On 23 September 1996 Professor Praveen Aggarwal in New Delhi appealed to doctors
and researchers around the world for help. "We are facing a near epidemic of dengue
haemorrhagic fever in Delhi, India," he said. "Despite managing these patients on the
lines stated in textbooks, many of our patients are dying. I wonder whether we are erring
somewhere in diagnosis and management of these patients. Therefore, I request you kindly
email me some of the recent information on pathogenesis, diagnosis, and management of these
patients."
Professor Aggarwal had sent his plea by electronic mail through a global
computer network called HealthNet. Specifically, he had posted his message to ProMed (the
Program for Monitoring Emerging Diseases): a 24 hour, seven day a week, electronic
conference on emerging diseases. Prompted by this appeal, a team from the World Health
Organisation's regional office for South East Asia visited Dr Aggarwal's hospital the next
day, bringing advice on staff training and two brand new reports on managing dengue
haemorrhagic fever. Over the next 10 days Dr Aggarwal was offered help by a doctor with 10
years' experience of treating the disease in Rio de Janeiro and put in touch with another
doctor in Bangkok who worked at the centre of a major dengue epidemic last year.
Professor Aggarwal works in the All-India Institute of Medical Sciences, a large and
prestigious medical school in a city. But he could have been practising in a remote rural
village with no phone lines and still have got the help he needed. This is because
SatelLife, a not for profit organisation based in Boston, has spent the past 10 years
linking up health professionals and researchers in the developing world through satellite,
radio, and - where available - telephone systems.
HealthNet, SatelLife's electronic
network, is just one of many initiatives currently trying to solve the problem of what is
increasingly called information poverty. HealthNet has two special advantages: it can reach
the parts of the world that other schemes cannot reach, and it sifts much of the information
it carries to ensure its high quality and its relevance to the developing world.
Information poverty
It goes almost without saying that doctors and other
healthcare workers, wherever they are, have much to gain from keeping up to date with
medical research and development. But it is often very difficult to do: in the rich northern
countries of the world doctors are overloaded with information.(1) And, more
worryingly, in many poor southern countries doctors have little or no current relevant
information to learn from.(2)
One big problem is the lack of books and journals in
libraries in poor countries. The BMA library in London subscribes to around 700 journals;
many libraries in the developing world can afford to take only a few, if any. Several
organisations are trying to put this right, such as the International Network for the
Availability of Scientific Publications (INASP).(2) (3)
Getting print media
to medical libraries is obviously very important, particularly for teaching students. But
books and journals have two main drawbacks: limited relevance and limited distribution.
Firstly, for many doctors in developing countries print media are too heavily based on
research and practice in the developed world. Publications produced more locally, however,
are even harder to acquire, partly because they are rarely indexed in international
literature databases such as Medline. This is doubly wasteful; medical workers in developed
countries could also learn from such publications.
Secondly, books and journals rarely
reach doctors and other health workers in remote towns and villages, who seldom, if ever,
get to a library. SatelLife's electronic HealthNet system has got round both these problems.
SatelLife's chief medical adviser, Dr Ramnik Xavier, explains why electronic
communication is so important to doctors in the developing world: "Undergraduate medical
education in the developing world often meets high standards, and graduates who can continue
postgraduate education do well in exams and provide good medical care," he explains. "But
those who return to their communities often suffer from lack of access to medical
information. If they want to do research, they have to move away, causing a local brain
drain." SatelLife, says Dr Xavier, can help them to stay where they are and still
learn.
Leela McCollough, SatelLife's information director, emphasises that
the organisation is an information broker, seeking out information and enabling information
exchange that is relevant to the developing world. "Of course, the Internet offers more
medical information than HealthNet. But relatively little of it is generated in, or relevant
to, poorer countries. And it is much more difficult and expensive to access than
HealthNet."
| Waiting for a telephone in the developing world |
| If you applied now for a new telephone line in the following countries it would take(5): |
| Bangladesh | 10 years |
| Ghana | 6.5 years |
| Kenya | 8.4 years |
| Malawi, Mali, Nigeria, Tanzania, and Zambia | 10 years |
| Zimbabwe | 5 years |
| Nepal | <10 years |
| Source: International Telecommunications Union |
SatelLife
SatelLife is the brainchild of Dr Bernard Lown, an American
cardiologist who founded the Nobel peace prize winning organisation International Physicians
for the Prevention of Nuclear War. Through his campaigning Dr Lown was keenly aware that
truly international cooperation among health professionals was badly hampered by poor
communications systems. Those in the world's rich northern countries could happily chat
among themselves by post, telephone, fax, and email. But very few doctors in the poorer
countries of the south, particularly in Africa, could join in.
Even now, as the
millennium closes, people in the world's poorest countries are having to wait 10 years to
get basic phone lines installed (see box). And, as the Economist put it earlier this
year, "While the lucky few million in the rich world amuse themselves in cyberspace, half
the human race has never made a telephone call."(4) How many of that unlucky half
have suffered and even died because their doctors have been unable to keep up to date with
modern medicine?
