for the elderly population, and should be part of public policy. Given this scenario, telehealth resurfaces as an instrument for health promotion and prevention, which are even more essential in the current situation. The strategy of using digital tools, like videos and web conferencing, enables continuity in physical exercise health promotion programs, which are essential to overcome the disuse imposed by confinement. In this sense, we would like to share our experience of using telehealth for the continuity of the program Elderly in Movement: Maintaining Autonomy (IMMA). How did IMMA come about? On October 17, 1989, Professor Dr. Alfredo Gomes Faria Júnior (22/08/1937 - 11/06/2019), Doctor Honoris Causa from the University of Porto, created the IMMA Project, which offers regular and free physical activities and assessments to people over 60 years of age, at the State University of Rio de Janeiro (UERJ), Brazil. It was a little early at that time to be thinking about the ageing process experienced by retired people in our country. The Brazilian demographic pyramid and entire socioeconomic context back then showed that caring for older people "was not important”. Times have changed and scientific evolution and world society has proven that longevity can (and should) be accompanied by more autonomy and quality of life for the individual. The creation of the IMMA was one of the historical milestones in Brazil, disrupting the thinking about health promotion for the elderly, predicting that, yes, these people would retire, but they would still be a part of society and, therefore, should be included. With a great chronological leap, IMMA continues to innovate and try to include the elderly in a society that is once again discussing the importance of older people in the composition of our community. When Brazilian President Jair Bolsonaro proposes vertical isolation, i.e., the elderly remain at home without contact with younger members, who can continue generating the necessary wealth for the country; and when recent speeches by the new Minister of Health suggest that if faced with a choice between saving an elderly person or an adolescent, priority should be given to the young for economic reasons, it is time to return to defending the portion of the population that is most vulnerable.  IMMA participant Maria Avelar, 93 years of age and still exercising! The IMMA in current times This new coronavirus has left us living in a time of crisis and local authorities are asking us to remain isolated at home whenever possible, and for this reason, activities at the UERJ have been suspended. Nonetheless, given this scenario and considering the importance of its students remaining physically active, the IMMA decided to continue functioning. In an innovative way, physical activities always guided in person, in addition to "live" hugs and greetings, gave space for a greater exchange of messages via WhatsApp. The IMMA team's major concern was to minimise the functional losses that physical inactivity could cause in the elderly, both from a cognitive and physical point of view. Therefore, daily cognitive games were initially proposed, giving the team the necessary time to set up the training routines to be performed at home by the elderly. Participation was immediate, interaction was great, and everyone’s mood lifted in these times of uncertainty. Good-humoured reports and thanks also came from family members of the participating elderly. After the round of cognitive games came the first physical exercise classes, which were joined by parents of the Physical Education students, members of the IMMA team, who served as models in their videos and instructional photos (as a university project, it is worth mentioning that the IMMA serves as a field of pedagogical activity for Physical Education academics at UERJ). The adherence of participants was inspiring, especially as the elderly began to send videos and photos of their individual routines. Finally, in these confusing and difficult times, the IMMA continues to maintain its social commitment, innovating, stimulating and contributing to the health and quality of life of its users, demonstrating that we can unite, even at a distance, to combat the adverse effects of confinement.
Authors: Prof Flávia Porto*, Prof Nádia Souza Lima da Silva* and Prof Jonas Lírio Gurgel***Instituto de Educação Física e Desportos, Universidade do Estado do Rio de Janeiro (UERJ)
 A pandemia do coronavírus (COVID-19) nos impõe poucas estratégias de enfrentamento, das quais se destaca o isolamento social. Se por um lado tal medida proporciona uma eficaz forma para reduzir a proliferação do vírus, por outro, traz uma gama de problemas para os indivíduos e para as famílias, em especial para os idosos, como limitá-los a participarem presencialmente de programas de promoção da saúde. Em uma sociedade altamente conectada, através da internet, boa parte dos idosos ainda compõe o grupo dos excluídos digitais, apresentando uma maior resistência ao uso de ferramentas de tecnologia digital.
