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5.3 The revolution in electronic communication and public health

5.3 The revolution in electronic communication and public health
Oxford Textbook of Public Health

5.3
The revolution in electronic communication and public health

Elliot R. Siegel, Julia Royall, and John C. Scott

Introduction
The Internet
The World Wide Web
On-ramps to the information superhighway
Factors limiting use of the Internet
Public health information content on the Web
Telecommunications technology for developing regions

Terrestrial telecommunication

Satellite communications
Public health applications of telecommunications technology
Remote sensing and early warning
Telemedicine
The case for Internet connectivity in Africa
The Multilateral Initiative on Malaria in Africa

The malaria crisis

The fundamental goals of the Multilateral Initiative on Malaria

Communications as an enabling resource

The Communications Working Group

Building new partnerships

Methods of operation

More than wires and dishes

Accomplishments
Conclusion
Chapter References

Introduction
Advances in computing, information, and communications are dramatically transforming the health sciences, and they underpin the very means for generating new knowledge and aid in its rapid utilization by scientists and health workers in the field. Investigators in basic research need access to databases and repositories. Developers of new vaccines, drugs, and diagnostics need access to discussion groups for product development work and co-ordination of clinical trials. Published literatures are readily identifiable and accessible through computer databases. Electronic versions of printed journal articles are sought especially where library resources are poor. Epidemiologists engaged in vector control and surveillance programmes use geographic information systems and satellite-based remote sensing technologies. It is highly desirable that collaborating units, within countries and around the globe, maintain contact through e-mail and other electronically mediated means of communication that are becoming increasingly possible over the Internet. New modes of communication and publication, particularly electronically linked World Wide Web sites, provide a central means for identifying and networking with fellow researchers and public health workers, and accessing related scientific resources.
Scientists and public health workers in developing regions face particular challenges in accessing the products of this revolution in electronic communication. Traditional dial-up telephone connections can be slow, unreliable, and costly. More dependable solutions can include microwave, a point-to-point option that uses radio waves, and very small aperture terminals which communicate via geostationary satellites. Commercial development of low Earth orbiting satellite systems may be another promising option in the years ahead. Obtaining regulatory approval in some countries can be a significant impediment for very small aperture terminal and other wireless solutions. However, progress has been realized in recent years wherein full Internet connectivity has become a reality in most major cities in the developing world. This has been partly fuelled by special communications initiatives undertaken by donor agencies, and the growth of in-country public and private sector providers of commercial Internet services. Yet access in remote regions is still problematic. A case study based of the Multilateral Initiative on Malaria illustrates the promise and challenges of connecting malaria research and control sites in sub-Saharan Africa to the Internet, thus providing support for a viable and sustainable human and technical infrastructure.
The Internet
The Internet is a global network of interconnecting computer networks first developed over 25 years ago. This ‘network of networks’ allows any computer attached to it to communicate with any other computer using the same Internet protocol. From its start as a research network supported largely by American government agencies, the Internet has evolved to become a ubiquitous and largely unregulated carrier of data, images, voice, and full motion video available at the click of a button to users worldwide. The proliferation of low-cost personal computers with rapidly expanding memory capacity, coupled with increasingly affordable high-bandwidth telecommunications technology available at locations both accessible and inaccessible by wires, have together combined to produce a remarkable revolution in electronic communication.
In 1973, the United States Defense Advanced Research Projects Agency initiated a research project at several universities to develop communication protocols which would allow networked computers to communicate transparently across multiple linked packet networks. This was called the Internetting Project and the system of networks, which emerged from the research, was called the ‘Internet’ (National Research Council 1999). The system of protocols became known as transmission control protocol/Internet protocol. The Internet was designed partly to provide a communications network that would work even if some of the sites were destroyed by nuclear attack. If the most direct route was not available, ‘routers’ would direct traffic around the network via alternate routes.
In 1986, the United States National Science Foundation developed NSFNET, a major backbone capable of switching information ‘packets’ at speeds of 45 million bits per second (Mbps). The National Aeronautics and Space Administration (NASA) and the United States Department of Energy contributed additional backbone facilities. In Europe major international backbones such as NORDUNET were established. Commercial network providers worldwide soon entered the market and offered Internet backbone and access support on a competitive basis to any interested party. By the end of the decade, the Internet grew to include some 5000 networks in over three dozen countries, serving 700 000 host computers used by 4 million people. These numbers can only be grossly approximated today as virtually every country participates in the Internet revolution. The interested reader is referred to the Internet Society website where an excellent history of these developments may be found online, often in the words of the people who made the history, including Vint Cerf, Robert Kahn, Jonathan Postel, and Stephen Wolff (http://www.isoc.org/).
The World Wide Web
When computer experts, engineers, and scientists first used the early Internet, there was nothing user-friendly about it. The need existed for a tool which would unify Internet access for the general computer user population, a group which had become accustomed to graphical user interfaces, pointing-and-clicking, and simple commands masking complex software functions. This need prompted the creation of the World Wide Web in 1991 at the European Center for Nuclear Research in Switzerland (CERN).
The concept implemented by Tim Berners-Lee along with Robert Cailliau at CERN sought to develop a system of links between different sources of information (Berners-Lee et al. 1994). Parts of a file would be made up into nodes which, when called up, would link the user to other related files. They devised a document format called Hypertext Markup Language, a variant of one used in the publishing industry since the 1950s, and released it as a new Internet protocol, the hypertext transfer protocol. Like e-mail 20 years earlier, the World Wide Web quickly diffused from the physics community at CERN to become the new ‘killer application’ for the Internet (National Research Council 1999). In 1993, Marc Andreessen and his team at the United States National Center for Supercomputing Applications provided a major impetus to the protocol’s utility. The graphical browser Mosaic was developed and later commercialized by Andreessen when he founded Netscape. Microsoft’s full-scale entry into the browser, server, and Internet service provider market has accelerated the shift to a commercially based Internet, especially timely with the diminution of funding by the United States government agencies in 1995.
On-ramps to the information superhighway
