THE FUTURE OF HIGHER
(All chapters are intended for continuing revision)
(Update June 16, 2008.
Volume II - Chapter Nine
PLANETARY HEALTH CARE MANAGEMENT
For a first answer to ignorance see vast resources at : <http://www.who.int/en/>. And in health care, as in schools, human society's emerging technologies are going to be able to make health care dramatically better at the top and at the bottom. Health care is essential in the goal of achieving a quality life for everyone on the planet. Health care research and prevention planning must not limit itself to medicine, but to all of the global problems that bring people to hospitals: drug use, auto safety, civil wars, criminal violence, on-the-job accidents, air and water pollution, bad personal habits and more. Concurrently many other issues are involved: the status of women, prostitution, abuse of children, poverty. corruption, public health policy and graft. Micro-insurance should be provided worldwide. Information on many USA issues from Google: <http://www.lib.umich.edu/govdocs/pew8.html>
However it is preventive health care that can best and first be provided for all on the planet, and preventive health care is the way to drastically reduce health care costs. The Economist June 17, 2008 reports how some isolated islands in the South Atlantic Ocean have some of the best medical care in the world, tele-medicine yes, but more important `tele-health.' The local clinic has access to the most advanced medical facilities; for example sending and receiving x-rays and other diagnosis with top doctors via video. In many such clinics now surgery can be performed by robots operated from another country, etc. More important, however, is the ability now for patients to be treated at home. (The Japanese have toilets that regularly examine the stool and this is just the beginning of preventive health technology that can connect everyone from home..
At the top research and effectiveness can be enhanced as a result of global networking and interconnections, bring together all colleges, research and information. Drum Beat, October 28, 2006, reported on the first World Congress on Communication for Development. It was ” held by The World Bank, The Food and Agriculture Organization of the United Nations (FAO), and The Communication Initiative in Rome, Italy. Preparation included regional discussions, For example, see: http://www.comminit.com/la/drum_beat_152.html .on sustainable agriculture and health care. The Drum Beat,April 2 2007 points out how essential it is to solve many problems in Africa concurrently, showing the essential role of nutrition based on local foods as disease prevention.
At both the `top and the bottom, as OECD (2004) reported, new digital delivery technology' can reduce health care costs and increase effectiveness by using it for patient delivery, distant monitoring and consulting, making patient records available anywhere, for digital imaging, tracking diseases, health training and evaluating. The University of Missouri, Columia, Medical School in 2007 announced plans to use tele-medicine to provide "HIV consulting, non-evasive cardiology, podiatry and psychiatric evaluations." Easton (2006) reported that "a one percent reduction in cancer mortality would be worth would be worth about 500 billion dollars" to Americans.
At the bottom, health care can provide a unique, tailored and customized heath care program for each individual, since no diet or medication can work equally for everyone. So ultimately customized diets and customized medications can be provided a a result, of genetic, protein and other large scale research. A drug that can save the life of one person can kill another and that foods are even more complicated. The urgent area for global health care planning should begin with prevention that requires greater surveillance, a shift in financial priorities such as for vaccinations, better coordination of programs for safe drinking water and food and changing conditions in urban shack slums with open ditch sewers and so forth.
For successful programs and solutions of many health
problems in the developing world and poverty areas see: <http://www.comminit.com/drum_beat_305.html>.
For a glimpse at the digital future see plans for the health portal <http://www.manyone.com/tomorrow/casestudy/healthportal.html>
Also see: <http://www.cdc.gov. And
THINK BIG! Now is the time to develop long range plans and begin to put in place what must be accomplished in this 21st century: a global vision of health care for everyone on the planet beginning with preventive health care. Much is already done on how to use the Internet to accomplish that objective. It is closely related to accomplishing better education for all, and thus better income, for everyone on the planet...as a century long goal.. Many people, old and young, cannot learn well because of untreated illness, malaria, TB, diarrhea and much more. According to the MIT Technology Review, 336,000 people die every day from diseases caused by contaminated water. Solutions are available. In 2007, for example, 17 communities on both sides of the Jordan River--much of what had become a sewage ditch because most of the water was being used upstream--are cooperating in recycling water and using it, and collected rainwater for such needs as flushing toilets.
Maybe even before the 22nd Century, and automated medical technology is online it will be possible for a surgeon, for example, to try a procedure on a patient's virtual body to see how it will work. Some body organs are of such a virtual body are already created in New Zealand and physicians around the world are in 2004 working on the digital body project.