Ten years ago Bernard Lown learnt of a
surprisingly simple way to link up doctors in the south: low earth orbit communications
satellites. These are very different from the huge and costly satellites that beam telephone
and television signals to many of us from 35 400 km up in space. Low earth orbit satellites
are much tinier (no bigger than a refrigerator), cost 20 times less to build and launch, and
operate at an altitude of only 885 km. Yet, as Dr Lown found out, one such satellite can
link together a global email network. In 1989 Dr Lown set up SatelLife, having persuaded
several corporations and investors to fund the idea, and paved the way for a medical
information sharing network called HealthNet.
How SatelLife and HealthNet work
SatelLife provides a bridge between health professionals and the Internet using something
called "store and forward technology." This system does not rely on a continuous or "real
time" connection to the Internet to exchange data and thereby costs less to use. Instead,
SatelLife allows messages to be relayed from point to point along an electronic pathway,
using either the satellite or telephone modems, or both.
The
first satellite, Healthsat 1, went up in 1991 and was replaced in 1993 by the more
sophisticated Healthsat 2. Orbiting from pole to pole, Healthsat 2 can send and receive
electronic messages from each of its ground stations around the world at least four times a
day. Each ground station comprises an antenna, a personal computer, relatively simple email
software, high frequency radio and, where available, a telephone.
When the satellite
comes into range of a ground station it beams down data at a rate of about one page of text
per second. In addition, messages composed on the ground station computer are sent up to the
satellite, where they are stored and later delivered to SatelLife's headquarters in Boston.
From there, email messages are forwarded to other HealthNet users and also, via the
Internet, to anyone in the world with an email address. Messages back to the ground stations
take the reverse route.
| Where HealthNet operates |
| Africa - Botswana, Burkina Faso, Cameroon, Eritrea, Ethiopia, Gabon, The Gambia, Ghana, Kenya, Malawi, Mali, Mozambique, Nigeria, South Africa, Senegal, Sierra Leone, Sudan, Tanzania, Uganda, Zaire, Zambia, Zimbabwe
Asia - China, Indonesia, Myanmar, Nepal, Phillipines
Latin America - Bolivia, Colombia
Future centres - Bangladesh, Cambodia, Haiti, Madagascar
Satellite ground stations - Gabon, Northern Ghana, Nigeria, Tanzania, Sudan, Zaire, China |
While the satellite and ground stations continue
to serve remote medical units, much of SatelLife's email and Internet traffic is now sent by
telephone lines, as international telephone connections to capital cities in the developing
world are gradually improving
Even where the network relies on telephone lines, SatelLife
still uses store and forward technology. The HealthNet user prepares and stores messages on
a computer at home or work. When convenient, he or she calls up a local central computer or
HealthNet "node." The node holds the messages, acting as a post office for all HealthNet
users in the region or country. SatelLife retrieves such messages from the node several
times a day and shuttles them to the Internet.
How HealthNet is used
At the moment
around 4000 healthcare workers in 30 countries have access to HealthNet (see box). Many say
it is a life saver. Only this year, the Albert Schweitzer Hospital in a remote part of Gabon
appealed urgently through the network for information on Ebola virus, which had rapidly
killed at least a dozen people in a small village nearby. Within one week of the appeal, the
hospital had more than 40 pages of current information from the Internet, regular email
contact with the medical team who handled the major outbreak of Ebola virus in Zaire in
1995, and--with help from an American aid organisation, AmeriCares, and Sabena Airlines--a
big consignment of protective clothing. The virus was contained in the village, and the
hospital was fully armed for any recurrence.
As the Albert Schweitzer Hospital found,
HealthNet offers a wide range of services. And, most importantly, HealthNet is affordable
(see box). Subscribers can email each other; read and print out from 12 different electronic
publications; search 21 literature databases held at the US National Library of Medicine
(using an email system called BITNIS or Batch Internet National Library of Medicine
Information System); take part in continuous electronic conferences on subjects such as
AIDS; get formal education through distance learning programmes and teleconferencing; and
retrieve pages from the Internet indirectly using a special email web browser called Agora.