In the meantime, high-speed connections to the Internet—permitting faster web browsing and downloading of ever-larger datasets—is proceeding apace. Dial-up modems operating at speeds of 56 thousand bits per second (kbps) are widely supported by commercial Internet service providers serving homes and offices, but these are generally not fast enough to carry multimedia, such as sound and video, except in low quality. New technologies, such as cable modems and digital telephone lines that are continuously connected to the Internet are becoming increasingly available and offer relatively low-cost access to bandwidth in excess of 1 Mbps. Satellite broadcasting, discussed in some detail below, provides services at lesser speed (typically 128 kbps) but has the capacity to reach underserved regions of the world where wired communications lines are economically unfeasible or physically impractical due to distance, terrain, and climate. In contrast, large institutional users in the industrialized countries (that is, businesses, universities) routinely subscribe to broadband services offering shared Internet connections to literally hundreds of individual users wired together via local area networks, at speeds ranging from 1.5 (t1) to 45 (t3) Mbps.
In parallel to what is sometimes now referred to as the ‘commodity Internet’, we are seeing the development of a complementary ‘next generation Internet’ intended to serve the needs for higher levels of bandwidth by scientific and research communities. These on-ramps to the next generation Internet are capable of operating at speeds of 155 Mbps, and offer connection to the very high performance Backbone Network Service. Launched in 1995, the very high performance Backbone Network Service is a National Science Foundation-funded nationwide network supporting supercomputing centres and research institutions, a model having its roots in the original Internet a decade earlier. Some segments of the American very high performance Backbone Network Service are now operating at 622 Mbps (known as OC-12), with one link at 2.5 billion bits per second (Gbps) (OC-48) between San Francisco and Los Angeles. International consortia are working towards extending very high performance backbone network services worldwide.
Factors limiting use of the Internet
The American National Research Council underscores the increasing popularity of the Internet in health and health care, and the ability of the Internet to revolutionize the health sector by connecting people, information, and services from anywhere across the country, and around the globe (National Research Council 2000). At the same time, its report identifies a number of fundamental factors concerning security that can limit the use of the Internet in health applications, as well as technical limitations in the capability of the Internet itself.
Health information can be extremely personal and sensitive. Systems designed to transmit patient medical records across the Internet or to allow remote access to a patient’s medical record, for example, must have strong built-in security protections to ensure that the information remains confidential and is not intentionally or unintentionally altered. The limiting factor, from a health perspective, is the difficulty in verifying the identity of people communicating across the network and accessing sensitive information. Large organizations can overcome this problem by using digital credentials, or certificates, that can be verified by most web browsers. But mechanisms are not in place for distributing such credentials to everyone who might use the Internet for health purposes. This problem is referred to as an ‘authentication’ problem, and one proposed solution is the establishment of a ubiquitous public key infrastructure.
Another element of security is network availability. If the Internet is to be routinely used for critical health functions such as retrieving medical records, users must be sure the network is available 24 hours a day, 7 days a week. However, situations can arise in which denial-of-service can take place by so-called ‘hacker’ attacks. A combination of research and development, and the adoption of best practices, can achieve improvement of overall reliability by network operators and system administrators.
Quality of service can be variable. Enormous variations in download times can exist due to variations in congestion—across the Internet, at the source website, and at the user’s location. This can be a critical barrier for health applications that require downloading of large image files or videos. A recent evaluation study of end-to-end Internet performance revealed that local bottlenecks at the user’s site, rather than inadequate bandwidth on the backbone links, was the source of most of the congestion problems at the United States and international sites studied (Wood et al. 1998).
High-speed user access may be problematic in many locations where the health need is greatest. Broadband access via cable modems, digital subscriber lines, and wireless communications is not available in many areas that need them most. Rural areas that could benefit from telemedicine services tend to be the last to acquire broadband services, and many inner city locations are often unable to afford local connections. These issues, and others cast under the general rubric of the ‘digital-divide’ are addressed elsewhere in this chapter.
Public health information content on the Web
Despite these limitations, the Internet and the World Wide Web have become a major resource for health-related information for health professionals and, increasingly, for members of the general public. In 1999 an estimated 30 million Americans used the Internet to search for health-related information, many of them accessing consumer-oriented health websites created especially for the non-health professional user. Proponents of these sites make the case that the Internet can dramatically improve the public’s health by making information available to consumers in a more tailored and targeted fashion than is possible with other media. They also see the Internet as offering a means of changing personal behaviours, such as diet and exercise habits, in a way that will improve health. (One-third of these individuals also purchased prescription drugs and other health products as part of yet another revolution in electronic commerce, a discussion of which is beyond the scope of this chapter.) The appetite for authoritative and reliable health information on the Internet is large and growing. Approximately 600 000 searches each day from more than 120 000 different users are carried out on just one popular health information website (National Research Council 2000).
Thousands of health-related websites are presently available. Many provide convenient and often free access to bibliographic reference databases previously available in printed and/or limited electronic form. Others offer newly created digital versions of full-text journal articles directly from their publishers or by document delivery services. Still others provide information on specific health topics by leading medical specialty and lay organizational groups. Non-commercial websites geared to the public, patients, and their caregivers include MedlinePlus (http://www.medlineplus.gov/) and a newly developed comprehensive listing of clinical trials supported by the American National Institutes of Health (http://www.clinicaltrials.gov/). An entirely new category of communication, spawned by the Internet itself, provides a venue (sometimes called a ‘chat room’) for the anonymous discussion of health problems by patients and their families.
Such ease of access does come with a price, however. The contents of these Internet-accessible resources may be of uneven quality and questionable validity (Silberg et al. 1997). An international initiative, the Health on the Net Foundation (http://www.hon.ch/), offers a voluntary certification programme whereby information providers on the Web may elect to adhere to a code of conduct attesting to the reliability and credibility of the medical and health information available on their sites. A ‘seal of approval’ is awarded and may be prominently displayed for the assurance of users.
Examples of databases broadly relevant for the public health community include the American National Library of Medicine’s Medline (http://nlm.nih.gov/), which contains more than 9 million references to biomedical journal articles published in 3900 journals since 1965. The PubMed system offers a simple search interface that can also provide direct links to publishers’ websites for the full-text articles referenced in Medline. The Biosis Biological Abstracts (http://www.biosis.org/) offers a comprehensive and complementary reference source to the life science journal literature.