In Africa education erodes
as so many teachers are dying of HIV/AIDS. In Ivory Coast,
"AIDS has been responsible for 70 percent of the deaths among
teachers." (Rischard 2002) It is projected that 40 million children
will be orphaned by AIDS. A global health action policy (Lee et al 2002)
must strengthen infrastructure for the entire planet and especially
address health problems across national border. Yet providing clean water
for all would do more to prevent disease than high technology. The USA
Institute of Medicine (2003) warned of much worse to come, a global
"microbial storm." New epidemics like SARS show that everyone in
the world at serious risk. A " new influenza pandemic in humans is
inevitable" and human society is unprepared for it! Also the
solution also will require new research on how to deal with many
inter-related problems, such as the
international narcotics system and teenage sex. Solutions to these and
other crucial health problems is going to require "interdisciplinary
and international teamwork in research and practice. New systems of
prevention-based health care delivery need to be invented for the whole
world. Yet much more can now be done. The 2005 world summit in Tunis did
not find much money for the infrastructure. The first $1 million
is committed to bringing high-speed Internet access to some AIDS clinics
in Burundi and Burkina Faso. "Satellite and other communications
equipment will go to nine cities in the African nations, and an emerging
wireless technology called WiMax will extend access to more remote
sites. The clinics are getting videoconferencing units, with serial ports
Of course, can humanity have adequate `education for all' and 'jobs for all' unless there also is adequate health care for all? Health care access--such as through tele-medicine--should probably be part of every neighborhood learning center (See: <http://www.scientists4pr.org> This would require `barefoot doctors and nurses, paraprofessionals who are resident in impoverished neighborhoods with electronic connections to whatever they need.. When one Asian government proposed to establish a `barefoot medical school" to provide training to midwives and other `amateurs' who were providing the only care available, the national government would not allow it. National pride required that all medical care had to meet the highest international standards, even if it meant providing none for most impoverished rural people. However, many such governments do not hesitate to fund rural schools with teachers who have only an eighth grade education. (The May 5, 2002 New Scientist reported on `barefoot schools' in India that train illiterates to become `barefoot professionals' who can provide most needed services in their neighborhoods. A web search for `barefoot doctors' leads to descriptions of their work in China and Latin America, for example to a samizdat: <http://peaceworld.freeservers.com/270AMA.htm>. `Barefoot teachers'--connected to automated tutoring (3.9) and other resources may be an affordable first step towards health `education for all.'
A telling fable was about Louis Pasteur coming back to see what progress was being made in bringing adequate health care to everyone in the world. He was told: "Thanks to vaccination that you developed we have totally eliminated small pox and we could now also eliminate other major childhood diseases...for every child in the world!" Easterling (2003) has proposed, for example, the `Colorado Healthy Communties" project as a model to begin with. Relman (2003) called for "a universal non-profit insurance system." The `ghost' of Pasteur noted the deaths of a hundred million children in the last decades, deaths from causes that could have easily been prevented, and asked; "Then why don't you do it?" One reason it does not yet happen is ignorance--of politicians, of the public, even of those deprived of health care--and this points to the need for better global-scale education. Bill Gates of Microsoft, in a perceptive interview by Bill Moyers on PBS-TV, Friday May 9, 2003, asked a fundamental moral and ethical question: Why does a plane accident that kills a few people make news when the easily-preventable death of a million children each year because of malaria is rarely even mentioned. Capitalism and the market system, Gates said--neglecting the diseases like HIV-AIDS that are killing millions--, is miserably failing the poorest of the world's poor.
One answer, perhaps, could be the WHO's "Health Academy.' <http://www.itu.int/newsroom/press_releases/2003/34.html> that in 2003 was planning along with the ITU "to harness ICTs to deliver vital health care information to impoverished areas of the world," using community tele-centers for training centers in 47 countries. Sterling (2004) insisted that a networked strategy--illustrated by the World Health Organization's "Global Outbreak Alert and Response Network.'-- can defeat epidemics - if the world will let it.". Required will be "common data standards and rapid sharing of problems, information and solutions." One cannot even list all th initiatives and ideas; for example Foster (2004) reports on a video game to facilitate local community heath care planning. And WorldVista, as of January 2004, was preparing an open software, public domain, financially feasible international hospital system <http://www.worldvista.org/> that can be a major step towards using the Internet and Information Technology to providing health care for everyone on the planet
This chapter, not for health care experts, asks questions of people in other fields, politicians and the public. Could larger-scale research and coordination find ways to provide preventive health care for everyone in the world, especially using demonstrations to motivate the political will? A step ahead in this process was taken at the `World Summit on the Information Society' in December 2003. Eleven thousand people from most countries were involved in defining the objective of "connecting all villages on the planet" and "bringing ICT's to all schools, universities, hospitals, research centers etc." Note also the increasing need for mental health care. Mickelberg 2006)
Can even a discussion of larger-scale research initiate a more holistic approach, involving scientists beyond the medical field in finding ways to provide health care and health education to all the world's children? A holistic view of human problems challenges existing health care systems that, for the most part, are still disease oriented, and not much to preventive health of people and of the planet itself; human health for example requires improved air quality, safe water and food quality. Unfortunately, a leading researcher points out, "medical schools are resistant" to the revolution that is coming; for example, "predictive medicine" and trans-disciplinary research that require connections that academics have as yet been unwilling to tap. (Hood 2001) Discussing tele-medicine in Asia, Rao (1999) also called for a "multi-disciplinary approach" that "brings to the table" a wide variety of professions and technologies.
