We asked the experts: Ensuring the quality and security of surgical teleconsultation in low‐resource conflict settings

The adaptation of telemedicine holds the potential to increase access to surgical care in resource-limited settings. Technological advancements in processing bandwidth, ease-of-use, and portability of mobile devices have now enabled over 85% of the world's population to access telecommunication.1 The utilization of telemedicine within low- and middle-income countries (LMICs), where system insecurities, resource constraints, and sparsity of specialists have traditionally limited access to comprehensive surgical care, has markedly increased since 2010.2 Over 170 publications now detail various uses of surgical telecommunication in LMICs to facilitate patient education, postoperative follow-up, and exchange of expertise.2 Monitoring of patient outcomes is inconsistent, but most publications report perceived benefit.2 For example, teleconsultation was shown to improve outcomes for pediatric patients with over 60% total body surface area (TBSA) burns outside of the major urban centers in South Africa, where greater than 40% TBSA is associated with high mortality.1 Most existing literature on the utility of telemedicine in low-resource settings has examined its application in relatively stable regions, while less attention has been paid to its implementation in low-resource conflict settings (LRCSs).2 Modern conflict is largely characterized by siege and asymmetric warfare, the use of explosive weapons in populated areas (EWIPA) resulting in multidimensional injuries, and targeting essential civilian infrastructure such as healthcare facilities. These features increase both the need for and barriers to the provision of comprehensive surgical care by multidisciplinary teams ideally including trauma and general surgeons, orthopedists, urologists, neurosurgeons, and burn specialists.3 Over the course of the United States wars in Iraq and Afghanistan, advances in the development of the Joint Trauma System (JTS) compositely achieved a significant reduction in preventable mortality and morbidity among military combat casualties despite concurrent advancements in morbid war technologies.3 The implementation of teleconsultation played an important role in this process, particularly under circumstances where patient evacuation was not feasible. Formal email referral chains and weekly teleconferences were used to facilitate remote subspecialist support for field surgeons of various training levels and resulted in enhanced management of complex casualties in austere operational environments.3 Civilians account for an increasing proportion of conflict-related casualties and lack the option of evacuation "out of theater". Many LRCSs have a reduced specialist workforce at baseline, which is further exacerbated as those with sufficient means flee for personal safety. The remaining local workforce, including surgical trainees or other healthcare providers lacking formal surgical training, is then tasked with the burden of caring for a diverse surgical workload comprised of complex polytraumas in addition to routine nontraumatic emergencies. Humanitarian actors can play a role but are constrained by ethical and security considerations regarding the positioning of medical personnel close to the front lines and maintenance of controlled evacuation routes. Therefore, appropriate application of teleconsultation models may augment the capacity of local personnel to effectively deliver high-quality surgical care in such environments.3 In contemporary conflicts, such as Gaza, informal communication networks have arisen through which a range of international subspecialists provide remote clinical support to local personnel caring for complex casualties.4 The organic establishment of such networks highlights the need and applicability of teleconsultation in LRCSs. However, significant vulnerability is associated with the use of widely available communication platforms for the sharing of health information in insecure environments.4 One commonly used platform is WhatsApp, an encrypted smartphone messaging application with image exchange, video messaging, and texting capabilities that is widely used internationally for routine personal communication.1 Humanitarian press sources have reported evidence that certain involved parties are using artificial intelligence to assign "suspicion scores" to identify militants and target strikes using cellular metadata including traffic analysis of WhatsApp activity.5 This is especially troubling for healthcare providers, who in adherence to the humanitarian principle of impartiality interact with both civilians and combatants indiscriminately to provide life-saving surgical care. Additional concerns surrounding informal teleconsultation include inconsistent regulatory processes for member entry and participant vetting. Because legal and ethical responsibility ultimately falls to the user of telecommunication platforms rather than the system components,1 quality assurance protocols need to be delineated. Platform specifications: Surgical teleconsultation platforms to be used in LRCS must balance the competing priorities of low bandwidth requirements with adequate security protections. Collaboration between humanitarian health practitioners and telecommunications experts is required to evaluate the strengths and vulnerabilities of existing options. This exercise could lead to the development of a risk and efficacy matrix assessing bandwidth requirements and vulnerability profiles of various communication platforms. This process can also identify areas requiring technical innovation and refinement via pilot activities in less volatile environments. Standardization and centralization of consultant vetting and member entry: Explicit credentialing requirements for surgical consultants engaged in teleconsultation in LRCS should be established. Vetting of potential consultants should be handled by a central body tasked with oversight of the teleconsultant network. Terms of participation (e.g., expected volume of consults over a given time-period, minimum percent response rate, and acceptable response times) should be delineated, and consultants not consistently meeting these targets removed from the network to minimize the number of individuals with access to sensitive patient data. Appropriate expertise should be engaged to clarify potential legal implications and protections for both international consultants and the local providers who will be implementing the elicited medical recommendations. Integration of teleconsultation activities with secure data collection and sharing: Improved regulation and centralization of surgical teleconsultation in LRCSs also holds potential to provide valuable data for the tracking of surgical outcomes within LRCSs and evaluation of further initiative.2, 3 Secure pathways for legitimate-use data sharing and analysis should be embedded within the developed teleconsultation platforms for this purpose. These basic measures represent an initial foundation from which future efforts to iteratively improve teleconsultation in LRCS should build. However, these three steps compositely may improve the quality of surgical care provided in LRCS and strengthen protections for patients and healthcare personnel operating in such environments. Abbygale Willging: Conceptualization; investigation; project administration; visualization; writing—original draft; writing—review and editing. Hannah Wild: Conceptualization; investigation; project administration; supervision; visualization; writing—review and editing. The authors declare no conflicts of interest. Not applicable.