A atual conjuntura vem impondo mudanças em nosso comportamento, servindo de catalisador para modificações dos hábitos de todos, levando-nos a aumentar o uso de ferramentas digitais de modo a mitigar o distanciamento social. Neste contexto, formas visando a continuidade de programas de exercícios físicos durante o isolamento social, principalmente para a população idosa, são essenciais para a manutenção da saúde, devendo fazer parte das políticas públicas. Diante desse quadro, a telessaúde ressurge como mais uma ferramenta de promoção e prevenção da saúde, as quais são ainda mais essenciais na atual conjuntura. A estratégia de utilizar ferramentas digitais, como vídeos e webconferência, possibilita a continuidade dos programas de promoção da saúde através do exercício físico, que são essenciais para superar o desuso imposto pelo confinamento. Neste sentido, gostaríamos de dividir nossa experiência com o uso da telessaúde para a continuidade do programa Idosos em Movimento: Mantendo a Autonomia (IMMA). Prof. K. GanapathyInnovaSpace Advisory Board member, Past President Telemedicine Society of India, Former Secretary/Past President Neurological Society of India & Indian Society for Stereotactic & Functional Neurosurgery, Emeritus Professor Tamilnadu Dr MGR Medical University, Former Adjunct Professor IIT Madras & Anna University Madras, Founder Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health. Could Telehealth be the way forward in helping to manage the COVID-19 pandemic in India?  Blog author, Dr. K Ganapathay is a Past President of the Telemedicine Society of India, Neurological Society of India & Indian Society for Stereotactic & Functional Neurosurgery. Emeritus Professor, Tamilnadu Dr MGR Medical University, he has 43 YEARS of clinical experience. He is on the Board of Directors of Apollo Telemedicine Networking Foundation and Apollo Telehealth Services – the largest and oldest multi specialty telehealth network in South Asia, an Advisory Board member of InnovaSpace, and recognised as a staunch advocate par excellence in promoting telehealth. For more details see www.kganapathy.com. I am thankful to Prof. Thais Russomano, Space doctor, for rekindling my dormant interest in outer space. 11 years ago I started taking my grandson to the terrace in my house and repeatedly showed him the moon and said "I want you to work there as a doctor". Who knows? This may actually happen in my life time.
As a 'Made in India', totally indigenous product, who has worked only in India, I am absolutely thrilled to learn about INDIA’S FIRST MANNED SPACE MISSION - Gaganyaan, scheduled for launch in December 2021.  GSLV Mk III Lift Off Image: ISRO The mission, which was announced by Prime Minister Narendra Modi in his Independence Day speech, is set to be a turning point in space history, as it will make India one of only four countries in the world, after Russia, USA and China, to launch a manned space flight. The plan involves sending three Indians into space for 5 to 7 days on a Low-Earth-Orbit mission (altitude of 300-400 km). At 27,000 km/h, a spacecraft completes an orbit around the Earth every 90 minutes. Costing within 1.5 billion US$, this 40-month project will employ 15,000 individuals, including 13,000 from industries and 1,000 from academic institutes – and of course, Indians!! Vyomanuts (Indian astronauts) for this mission are likely to be selected from 200 shortlisted Indian Air Force pilots, with just 4 being selected and trained. The best among the superhuman test pilots will get the golden ticket. On the seventh day after launch, the crew module will re-orient and separate itself from the service module, landing on Earth within 36 minutes, in the Arabian Sea, close to Ahmedabad.  Crew module splash down Image: ISRO One of the six largest space agencies in the world with the largest fleet of communication (INSAT) and remote sensing (IRS) satellites, ISRO has already developed most of the technologies required for manned flight. In 2018, it performed a Crew Module Atmospheric Re-entry Experiment and Pad Abort Test for the mission, while the Defence Food Research Laboratory (DFRL) has already worked on producing space food, and has been conducting trials on astronaut G-suits Most governments are averse to taking risks. It is a sign of the times that a popular government, in an emerging economy is willing to invest effort, time and money in what would, as a knee jerk response by many, be considered “preposterous”. One has to have the foresight that early investments in space would indeed be a differentiator. There are incredible resources out there. The moon has sufficient helium to power the entire globe. We will soon have an energy crisis and we are depleting all of our resources here on Earth. Whoever controls the valuable resources found in space will perhaps control the world. Unless goals are set, we will never get there. As the late chairman of ISRO Prof. U R Rao once remarked “...a government’s approach is to avoid all failures, but sometimes we need failures to push the boundaries”. Space