Specialized information resources abound as well. Those pertinent to the concerns of environmental health workers, for example, include the TOXNET (http://sis.nlm.nih.gov/) cluster of databases for toxicology data (for example, Hazardous Substances Data Bank), toxicology literature (for example, TOXLINE), and toxic release information collected by the Environmental Protection Agency. Other resources are initially released on CD-ROM but are created to be accessible on the Web when connectivity becomes more widely available in regions not now well served. An example is the Virtual Disaster Library, which is produced by the Pan American Health Organization’s Latin American and Caribbean Center on Health Sciences Information. The Virtual Disaster Library contains more than 250 publications in English and Spanish on disaster preparedness, mitigation, and response.
Use of electronic information resources by the AIDS community is particularly noteworthy. It has been especially quick to realize the benefits of Web technology and the Internet as a means to access and provide a cost-effective and rapid means for AIDS service organizations to disseminate new and authoritative information, and to communicate with difficult to reach clients. Patients living with AIDS and health workers serving the HIV/AIDS community have numerous Internet resources available to them, including literature references (for example, AIDSLINE), drug information (for example, AIDSDRUGS), clinical trials (for example, AIDSTRIALS), and electronic gateway services and treatment guidelines (http://hivinsite.ucsf.edu/). Many health institutions and community-based organizations offer their own information services on the Web, many of which are geared to particular ethnic, cultural, or the sexual preferences of their intended users (Kuromilya and Bauer 1998). The University of Washington, in collaboration with the National Library of Medicine, is connecting 16 American Indian and Alaskan native communities to the Internet. The aim is to improve access to social and health resources, emphasizing HIV/AIDS (http://www.tribalconnections.org/).
In 1999, a major experiment in scientific communications was initiated by the National Institutes of Health in collaboration with authors and members of the international publishing community (Marshall 1999). PubMed Central (http://www.pubmedcentral.nih.gov/) contains two separate collections of life science research and related materials. One consists of the contents of peer-reviewed journals, deposited as soon after publication as the journals are willing to make publicly available without charge. The other will contain articles that have been submitted directly by authors and that have undergone screening. Not without controversy, PubMed Central may be the cornerstone of a new era of publishing in the sciences, or evolve into a somewhat different approach to electronic publishing not yet defined. In any case, such an experiment reflects the frustration of authors with the present system, and the opportunities offered by the new technologies that will transform the landscape of scientific communications (Caelleigh 2000).
In short, the Internet and the World Wide Web offer unprecedented opportunities for the exchange of all manner of public health information around the globe. Accessible and affordable telecommunications technology is the means by which connectivity to the Internet is achieved and all forms of communication may occur.
Telecommunications technology for developing regions
The almost daily improvement in telecommunications and information technology is fuelled partly by the realization that low-cost, easy to access, and easy to use systems are available. No better example of these rapidly developing technologies exists than the Internet. Though not yet universally available, the Internet is moving in that direction. The increasing utility of mobile portable communications, linked with various terrestrial distribution systems and peripheral technologies, will help to ensure growth of Internet use in the public health sector (Scott et al. 1997).
Epidemiologists and a host of other professional disciplines have long appreciated the benefits of interactive real-time telecommunications links. Realizing these benefits has been a challenge in many areas of the world, however. In urban centres of countries with highly developed economies (locations that provide the economic stimulus frequently needed to motivate the development of new technologies) some of these systems can be found operating. But in remote areas of these same countries, and in developing countries in general, if such networks are available at all, they are not yet likely to be widely spread.
Telecommunications systems mediated by international satellite links will in the near future provide an attractive technical solution in many instances. Geostationary satellite systems are readily available now; low Earth orbiting systems deploying multiple satellites capable of supporting interactive communication are literally on the horizon. Other communication modalities are available and should be utilized in the meantime (Acosta and Scott 1999). A brief description of these follows, with a contextual view of their relative utility for the disaster and emergency relief community given as examples.
Terrestrial telecommunication
‘Plain old telephone service’
Traditional terrestrial telecommunications services, the most characteristic of which is telephone service provided via ‘telephone wires’, have been costly to install, difficult to repair, and vulnerable to disasters, particularly in remote areas of developing countries. Telephone systems in difficult terrain or climates or in undeveloped areas are notoriously unreliable. If even one ‘telephone pole’ is incapacitated in a terrestrial network, all communications past that point are affected until that pole and its connection to the system can be repaired. Thus, although they may play a role in the early phases of disaster planning and warning, terrestrial communications cannot be relied upon for continuous use during a disaster event.
Even if the telephone system is not damaged by the disaster event, it is likely to be made unreliable or unusable because of heavy demand by the affected population. Outages (service interruptions) due to overloaded circuits can last anywhere from several hours to several weeks. Dial tones can also be affected by power outages and overloads, and this can be a further obstacle to disaster management.
The Disaster Relief Communications Foundation (http://www.reliefweb.int/) recommends that health sector disaster managers should develop and maintain good working relationships with local and national telecommunication service providers and work with them to develop disaster services and emergency protocols based on infrastructure at hand. National governments should be strongly encouraged to strengthen their terrestrial telecommunications infrastructure and make it resilient to the type of disasters to which their area is vulnerable. Until that time, disaster managers should not rely solely on these systems for onset and acute phases of response.
Radio communications
Radio systems offer many advantages in the developing world. However, while operational costs are low, the costs of installing and maintaining an efficient system can be high. In most countries medical and other community lifeline sectors maintain some type of radio link, although each service tends to operate its own system independent of the others. There is a wide range of available technology and possible uses. A brief summary of some the systems is given below.
High-frequency single-sideband units
Communication in the field is most frequently conducted over long distance using high-frequency radio. This communication is point to point and permits voice and low-speed data communications between and among fixed installations at field headquarters and regional offices. Mobile high-frequency single-sideband units can also be used in a similar manner (although by definition ‘mobile’ units are considered to be permanent installations in vehicles), as can transportable units which are integrated communications packages designed to be deployed at single locations at short notice.
A significant advantage of high-frequency single-sideband networks is that hardware costs are minimal and use is free. A disadvantage is that, because of its wide use, it is difficult to get allocation of the dedicated high frequencies required to operate. High-frequency transmissions are also subject to propagation effects that occur both daily and seasonally.
Effective distance of high-frequency voice communications is from 2000 to 10 000 km, typically sufficient for communications between field operations and national headquarters. The use of advanced technology, namely the Pactor Level 2, Clover, and other data modes, along with the use of enhanced modems, permit effective data communications worldwide.
VHF hand-held radio communication