For example, Jonietz (2004) pointed out how boundaries are disappearing between such research fields as bioinformatics, brain-computer interfaces, electronic health care, synthetic biology, and ultra-sensitive diagnostics. The whole medical process can become more mobile with `at home diagnostic tests as researchers learn to `think big, to personalize treatments and prevent epidemics before they happen. Crucial in this effort is safe drinking water, and sophisticated technology in the Netherlands to prevent flooding has, as a by-product an effective system to keep water clean (van den B rink 2005) by using "environmentally friendly techniques" including ultraviolet light. Also much safer foods are being developed that will actually prevent some diseases.
The urgency of a comprehensive global health plan and system is seen in the way dangerously worrisome new diseases are related to human activity such as air travel, huge slum cities, factory farming, abuse of the environment, ignorance, blood banks and so forth. So a long term health strategy must move beyond medical research to include "modernizing the world's factory farms," safe approaches to land use and wilderness preservation, coordinated communications and more. (Cowley 2003). Human society cannot long survive half sick and half well--when new plagues like new forms of tuberculosis threaten from poverty areas--and in a time when the health of every human being on our globalized and inter-related planet is affected by disease anywhere and is related to the ecological and economic health of our ecologically angry planet. Researchers have been creating the preliminary blueprints for a preventive health care system to save the lives of a billion people in the next decades. "There is no evidence from any country that systematic approaches to improving care have been successfully implemented." (Marshall 2002) Improving the health of communities has been neglected. (Pollak 2000) Safeguards against the outbreak of epidemics are in a dismal state. (Garrett 2000) Much ill health can be attributed to environmental factors. (Smith 2001).The Drum Beat, June 2008 discusses the health needs of those least served by existing programs, including survivors of gender-based violence, refugees, sexual minorities, indigenous women, adolescents and young girls, and women who have been trafficked. http://www.comminit.com/en/node/271375. Economies to make a planetary health system possible can in part be accomplished by an electronic global system that keeps all records online. <http://www.mercksource.com>'.This technology alone could go far to reduce health care costs. would save lives by having a patient's medical records available anywhere as needed. Mashberg ( 2006) reported on the `medical grid,' consisting of "vast interconnected databases of information" to become "a world wide web of cancer research. It will :aggregate and correlate cases from around the world".
Of course, facilitating global-scale research, as scientists all over the world increasingly cooperate on line, could rapidly improve therapies and progress in biomedicine. (Lok 2004) Perhaps a planetary health system might include the use of satellite photos of every neighborhood in the world to note flooding and other such factors that impact health and which can use color to identify geographic factors to which can be added layers of health care and and all other relevant data from census and other sources. Detailed photos might be part of a warning system about dangerous new diseases, what is available in an endangered neighborhood and what is immediately needed. Every neighborhood school and lifelong adult learning center might be a partner in this; with at least a medical paraprofessional--often of the `barefoot' type-- with tele-medicine connections. For, "between the health care we have, and what humanity could have lies not just gap, but a chasm." (NIM 2001) To provide everyone on the planet with health care that is "safe, effective, patient-centered, timely, efficient and equitable" there must be a monitoring and tracking system and efficient use of information technology, which has begun in much of the world. Technology can make available 'global expertise and data bases, and more health care will be provided remotely." (Dargie 2000) There can soon be a complete medical diagnosis lab on a single computer chip, Futurist, July 2003)
Peck (2005), on the basis of present research, forecasts a `Health Care Avatar' for each individual that can provide access to all that is known about a person and all medical knowledge relevant to that person "that can be a coach, educator and health manager," benefiting each individual as well as society.