law (spearheaded by the US) at present mandates that the natural resources found in space can be owned but not the place itself — like catching fish at sea. This has encouraged the pursuit of space business and millions of dollars have come in from private players. Today, if one finds a rock with valuable materials (precious metals like gold/platinum), it is yours. India is indeed a paradox. We have centres of excellence better than the best. We no longer talk of achieving world class, and indeed, in several disciplines, the world talks of achieving India class! It is true that we have a long long way to go. Internationally, an income of less than $1.90 per day per head of purchasing power parity is defined as extreme poverty. By this estimate, about 12% to 15% of 1.3 million Indians are extremely poor. Are we justified in denying millions of people good drinking water to satisfy an “ego trip”? In my view the answer is a resounding Yes. How else would you explain a billion plus mobile phones in the country. We are in a stage of transition. As Lloyd C Douglas remarked “this too will pass”. The future is always ahead of schedule. The Gaganyaan mission when (not if !) successfully executed will have untold spin-offs impossible to quantitatively qualify. It will show every one of us, that the ISRO culture of meritocracy can be imbibed by everyone, that minute attention to the nitty gritty in everyday life is doable, that failure is not an option.  Image: Canadian Space Agency Manned space missions do pose health risks pre-, during and post-flight for crew members onboard a spacecraft or station. There are communication challenges for medical doctors monitoring them from the ground. Physical and mental changes related to adaptation to the space environment need to be monitored in real-time. Changes in clinical parameters and management of unexpected medical emergencies need to be addressed and prepared for. Removing the effect of Earth's gravitational force alters all organic functioning. Space motion sickness, characterised by impairment of performance, nausea, vomiting and a diffuse malaise, occurs in astronauts and lasts for the first 72 hours of a space mission. Normal process of bone formation and resorption is disturbed. All of these aspects still require further study and understanding, and perhaps the Gaganyaan mission can also inspire and motivate Indian researchers to address these issues. For the last few years in all my talks I have been mentioning that India no longer follows the West. We no longer piggy back. We don’t even leap frog. After all how much can a frog leap! We pole vault!! A few years ago, President Obama warned American doctors that if they “don’t wake up” more Americans will start going to India for health care because it is cheap there. Indian doctors protested. They said in one voice “Mr. President, they don’t come to India to save a few thousand dollars. They come to India because our outcomes are as good as any of your hospitals. We are inexpensive not cheap!!  Just one more comment of interest...
Dr. K. Sivan, Chairman ISRO, within hours of the Prime Minister’s announcement, disclosed the appointment of Dr. Lalithambika as the first Director of ISRO’s Human Space Programme. Going by the number of women in top positions at ISRO, it is obvious that, if there is gender discrimination at all, it is of the reverse type!! Speaks volumes that Indian women are second to none .
Blog written by Prof. Dr. Thais Russomano, InnovaSpace Co-Founder & CEO
Telemedicine is a rapidly emerging and growing area of health assistance, research, and education that uses information and communications technologies to provide remote assistance to communities that currently lack specialist healthcare, or access to any form of medical assistance. Imagine living hundreds of miles from specialist doctors, such as cardiologists, dermatologists, and radiologists, to name but a few. This very situation occurs in many thousands of places all over the world; it is a huge problem that can impact very negatively on people's lives. In such circumstances, telemedicine is a potentially powerful tool that can not only improve the quality of healthcare, but also help in reducing the costs of healthcare delivery. While travelling in India at the end of 2017 and visiting the Apollo Hospital in Chennai, I came across a classic example of a place where telemedicine fits in perfectly - an extremely remote area high in the Himalayas.
At an altitude of around 13,500 feet sits the world's highest altitude Telemedicine Centre, implemented by Apollo Telehealth Services. This outstanding telemedicine program was established by Apollo under the directorship of Dr. K Ganapathy (President, Apollo Telemedicine Networking Foundation; Director of Apollo Telehealth Services; and InnovaSpace Advisory Board member), and aims to make quality healthcare accessible to the unreached populations of the towns of Keylong and Kaza, both in the Himalayan state of Himachal Pradesh, and with a total population of around seven thousand people.