For short-distance communication (within cities and within geographic regions of approximately 100 km) use of VHF hand-held radios is ubiquitous among national authorities, United Nations agencies, and non-governmental organizations for communication between and among staff. Like high-frequency radios for longer distance, VHF radios are relatively inexpensive to purchase and free to operate. However, the use of VHF equipment is subject to the delivery of a license with a limited number of assigned frequencies, a process that requires a significant amount of negotiation with local telecommunications authorities. In the absence of regular telephone communications these VHF radios provide a basic and vital administrative function. Another important function is security and maintaining contact with staff travelling from one part of a city to another.
Amateur radio operators
Amateur radio operators have historically been the first group to establish and operate communications networks locally for governmental and emergency officials during and immediately following a disaster. Amateur radio facilities can generally be characterized as having a high survival capability. Although amateur radio operators are most likely to be active after disasters that damage regular lines of communication such as power outages and destruction of telephone lines, they frequently support the delivery and relay of predisaster and warning information. Amateur radio operators are generally well motivated, willing, and prepared to work under extreme conditions encountered during acute emergencies, where both solid technical knowledge and the ability to improvise are required. Although most ‘ham’ radio operators belong to organized groups and show a great sense of discipline and responsibility, the accuracy of their reports may vary widely. Direct close co-ordination of these groups by emergency telecommunications managers is critical to avoid the danger of transmitting inaccurate, unconfirmed, or unreliable information.
Governments license amateur or ham radio operators in most countries. Some governments severely restrict the use of amateur radio operators. The International Amateur Radio Union co-ordinates the activities of amateur services and actively supports their introduction in those countries where the value has not yet been fully recognized.
Radio paging service
Radio paging is increasingly common in most countries. Its coverage, which can range from local to international, is of unquestionable value to disaster managers. Access and reliability of these systems during periods of disaster depends on a variety of factors. These range from the availability of telephone, cellular, and/or satellite lines to interconnect and operate the system, through independent sources of electrical power, and the quality (that is, robustness) of the actual paging transmitter.
While the majority of paging systems are one-way and do not guarantee delivery to the recipient, ‘one-and-a-half way’ systems (message receipt acknowledgement) and two-way systems are emerging, often with e-mail links.
In countries where there are sizeable global systems for mobile communications (that is, mobile telephone) penetration, traditional paging systems have been supplanted by the short message service built-in to the global system for mobile communication protocols.
Limited resources may not make possible the routine use of pagers. If a paging service is available the possibility of leasing the service for essential personnel in disaster situations should be considered. It must be kept in mind that most radio paging services rely on terrestrial infrastructure that is vulnerable during disasters. This is the case to a lesser extent with satellite-based paging systems.
Satellite communications
Fixed satellite service
Early satellite communications service and infrastructure were developed first within urban areas with large populations. Then, largely through rapid advancements in space technology, population centres were connected. Early communication satellites developed in response to the demand for their services. They were designed to provide the most powerful coverage and greatest service to the most populated areas.
Furthermore, the phenomenon of television resulted in an increased requirement for greater satellite capacity that was, again, dedicated largely to population centres. Because the technology of these early fixed satellite services did not provide for powerful transmitters, large, complex, and expensive Earth stations had to be used to receive signals from the satellites and send signals to them. Their use, therefore, was as regional or national gateways for major telecommunications trunking services and for television distribution. They are still mostly limited to communications within and between capital cities and large urban areas.
Space segment providers and satellite designers soon recognized the increasing need to reduce the size and expense of the ground hardware and launched a new generation of services that relied on more versatile and powerful satellites. Because these new satellites transmitted more powerful signals, the new ground hardware size and power requirements were significantly reduced.
The capital cost for hardware and the recurrent cost of satellite time were also reduced. In practical terms this meant a move from stationary to transportable Earth stations (not portable). These changes in service made possible the advent of very small aperture terminals. The applicability for very small aperture terminal services could include linking, in a permanent or semipermanent network, national health sector disaster managers. This is still relatively costly and it still must be remembered that, as with terrestrial telecommunications links, fixed satellite service infrastructure is susceptible to damage or destruction at the onset of the disaster. Unlike its terrestrial counterparts, however, if one link goes down all others are not affected.
Global mobile personal communications by satellite
Within 3 to 5 years there will probably be several low Earth orbit satellite systems covering the whole world in addition to the existing geosynchronous satellite networks. They will consist of betwen one and as many as 325 satellites per system, and will be part of a new category of service, global system personal communication by satellite. These systems offer the health sector the promise of easy-to-use, reliable, and affordable communications that was not possible 5 years ago.
These emerging systems will have a wide range of capabilities ranging from narrowband (data only) to broadband (making possible video, voice, and data) communications. Global system personal communication by satellite technologies will probably be of such low cost as to be affordable to all sectors and thus should be of great interest to health sector managers.
Despite their promise, in the near future health professionals should be cautious when deciding what new and emerging technologies to use and invest in. A safe bet is to explore a mix of technologies, including but not limited to new global system personal communication by satellite services, until such time as their strengths and weaknesses have been proven.
Mobile satellite service
Mobile satellite services were first developed for maritime applications and now are broadly used for aeronautical and land-based purposes as well.
Mobile satellite services are less expensive than traditional fixed satellite services. They are easily transportable and are not technologically dependent on terrestrial telecommunications infrastructure. They are far less vulnerable to natural disasters and, because they can be used reliably to send data or call anywhere in the world, their use in the field has grown rapidly.
Although lower in cost than fixed systems, they are not inexpensive, and are still used almost exclusively by United Nations agencies and the larger non-governmental organizations. Although some national/domestic systems are available, the most widely used—and the only system available worldwide at this time—is the international consortium INMARSAT.
Additional systems at either end of the technology and cost spectrum are rapidly becoming available. These range from Iridium, featuring hand-held telephones that allow for voice calling from anywhere in the world, to Orbcomm, which offers low data messaging and data collection from fixed sites or hand-held units on a worldwide basis.
E-mail services
Communication by e-mail has undergone explosive growth. Initially, it was possible to communicate within closed networks, but with the opening of the Internet to the civilian world, millions of individuals and institutions can exchange information from almost any point on the planet. E-mail requires a computer with a modem, access to telephone or other telecommunications service, an account with an Internet service provider, and some training.