A HealthNet user cannot interact directly with the Internet pages that the Agora software
provides. Because an Internet user is operating in real time he or she can jump to other
parts of the Internet immediately, by clicking on links that have been set up within the
screen. Agora is simply providing the HealthNet user with a copy of the Internet page, so it
translates these interactive parts into written Internet addresses. HealthNet users then
have to note down the addresses that they want and send email messages to SatelLife in
Boston, giving those Internet addresses within the text of those messages. SatelLife then
retrieves the desired information from the Internet and sends it back to the HealthNet user
by email. It is a bit long winded, but it works.
| Value for money in Africa |
| Typical costs in $ |
| Average spending on health per head each year | 10 |
| Monthly income for average doctor | 150 |
| Three minute phone call from Burundi to Botswana | 23 |
| Six page fax from Mali to Zambia | 180 |
| Monthly cost of Internet connection (individual) | 100 |
| Monthly cost of HealthNet connection (local phone call rates plus a nominal monthly subscription) | 10 |
HealthNet
News
SatelLife's main publication is its electronic newsletter, HealthNet
News. Updated every day, it summarises current information that could realistically and
affordably improve medical care and prescribing in the developing world. Dr Ramnik Xavier
edits HealthNet News from Boston. He scans about 25 international and local journals
a month (including the New England Journal of Medicine, the BMJ, ACP
Journal Club, Evidence Based Medicine, Journal Watch, the South African
Medical Journal, and the East African Medical Journal) and picks out relevant
articles and abstracts to include in the newsletter.
Dr Xavier aims for high quality as
well as relevance, sticking to medical science based on good evidence. But he also goes for
articles introducing non-clinical developments such as managed care, audit, medical
computing, and biostatistics. And the flow is two way: subscribers can tell SatelLife what
they need to know, and some, through reporting back from conferences they have attended, can
contribute to the newsletter. Few doctors and researchers in developing countries, however,
get the chance to attend major conferences. So HealthNet offers its subscribers, at no extra
cost, its own ongoing moderated conferences on HIV and AIDS, infectious diseases, and drugs.
| HealthNet's electronic publications |
HealthNet News
AIDS Bulletin
WHO Library Digest for AFrica
WHO/AFRO Infodigest
AIDS Action
CBR News
Child Health Dialogue
Health Action
Practical Pointers on Primary Care
HDD Flash
Emerging Infectious Diseases
Morbidity and Mortality Weekly Report |
Continuous electronic conferences
ProCAARE
The United Nations AIDS
programme reckons that, of the 21 million people infected with HIV around the world, 94%
live in developing countries. This year hundreds of healthcare professionals and researchers
in those countries have been able to confer for the first time, day or night, through
ProCAARE (Program for Collaboration Against AIDS and Related Epidemics), a special part of
HealthNet's email system.
SatelLife has an illustrious array of
collaborators in ProCAARE: the Uganda Viral Research Institute, the All-India Institute of
Medical Sciences, the Harvard AIDS Institute and Harvard School of Public Health, and the
European AIDS Commission. Just as importantly, however, any interested medical worker or
researcher can sign up and take part. Indeed, one of the first messages was an appeal from a
doctor in Pakistan for information on home care for people with HIV. Within two days he had
learnt what he needed from staff running home care in Puerto Rico and Zambia; he had not
needed any help from the developed world.
ProMED
ProMED was set up in 1992 by the
Federation of American Scientists, a charitable think tank based in Washington DC. It covers
diseases of man, animals, and plants. Initially available only to those with access to the
Internet, it can now be reached by SatelLife's email system.
E-Drug
This
conference regularly disseminates information on essential drugs, treatment guidelines, and
new developments, pulling together material from the World Health Organisation and other
international bodies. Its subscribers are warned, however, not to clog up E-drug's channels
with requests on how to treat specific patients or with advertisements for drugs.
SatelLife in the future
SatelLife's plans for expansion include evaluating the
effect of HealthNet on educational and clinical outcomes, compiling a database of library
resources in the developing world, making greater use of its own subscriber database so that
fellow users can contact each other more directly, offering more conferences (for example on
tuberculosis), and making wider use of languages other than English (for users in
Francophone Africa, Latin America, and Asia).
Some subscribers have defected recently to
the Internet. But John Mullaney, SatelLife's executive director, remains certain that this
less glamorous system--based on rational technology--will have a vital role for many years.
HealthNet works well enough and is affordable. Full and direct connection to the Internet
may be more exciting and, in theory, may be much quicker because it delivers information
immediately. But it is more expensive to set up and use, is difficult to use well (because
it is unregulated and messy), it needs expensive technical support, and its telephone lines
are often engaged or prone to disconnection. "Our store and forward low earth satellite
technology may appear to some to be a Model T on the information highway," say SatelLife's
directors. "Nonetheless it is appropriate, simple, inexpensive, and sustainable."
Publications are distributed in collaboration with other organisations including the
World Health Organisation, the Centers for Disease Control, Atlanta, Appropriate Health
Resources and Technologies Action Group (AHRTAG), World Bank, and publishers of medical
journals.
Trish Groves,
assistant
editor
BMJ
London WC1H 9JR
101317.467@ compuserve.com
References:
1 Smith R. What clinical information do doctors need? BMJ
1996;313:1062-8.
2 Groves T. Information sharing: getting journals and books to
developing countries. BMJ 1996;307:1015-7.
3 Kale R. Health information
for the developing world. BMJ 1994;309:939-42.
4 Tele-haves and
have-nots. Economist 1996;18 May:19-20.
5 SatelLife News
1996;13:3.