The main health services provided are the delivery of medical assistance in emergencies, and primary and specialist tele-consultations. As of the 14th December 2017, a total of 9,389 consultations between the two remote towns and the Apollo Hospitals in Chennai had taken place (666 emergencies; 8723 outpatient consults). One such emergency involved local farmer Ram Singh who began to feel short of breath one day while out tending his cows. Fortunately for him he was able to attend the Apollo Telehealth service in Keylong and was treated remotely by a cardiac specialist in Chennai. Thankfully Mr Singh survived his heart attack and is able to tell his story in the above video, which makes him a classic example of how telemedicine can save lives!
 Blog written by Anna E. Schmaus-Klughammer, Director, Klughammer GmbH Mongolia is a huge country, being four times bigger than Germany, with nomadic cattle ranchers (herders) making up a large part of the Mongolian rural population. Due to the vast distances between cities, these populations living and working in the remote desolate regions of the country have very limited access to specialist doctors and hospitals, and the rural-based doctors work in isolation and are often left to make their own decisions in difficult cases. Although a hospital is located in each of the 21 provinces (Aimags) of Mongolia, each Aimag is three to four times the size of Switzerland, meaning that, in general, a journey of several hundred kilometres is required to reach it. Mongolia's desolate landscape and vast open spaces
Upon arrival at a hospital, the facilities encountered are fairly limited and the health care professionals often inexperienced, as it is state policy to send young doctors to the provinces. This situation can leave the medical professionals handicapped when faced with complex cases; with no specialist doctors to consult, patients are frequently referred on to hospitals in the major cities. This in itself is a problematic and costly procedure due to the great distances involved, let alone the additional difficulties faced when travelling whilst sick. As an example, the city of Ölgii, which is the major city of the Bayan-Ölgii Aimag in the extreme west of Mongolia, is 1636 kilometers from Ulaanbaatar, Mongolia’s capital city. Logistically, therefore, a journey between these two cities will take 3-4 days and will frequently involve travelling on overcrowded buses driven on unpaved roads. Camels, yaks and the herders live in desolate regions
In such an environment the use of telehealth and telemedicine can bring enormous benefits in terms of widening access to care and to expert medical opinion, and by overcoming the isolation of patients and health professionals. In this respect, in 2009, the German company Klughammer GmbH implemented a web-based telemedicine network in Mongolia in order to help Mongolian doctors access diagnoses and make clinical decisions. The project, funded by the Swiss Development Corporation (SDC), LuxDev/UNFPA, and the Millennium Challenge Account - MCA (USA), focused on mother & newborn health care, newborn hip screening, tumour detection, and cervical and breast cancer investigation.  Health professionals were trained to use the medical devices/telemedicine platforms All 21 provincial hospitals were connected via an interactive Internet platform to hospitals in Ulaanbaatar, with the Mongolian University of Health Services, National Center for Mother and Child Health of Mongolia, and National Cancer Center of Mongolia all being a part of this telemedicine network. Klughammer supplied, assembled and installed all the hardware and software required, such as computers, monitors, apparatus for transmitting patient image or laboratory results, and microscopes and radiology equipment, as well as providing staff training in the use of these. A web-based Electronic Health Records system, called CampusMedicus, was also introduced. This important healthcare IT application permits the secure storage of patient data, medical history, laboratory test results, and radiology and histopathology images. Each patient record allows case discussions to take place between doctors at a local, national and international level, giving access to expert medical opinion and enabling conference calls, for example to discuss patient tumour cases, among others. Medical staff in a provincial hospital using the Klughammer telemedicine platformThe practicalities of such a system have enormous potential to make a real difference to the lives of patients and doctors in remote regions such as Mongolia. It provides the opportunity for medical staff in the remote provinces to upload patient exams onto the platform, like tumour tissue microscope images, X-ray images of fractures, and ultrasound images from pregnant women, which can be securely stored and forwarded to specialist hospitals. Medical experts in the capital city Ulaanbaatar can then study these images and give their opinion for each patient case, adding it to the telemedicine platform, which operates in real-time. Access to the platform can also be made available to international specialists when needed. Since 2009, this ongoing project has led to the review of approximately 50,000 patient dossiers, leading to a decrease in the number of patients referred to Ulaanbaatar, and therefore improving the service provided to patients, speeding up diagnoses, and enabling large savings to be made in terms of time and money.
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