The Internet has become very useful in the health sector to support medical care as well as many aspects of public health including disease prevention and health promotion. It is inexpensive to use compared with traditional communication systems. The service makes it possible to contribute and use information on websites about disasters, form discussion groups and ‘virtual’ conferences among institutions worldwide, and send documents and graphics. It allows free exchange of information among interested parties, with a minimum of bureaucratic restrictions.
It should be understood, however, that most Internet service providers in the developing world rely on terrestrial telecommunications infrastructure and therefore Internet service is vulnerable during disasters. This is an issue not only in so far as the Internet may be relied upon to be a communications tool, but also because Internet users have become accustomed to ‘storing’ valuable data on the servers located at their institution or at their Internet service provider. The safety of these data may be in jeopardy during disasters or other emergencies.
Public health applications of telecommunications technology
Significant targets of opportunity exist for the application of new electronic communications tools to support the detection of public health threats, prepare for their management, and act to ameliorate their consequences. The Internet may be used beneficially to support new applications addressing public health surveillance, data integration, and the detection of bioterriorist attacks (National Research Council 2000).
The American public health system is hierarchically organized around community, state, and federal efforts. Each of these jurisdictions collects different data and shares them in different ways. Where the systems interact with one another, such as doctors and laboratories reporting the occurrence of communicable diseases (for example, tuberculosis), the Internet could vastly improve upon present paper-based methods that are fraught with errors and delays.
The Internet could also help public health officials to better integrate available data to improve data analysis and health monitoring. Vertically integrated disease-specific systems that serve traditional public health functions may result in extensive duplication, with a patient’s clinical information residing in several different systems that do not interconnect. The Internet could be a powerful technical tool to realign these programmes and allow better integration of data for monitoring public health.
The use of biological weapons by terrorists could inflict life-threatening illnesses on a large scale and, unlike explosions or chemical releases, could easily escape immediate notice. Days or weeks may go by before symptoms are produced, delaying recognition of a widespread problem. Initial clinical reports, for example, would need to be aggregated at a high enough level for a geographical pattern to emerge and a problem to be detected. The American Centers for Disease Control (CDC) is developing an Internet-based network to facilitate information collection from testing laboratories, and to support interactive collaboration among public health officials and multimedia distance training (CDC 1998).
Already in general use are remote sensing and early warning systems. Telemedicine applications continue to make important progress in overcoming technical and organizational barriers relating to reimbursement, licensure, and demonstrable cost–benefit effects. These limitations are less critical for use in developing regions and for disaster mitigation, the contexts in which they are discussed below.
Remote sensing and early warning
Early warning or early detection systems consist of telemetry between remote sensing or detection devices, and scientists involved with the specific phenomenon, for example, seismologists. The telecommunication component of these applications provides data, usually via dedicated telecommunications systems, making scientists and public health workers aware of the occurrence of a disaster and its parameters, or its potential characteristics. Many communities and countries are putting in place disaster preparedness plans that are supported by remote sensing technologies that go beyond disaster response, to disease prevention and control following disaster.
Remote sensing technologies can help to assess and communicate the areas of damage and the extent of damage. An accurate description of the location, and estimated number of people and types of facilities affected, enable a coherent response and plan for the institution of public health measures. They can also help better distribute resources throughout an area, and help to inform health and medical facilities of the likelihood of epidemics and other adverse public health consequences of a disaster.
Among the growing number of examples is health monitoring and disease forecasting and control by health sector disaster managers. Baseline surveillance data on endemic disease distribution in an area provided by geographic information systems can be used to assess the nature of disease threats to displaced people and enable public health action, such as immunization, to be taken to protect groups at risk. These types of data may also be used to evaluate the evolution of eventual outbreaks or epidemics, and to adapt disease control strategies.
The 1990 Baguio City earthquake in the Philippines provides an example. In the wake of the earthquake, the Philippines Department of Health issued a warning of the potential spread of typhoid fever, diarrhoea, amoebiasis, and cholera that had developed in refugee encampments in the area. By employing public warning systems, health authorities appealed to the public to co-operate with measures designed to check the incidence of these deadly diseases (Scott 1998).
Epidemiologists engaged in vector control and surveillance programmes also use geographic information systems and satellite-based remote sensing technologies. An example that illustrates the complimentarity of space-based communications, global positioning, and remote sensing technologies and other developing technologies, such as geographic information systems, is a project conducted in Chiapas, Mexico, in the early to mid-1990s. A co-operative effort of the Centro de Investigation de Paludismo and several teaching institutions in the United States, this was a model programme that addressed a potential health disaster caused by malaria-carrying mosquitoes (Beck et al. 1997).
With support from NASA, this project developed a landscape approach to using remote sensing and geographic information systems technologies to discriminate between villages at high and low risk for malaria transmission, as defined by the abundance of Anopheles albimanus mosquitoes.
Satellite data for an area in southern Chiapas were digitally processed to generate a map of landscape elements. Geographic information system processes were used to determine the proportion of mapped landscape elements surrounding 40 villages where data had been collected identifying an abundance of Anopheles albimanus mosquitoes. Analysis of the data indicated that rainfall and growth of vegetation could be correlated with malaria vector production, and that changes in these parameters can be monitored and quantified by remote sensors. Thus, changes in mosquito populations could be predicted and malaria controlled by the use of remote sensing images to monitor changes in these key environmental parameters. With data from 1985 and 1987, the programme team successfully demonstrated that remotely sensed spectral data can be used to predict, with an accuracy of 90 per cent, which rice fields would become heavy producers of malaria-carrying mosquitoes 2 months before peak production. Beck et al. (1997) predicted that, if employed on a large scale, this discovery can lead to economical and precisely targeted malaria control programmes. Such a programme is now under way in sub-Saharan Africa where the MARA project is mapping malaria risk by integrating spatial malaria and environmental datasets, and producing maps of the type and severity of malaria transmission (Snow et al. 1996).
Many countries of the world, including many developing countries, currently have a relatively high level of health disaster preparedness. What is frequently missing is information technology infrastructure and specific technical assistance required to implement appropriate applications that will strengthen local and regional services. Access to telecommunications and information technologies that can serve to connect key regional health sector agencies in a preparedness network (Scott 1998) could permit:

