Global public health and the information superhighway
Tomorrow, the world
New technology can vastly improve the accumulation and dissemination of
information on public health. (ref 1) Vice President Al Gore has written that the
United States's current national information policy "resembles the worst aspects
of our old agricultural policy, which left grain rotting in thousands of storage
files while people were starving. We have warehouses of unused information
'rotting' while critical questions are left unanswered and critical problems are
left unsolved."(ref 2) This also reflects the status of global public health: we
have vast repositories of "warehoused" information on health, nutrition, the
environment, demography, and society. Telecommunication systems will give us
access to this. Moreover, much of public health and prevention depends on the
transfer of information, which telecommunication systems provide very cost
effectively.
From Bitnet to Internet
Discussions about the applications of networking to health care have typically
focused on the potential of networking to transmit data (in particular, images)
and to reduce the cost of health care. But the vast potential of
telecommunications to prevent disease has gone undiscussed.
Telecommunication networks began with electronic computer-to-computer
correspondence among scientists.(ref 3) In the early 1980s networks began forming
among academic institutions; one of the first was a system called Bitnet (Because
It's Time Network).(ref 4) Although it linked institutions that granted degrees,
Bitnet was handicapped because government agencies and industry were not
represented. During the 1980s Internet evolved.(ref 5) Internet represents a
"meta-network" - a network of networks. It provided a way of joining many diverse
networks, including those of governments and very recently industry.
The number of its users is growing by 12% a month: 10 million people in 91
countries now have access to the system. Internet was initially used for
electronic mail and allows "bulk" mailings, with over 2500 electronic newsletters
and 4000 discussion groups. Bulletin boards supply information of public
interest, details of relevant meetings, and the like.(ref 6)
In addition to these, Internet supports three tools to help find and retrieve
files (ref 5): the gopher, the wide area information server, and the worldwide
web. The gopher (from "go for") allows you to tunnel through "gopher space" to
identify various databases. It provides a means to move through various layers of
databases. With the gopher you can browse the card catalogue of the Vatican
library, gain access to data on global weather, examine labour statistics, obtain
publications from the United States government, and review pictures from art
galleries.
While the gopher finds information by going through a series of menus, the wide
area information server (WAIS) searches the full text of stored articles for
keywords provided by the investigator. The third information server is the
worldwide web (WWW), which is a hypertext information retrieval system. Hypertext
joins documents through a preselected group of words and thus permits rapid
linking of ideas.
In Krol's example (ref 5) you could identify the specific title of a book (for
example, J Last, Public Health and Preventive Medicine; subject: public health,
preventive medicine). Hypertext would then allow you to obtain Dr Last's
curriculum vitae (if this was available), his picture, and articles that he had
published (through Medline). You could expand on the subject of public health,
obtain the definition from a dictionary, identify papers on the topic, and enter
databases on the subject in the public domain. Thus you "jump" from topic to
topic on the basis of interest and need. All these systems and more can now be
accessed using systems such as Mosaic, which allows access to picture, video, and
sound.
Lessons from elsewhere
This is today; what of tomorrow? Given the technology that
is already available, we could inaugurate a global health information
infrastructure to improve health worldwide. Clearly, we cannot achieve this
vision overnight; we need to progress systematically, collaborating with
governments, learning from existing models, and selectively deploying
technologies appropriate to host cultures and existing practices. As far as
possible we must draw on lessons learnt from other wide area information systems,
such as the National Aeronautics and Space Association Science Internet (NSI),
which links the association's scientists worldwide with most of the world's
networks.
Perhaps a partnership with organisations such as this one, along with
the strong support of national and international health organisations, can bring
standardisation, new perspectives and resources to a set of urgent global health
problems. The first step is to connect everyone in public health: without this
a telecommunication system for global public health will fail. Public health
organisations such as ministries of health, the World Health Organisation, the
Pan-American Health Organisation, the United Nations, and public health and
medical societies should encourage members to be reachable electronically.
Once local and global public health centres have been connected, how can these
links be used? Obviously, computer based telecommunication will vastly improve
communication owing to effective transmission of information. There are, however,
several further possibilities for its use in public health.
Using links - Public health networking
Networking public health workers, including those in
local health departments, academia, governments, industry, and private agencies,
will bring great benefits. Information regarding what works (and what doesn't)
can be transmitted almost instantaneously. Here is how the public health web
might work in the case of an outbreak of cholera in Peru. News of such an
outbreak could be almost instantaneously transmitted to Peru's minister of
health, the Pan-American Health Organisation in Washington, the World Health
Organisation in Geneva, leading experts in cholera working outside Peru, and
people experienced in dealing with cholera outbreaks in Pakistan and Thailand.
Information on improving water quality would be identified by use of the gopher.
Technical reports concerning the control of cholera could be sent immediately to
Peru. Linkage to medical libraries could provide immediate access to relevant
information.
Global disease telemonitoring
With new epidemiological techniques such as
capture-recapture and a telecommunica telecommunications backbone, accurate
estimates of incidences of important communicable and non-communicable diseases
can now be obtained.(ref 7) Data on registered cases can be sent nightly from the
disease reporting centres to national centres. Rates adjusted for missing cases
by using capture-recapture can be reported to international centres by Internet,
with accurate information concerning the patterns of disease available almost
daily.
Issues such as confidentiality need to be worked out, but extraordinary potential
exists for very accurate disease monitoring and forecasting in much the same
manner as we monitor and forecast the weather.(ref 9) Currently all countries in
the Americas except Haiti are connected through Internet. Connections to Africa
are rapidly being established, with integrated systems of telecommunication being
developed in, for example, Zambia and Mozambique. No systematic integration of
telecommunication and public health systems across countries has occurred.
On line vital statistics
All vital statistics (but especially births and deaths)
could be entered electronically and be usable almost instantaneously. This would
facilitate monitoring and forecasting of population growth and the health needs
of mothers and children.
Environmental monitoring
Data systems for environmental monitoring have not been
organised with user friendly databases that integrate environmental information
with morbidity data as morbidity data for non-communicable diseases are poor.(ref
9) Linking global disease telemonitoring with environmental data would
considerably improve our understanding of the environmental determinants of
disease.
Email searches
Internet is already linked to the National Library of Medicine
through Bitnet. Should someone in Bolivia be interested in having the library
search for references on a particular topic the request and the results can be
transmitted through Internet.
Public health gopher
We are establishing a public health gopher, which will allow
people to roam through the existing sources of data relevant to public health.
Gophers can also be developed for national data with a common set of querying
commands to find data, reports, or other materials.
Distance education
Computer based distance education is rapidly improving. For
example, networking of injury epidemiologists would allow electronic courses on
injury prevention to be provided across the world. Reading materials, video,
pictures, and sound could be transmitted across huge distances for low costs, and
interaction would be possible. Students from several countries could work
together to establish research programmes in public health. Health education
might be targeted at those most in needÑfor example, maternal and child health
programmes could send targeted messages to mothers and have mothers ask questions
through media such as television. The links are being established between cable
television and telecommunication systems. Hundreds of schools are already
networked together.
On line journals
Much has been written concerning electronic journals and books
and their potential for improving the dissemination of information. Manuals of
operation and protocols for studies and public health actions could be made
available for free and almost instantaneously through gopher servers. Global
public health needs to begin to plan for a public health communication system
that can reach all the public health workers in the world. The first step is to
network public health workers. It is time for public health to enter the
electronic information superhighway.
We thank Tony Villasenor for his comments.
Ronald E LaPorte
Professor
Department of Epidemiology
University of Pittsburgh,
Pittsburgh, PA 15213, USA