support for maintaining effective co-ordination and co-operation between and among national and regional organizations (public as well as private) in the implementation of national disaster management plans

maintenance of current inventories of human, material, and institutional resources in the medical care area

preparation and presentation of national and international workshops and courses on topics ranging from refugee health care and emergency sanitation to administration of health relief and hospital disaster preparedness

preparation and dissemination of technical manuals, audiovisual training material, simulation exercises, and access to epidemiology and other health science articles and databases

‘on-line’ access to short-term services of experts in disasters as they relate to primary health care, health services management, disease surveillance and control, water supply and sanitation, mental health, and nutrition.
Telemedicine
Telemedicine can be defined as the use of telecommunications technologies that provide and support health care when distance separates the participants. At the simplest level of technology, the most commonplace telemedicine application is the 911 emergency call number in the United States. Other applications, such as telesurgery, involve exotic technologies and procedures that are still in the experimental stage. In between are applications that employ telemetry (for example, between ambulance and emergency department personnel), patient monitoring in the home, teleradiology, and consultations involving all manner of voice, image, and video configurations (Institute of Medicine 1996).
Telemedicine consultation frequently brings to mind an image of two-way high-resolution video interaction for clinical consultation. This is perhaps too limiting; a broader conception extends this definition to include applications of telecommunications and information technology for health. For it is health—not just curative relief, but preparedness and population-based public health as well—that will benefit from telemedicine. Furthermore, it is a broad spectrum of applications that ultimately will justify the capital investment and recurrent cost of the infrastructure.
In disaster situations, for example, a variety of applications can be valuable. In the acute phase, there seems to be little use thus far for telemedicine consultations between first responders and colleagues outside the disaster site, where triage is the priority. Once the most acute phase is over, consultation with specialists becomes important when there is time to deal with more complex cases and diagnostic problems. However, implementation of that advice by a local health provider or first responder may require technical support beyond what is available in the field. Conversely, there are numerous positive applications of telemedicine in disaster scenarios (Scott 1997, 1998).
In December 1988, a major earthquake struck the Republic of Armenia, causing widespread destruction and devastation, leaving much of Armenia’s health-care delivery in ruins. NASA, under the auspices of the United States/USSR Joint Working Group on Space Biology and Medicine, developed a link using space-based communications technology to provide medical consultations. The project was named Telemedicine Spacebridge to Armenia. Later that summer, the same communications network was extend to provide assistance to burn victims of a gas explosion in Ufa, in the former USSR.
Remaining in operation for nearly 3 months, the Spacebridge provided an opportunity for 209 patients to be presented to clinicians at several United States medical centres via the satellite-based communications network. During the 12 weeks of the Spacebridge operations, 247 Armenian and Russian and 175 American medical professionals participated in 34 clinical sessions on a variety of clinical disciplines, including rehabilitation medicine, reconstructive surgery, burn management, sanitation and epidemiology, preventive medicine, and post-traumatic stress, among others.
The use of the Spacebridge for medical consultations resulted in 54 altered diagnoses, nearly 26 per cent of the total patient consultations. The participants judged that the format and quality of transmission of video was successful and beneficial. These results suggest that interactive consultation by remote specialists can provide valuable assistance to on-site doctors and favourably influence clinical decisions in the aftermath of major disasters (Nicogossian et al. 1989).
In recent years the American Department of Defense has been engaged in humanitarian initiatives in Somalia, Haiti, Macedonia, Bosnia, and Kosovo. They have deployed INMARSAT and fixed satellite terminals to support emergency telemedicine applications in each case. Interactive telemedicine consultations have been instrumental in saving the lives of soldiers and injured civilians. These ad hoc efforts have helped diagnose infectious disease parasites, and have helped doctors deployed in advance to treat injured military personnel locally, avoiding costly evacuations for treatment of non-life-threatening injury or illness.
In the United States permanent telemedicine systems have been established on a statewide and regional basis. The East Carolina University telemedicine programme, for example, has improved access to care for hundreds of patients in rural areas. Rural doctors can reach medical specialists using secure Web-based links transmitting voice and video, enabling them to make more accurate assessments for patient management. Patient travel time, effort, and expense are also significantly reduced. Emergency care has benefited as well. Swift consultation by emergency doctors can determine the need for trauma team mobilization or air evacuation. By reducing the need for helicopter transport, telemedicine can greatly reduce the cost of emergency care (Harr et al. 1997).
This existing telemedicine infrastructure was put to the test in September 1999 when hurricane Floyd struck North Carolina with torrential rain and flooding. Food, water, and medical supply lines were cut off. The emergency situation was greatly exacerbated by medical and environmental concerns stemming from extensive livestock deaths and damage to sewage treatment plants. The Telemedicine Center at East Carolina University School of Medicine set up four emergency telemedicine systems in area shelters isolated by flood waters and hurricane damage. Airlifting telemedicine equipment into these areas and using military vehicles to move between sites, they were able to set up videophones at each of these makeshift clinics. Upon arrival of the telemedicine teams, three of the four shelters were without phones in their makeshift clinical rooms. Amateur radios were used to work with the emergency operations centre and temporary telephone lines were pulled to establish the telemedicine links.
Within the first day at the clinics, the telemedicine team was able to establish functional telemedicine links and provide crash course training sessions for the already fatigued volunteer clinic staff. The telemedicine links were used immediately. The primary uses were communication between medical staff and triage of chronically ill patients. Over time, the systems were able to help relieve the load on doctors, who are only needed at the sites intermittently, and the links also lightened medical personnel traffic on the helicopters so that they could be used to transport food and supplies (D.C. Balch, personal communication, 1999).
The case for Internet connectivity in Africa
Nowhere has the challenge to effective communications been greater than in Africa. At the beginning of the 1990s, SatelLife’s HealthNET system succeeded in establishing a low Earth orbiting satellite service that enabled health professionals in developing countries, including seven in Africa, to send and receive e-mail. It used a ‘store-and-forward’ sequence that corresponded to the timing and footprint of the satellite’s periodic overflight (Royall 1998). But full Internet connectivity, permitting real-time interactive information exchange was essentially non-existent on the continent, outside of South Africa. Mike Jensen, a chronicler of Internet connectivity in Africa, documents the rapid growth of the Internet in recent years (http://www3.sn.apc.org/). At the end of 1996, only 11 countries had local access, but by 1999 only Congo, Eritrea, and Somalia were still without local services. Estimates place the number of African users at 1.5 million, with two-thirds in South Africa alone, and the remaining one-third allocated among the continent’s nearly 750 million people. On a relative basis, this represents one Internet user for every 1500 people, compared with a world average of one for every 38 people, and a North American and European average of one in every four people.
Internet access in Africa is still confined largely to the capital cities. More widespread access has been constrained by a number of factors: low density of telephone lines and the poor quality of an ageing copper infrastructure, expensive international connections for Internet service providers, and a tight control over the telecommunications and Internet market which frequently remains under monopolistic state control. Rural areas, where the majority of the population lives and research stations are frequently located, have poor access to telephones. Lack of a stable power supply and a lack of personnel able to maintain sophisticated computer and telecommunications equipment compound this (Jensen and Bennett 1999). These factors all combine to create an enormous barrier to the use of modern communication technology for the support of new research and public health control measures that have recently been directed at malaria, a newly re-emergent infectious disease having disastrous consequences for the peoples of sub-Saharan Africa.
The Multilateral Initiative on Malaria in Africa
The malaria crisis
Three million deaths per year (mostly children), one death every 20 s, had a punishing impact on the health and economy of Africa. This is the cost of malaria as a re-emergent infectious disease in Africa. Traditional means of malaria prevention and treatment are failing due to drug resistance, insecticide resistance, and new and dramatically different patterns of disease transmission.
The fundamental goals of the Multilateral Initiative on Malaria
In a landmark conference held in Dakar, Senegal, in January 1997, 125 malaria experts from 35 countries, 50 from 22 African countries, came together to seek means to strengthen and sustain, through collaborative research and training, the capability of malaria-endemic countries in Africa to carry out research to develop or improve tools for malaria control. An essential goal of Multilateral Initiative on Malaria is to enhance the capacity of African scientists to do research in Africa. The Dakar participants identified access to communications and information resources as an essential means to that end. At a minimum these should enable African scientists to communicate electronically with colleagues in Africa and the North, and to access scientific information from libraries, remote databases, and on the Internet (http://niaid.nih.gov/).
Communications as an enabling resource
Investigators in basic research need access to databases and repositories. Access to genetic sequence databases such as GenBank and BLAST (http://ncbi.nlm.nih.gov/) are essential for the complete genome sequencing of malaria parasites that will provide the basis for rational approaches to the design and development of vaccines and new drugs. Similarly, the new Malaria Research and Reference Reagent Resource Center (MR4) will provide access to parasite, vector, and human host reagents and standardized assays using well-characterized renewable reagents (http://www.malaria.mr4.org/).
Developers of new vaccines, drugs, and diagnostics need access to e-mail and discussion groups for product development work, and co-ordination of clinical trials with research colleagues within countries and abroad, and with testing sites in the field (http://www.mimcom.net/ and http://www.malaria.org/).
Published literature is readily identifiable and accessible through computer databases, such as Medline and Biological Abstracts. Electronic versions of printed journal articles are sought, especially where library resources are poor. The newly announced PubMed Central system promises to greatly expand easy and affordable access to full-text journal articles available on the Internet in the future.
Epidemiologists engaged in vector control and surveillance programmes use geographic information systems and satellite-based remote sensing technologies. The multicentred collaborative MARA project is mapping malaria risk in Africa by integrating spatial malaria and environmental datasets, and producing maps of the type and severity of malaria transmission (Snow et al. 1996).
It is highly desirable that collaborating research and control units maintain contact through e-mail and other electronically mediated means of communication that are easily supported over the Internet.
New modes of communication and publication, particularly electronically linked World Wide Web sites, provide a central means for identifying and networking with fellow researchers, and accessing related scientific resources. The Medical Research Council of South Africa’s National Health Knowledge Network (http://www.healthnet.org.za/), and the European Commission-supported SHARED system for knowledge management are two noteworthy examples (http://www.shared.de/).
The Communications Working Group
In the months following the Dakar conference, a Communications Working Group was organized under the leadership of the American National Library of Medicine, a component of the National Institutes of Health, and formally launched in Bethesda, Maryland, in January 1998. The Communications Working Group is a collaborative undertaking seeking to promote cost sharing and partnership. Sustainability of its work is of paramount concern and is predicated on the principle that the cost of communications should be borne as a necessary part of the research enterprise.
The Communications Working Group seeks to enhance communications between African scientists and with colleagues worldwide by creating telecommunications links to the Internet that permit African scientists to participate fully in the work of the international research community. This includes access to the contents of the electronic databases and networks described above. The support of informatics training and knowledge management skills is also essential to develop a library infrastructure for collection development and document delivery. Improved communications will also promote interaction between scientists and communities involved in research and control (Royall et al., in press).
Building new partnerships
Like the Multilateral Initiative on Malaria itself, the Communications Working Group is diverse in membership and collective experience. It brings together African malaria research scientists and control workers; African governmental agencies and academic institutions; and representatives of the major Multilateral Initiative on Malaria research and donor agencies. These include the National Institutes of Health, the Institut Pasteur, the Wellcome Trust, the CDC, the Walter Reed Army Institute of Research, the National Naval Medical Research Institute, the World Health Organization Special Programme for Research and Training in Tropical Diseases and Regional Office with Responsibility for Africa Region, the World Bank, and the United States Agency for International Development. The inclusion of African health information professionals and telecommunications experts in the Communications Working Group helps to inform the malaria research community of the considerable number of technical considerations that must be addressed, while giving the technical community an appreciation for the scientific research needs that will benefit from improved communications. These experts also share prior experiences and lessons learned, as they comprise individuals and organizations that have contributed significantly to earlier communications infrastructure development efforts in Africa.
Methods of operation
Under American National Library of Medicine leadership, the Communications Working Group undertakes on-site assessments and technical consultations at selected malaria research laboratories in Sub-Saharan Africa. Candidate sites are prioritized on the basis of funding availability, and the presence of local leadership and on-site expertise capable of assuming responsibility for supporting initial and sustained infrastructure development efforts. Current and planned malaria research and/or control activities at the site are characterized for the purpose of identifying needed or enhanced communications capabilities. The team assesses the status of local information and communications technology and their Internet service providers, along with specific geographical or other local conditions that could impact on recommended technical solutions for achieving the desired level of Internet connectivity. Detailed technical specifications, budgets, and work plans are developed that address recommended technical solutions which may take the form of wireless links or very small aperture terminal satellite ground stations. The need for local area networks, file servers, and upgraded computer workstations may become part of the site assessment.
More than wires and dishes
The American National Library of Medicine has been fortunate to assemble an expert technical team, and new Multilateral Initiative on Malaria partners, from the international telecommunications community, medical informatics, and library community. Achieving full Internet connectivity at geographically remote malaria research sites is a difficult undertaking in its own right. It also calls for the need to train users in equipment operation and the skills needed to utilize newly accessible electronic information resources, including local and regional library services.
Preliminary plans are underway to put in place and support journal article lending arrangements that are centred in southern, central/eastern, and western Africa, with back-up access to major DOCLINE libraries in the United States and Europe. DOCLINE is an interlibrary loan request routing and order referral system long maintained in the United States by the National Library of Medicine, and recently extended internationally to promote more efficient sharing of medical information worldwide. DOCLINE libraries are committed to serving the medical library resource needs in their country or region, with back-up services provided by other DOCLINE libraries and, ultimately, the National Library of Medicine.
Accomplishments
Malaria Research and Training Center, Bamako, Mali. Direct microwave connection (56 kbps) to the local Internet service provider installed in 1998. Collections of the University of Mali library are undergoing enhancement to support its function as a DOCLINE library for the West Africa region. Partnering institutions include the National Institutes of Health and its National Institute of Allergy and Infectious Diseases, the American National Library of Medicine, the University of Mali, the Mali Ministry of Health, USAID, and the World Bank.
CDC/Kenya Medical Research Institute, Kisian, Kenya. Installed very small aperture terminal groundstation in 1999 linking the research site to a London hub and Internet backbone (64 kbps downlink and 32 kbps uplink) via the Intelsat801 satellite. Registered the Internet domain name (mimcom.net) for Kenya and other Multilateral Initiative on Malaria locations for e-mail addresses. Developed a World Wide Web site. Partner institutions: the National Institutes of Health, the American National Library of Medicine, and the CDC.
Wellcome Trust/Kenya Medical Research Institute, Kilifi, Kenya. Very small aperture terminal installation follows the Kisian arrangement, with shared services provided by the same vendor (Redwing Satellite Solutions). Partner institutions: the National Institutes of Health, the American National Library of Medicine, the Wellcome Trust, and Oxford University.
Walter Reed Army Institute of Research, Nairobi, Kenya. Very small aperture terminal installation in 2000 supports several collaborating and independent research efforts in the region. Partner institutions: the American National Library of Medicine, the Walter Reed Army Institute of Research, the CDC, the Kenya Medical Research Institute, the United States Library of Congress, and the Wellcome Trust.
Navrongo Health Research Center and Noguchi Memorial Institute, Accra, Ghana. Very small aperture terminal installations at both locations completed at the end of 1999. Infrastructure follows the Kenya arrangement, with shared very small aperture terminal services supporting malaria vaccine trials. With these additional locations in place, incoming bandwidth increased to 128 kbps for all sites on the ‘Multilateral Initiative on Malaria.Network’. Partner institutions: the American National Institute of Allergy and Infectious Diseases, the American National Library of Medicine, the American Naval Medical Research Institute (NAMRI), and USAID.
National Institute for Medical Research, Dar-es-Salaam, Ifakara, and Amani, Tanzania. Site assessment plans completed in early 2000. Technical solution calls for a wireless connection (64 kbps) from the Dar headquarters to the local Internet service provider, with very small aperture terminal groundstations at the two remote sites. Model expands on the Kenya arrangement, with shared resources and greater bandwidth allocation consistent with local needs. Installation scheduled in 2000. Partner institutions: the National Institutes of Health and the American National Library of Medicine.
University of Yaounde, Cameroon. Site assessment plans competed for a wireless connection (64 kbps) from the remote malaria research station to the university’s campus-wide fibre-optic network. Partner institutions: the National Institutes of Health and the American National Library of Medicine.
University of Zimbabwe, Harare, Zimbabwe. Facilitated wireless connection (64 kbps) to a very small aperture terminal link at the newly established WHO/AFRO headquarters. Literature holdings of medical library enhanced to support functions of a DOCLINE library for the East Africa region. Partner institutions: the National Institutes of Health, the American National Library of Medicine, and the British Medical Association.
South Africa Medical Research Council, Cape Town, South Africa. Existing DOCLINE services expanded to southern Africa region. Partner institutions: the American National Library of Medicine and medical libraries of South Africa.
Institut Pasteur, Dakar, Senegal. A dedicated leased line (64 kbps) to the Universite Cheikh Anta Diop. Partner institution: the Pasteur Institute, Paris.
Conclusion
As we enter the new millennium, we can be assured that the pace of change in information and communications technology will continue unabated. Changes that formerly took 3 to 5 years are now accomplished in less than half that time. Yet, the evidence of a widening gap between the information ‘haves’ and ‘have-nots’ is clear. Some of this is generational and will be overcome with the natural progression of time and training. A far greater threat lies in income and educational disparities, particularly along the North–South divide.
The communications connectivity work being carried out in the context of the Multilateral Initiative on Malaria is addressing this gap, albeit in a focused mode that limits these efforts to malaria research sites located in a limited number of countries in sub-Saharan Africa. But it is this focus that makes the task possible to finish, and hopefully sustainable. It is also the concept of partnership and a shared vision that shapes the ultimate formula for success. In Kenya, for example, the National Institutes of Health, the National Library of Medicine, the CDC, and the Wellcome Trust have come together in partnership. Each of these organizations separately, and together, has determined that access to the Internet and the World Wide Web is essential to their mission of malaria control and eradication. Moreover, the pooling of financial resources has made it possible to purchase broadband satellite capacity that would not be affordable by any one institution acting alone. The two Kenya Medical Research Institute sites, in Kisian and Kilifi, are sharing bandwidth and responsibility for the underlying communications infrastructure where, formerly, there was very little professional interaction at all. Communication has brought these scientists and health professionals together and very much in keeping with the spirit of that first Multilateral Initiative on Malaria meeting in Dakar.
Partnership and collaboration can make a difference in closing the information access gap, not just in the remote outreaches of Africa but in other locations separated by great distances and the uneven distribution of wealth. Research agencies, donor organizations, and non-government organizations acting in concert can achieve results far greater than each acting independently. This is a lesson that, no doubt, can benefit many other endeavours of importance to the public health community.
Lastly, this chapter has dealt with the specific communication tools that are supporting new directions and applications in the field of public health. The fascination of how it all happens will dim as people preoccupy themselves more with the application itself, and require more from the technology to serve that application. Health care, disaster relief, and the nature of research itself will gradually transform and be transformed by these tools in unimaginable ways. That is the way of all revolutions.
Box 1 Useful Internet websites

http://www.isoc.org/
http://www.medlineplus.gov/
http://www.clinicaltrials.gov/
http://www.hon.ch/
http://www.nlm.nih.gov/
http://www.biosis.org/
http://www.sis.nlm.nih.gov/
http://www.hivinsite.ucsf.edu/
http://tribalconnections.org/
http://www.pubmedcentral.nih.gov/
http://www.reliefweb.int/
http://www3.sn.apc.org/
http://www.niaid.nih.gov/
http://www.malaria.mr4.org/
http://www.mimcom.net/
http://www.malaria.org/
http://healthnet.org.za/
http://www.shared.de/

Chapter References
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CDC (Centers for Disease Control and Prevention) (1998). Strengthening community health protection through technology and training: The Health Alert Network. CDC, Atlanta, Georgia.
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Nicogossian, A., Rayman, R., Sarkissian, A., and Nikogossian, H. (1989). United States/USSR Telemedicine Spacebridge to Armenia and Ufa. National Aeronautics and Space Administration, Washington, DC.
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