The United Nations World Health Organization (WHO) developed plans for to learn about and track the spread of epidemics and diseases. With better funding it could complete the infrastructure in cyberspace to make prompt action possible in any health crisis. That consists of an international network of scientists, medical research institutes and laboratories that now need to be linked to every neighborhood, now possible using the Internet. In Africa and many other areas of the developing world, this strategy requires "capacity building." That means equipping all medical schools, scientists and medical personnel as competent participants in a global research and health care management system. All must have access to those who are able to identify a new virus as well as older diseases. Even in the United States a geologist died in hands of medical school professors who did not soon enough recognize the bubonic plague. A quick monitoring and report system is essential in a time of international travel when diseases can quickly move from one country to another. Scientists from the National Institutes of Health, the WHO and other agencies must quickly go to where some medical danger is reported. They go to help local scientists.
When Gro Harlem Gruntland, former Prime Minister of Norway, became head of the WHO, many researchers worldwide hoped to strengthen the emerging global medical tracking and research systems. The emerging international network of medical research institutions and scientists, the planned architecture of research on diseases in cyberspace is impressive and and its demonstrations have been most effective. Where, however, is the political strategy to bring at least minimum health care to everyone in the world? To the health of planet itself? Rose (2007) and Barr (2007) both point to the politics.
Harold Sackman (1997) in his book Biomedical Information Technology: Global Social Responsibilities for the litidcsemocratic Age proposed bringing all medical research together in a holistic system. He would also integrate "biological, biomedical, ecology and planetary sciences and the full spectrum of social sciences." Such a research scheme would move beyond and greatly enlarge existing scattered research projects to move into "participative information system design and development." He proposed a "rigorous system-wide testing, evaluation and quality control throughout the entire life cycle of health care information systems." This would include all doctor's records, all patient records, all insurance and health plan records and all research records when it is seen how useful all such records can be for research and treatment. (Mickelberg 2006). Comparisons can be made and research done without knowing the real names of patients.
Sackman paid special attention to larger social implications of the "national and international treasury of biomedical information related to the U.S. National Library of Medicine." It is available online interactively and includes medical imaging, low-cost computer-based systems for hearing-and-visually disabled people, computer-aided biomedical research and more `big science' on the scale of the Human Genome Project. However, he said, all this must be seen and used in a larger social context; for example illnesses caused by industrial, agricultural and auto emissions pollution, drugs, needless accidents and more. He suggested bringing together all the related problems of human culture, pointing out for example that `health care for all' is not primarily a medical matter. It involves ethics (2.14.1) and politics (2.15.1) He worried about the `medical-industrial complex' much as Eisenhower warned against the `military-industrial-complex.' Today, the medical complex is three times as large as the military complex and is increasingly oriented to corporate profits rather than to providing health care to all the world's ill people..
It is ironic--and immoral--that human society tries to provide health care through "an unhealthy system" with a great deal of graft, callousness and neglect. Are researchers ignoring other moral issues? One problem is the high percentage of hospital beds occupied by people whose health problem is caused by crime, by tobacco, alcohol or drug abuse, bad eating habits, lack of adequate exercise, etc. Some auto insurance companies give better rates to safe drivers. Is there research to find out if something like that could also be done to make health insurance more equitable and cost-effective? Sackman asked--in the context of health care--why humanity does not have adequate "computer-managed, court-monitored rehabilitation programs for alcoholic and drug-related crime" and "management systems for environmental pollution control."
In a global society without health care for all, the weakness of half the world is a drag on the global economy and imperils
the health all people. Fortunately this situation need not continue if more support is
provided to hardworking researchers worldwide. The WHO has data on the full extent of the problem and large plans--if not yet the public and political support--for providing health care to all. Research on treatment of disease and other kinds of patient care continues to be the crown of the medical care system. How to accomplish
global health care is a larger-scale issue in which medical researchers must join with those in many other
fields. Truly holistic research can take account of the health of a nation, a planet, as well as an
individual. Now is the time to begin research on a comprehensive blueprint for a global health care system in cyberspace.
Drum Beat, in May 2006 reported that almost eleven
Among the critical issues surrounding child mortality is the need for research to focus on "how to get appropriate interventions to the people who need them." Knowing how health systems function is key to understanding how to reform them by integrating low-cost interventions such as vaccines, vitamin supplements, and insecticide-treated bednets. For example, informed by research that stressed the importance of focusing on local diseases, Tanzania's Essential Health Interventions Project (TEHIP) led to a 54% reduction in infant deaths in the 2 districts and a 47% drop in under-5 mortality after 5 years.
This WHO/UNICEF endeavour aims to expand the reach of immunization and to develop new vaccines between 2006 and 2015. The GIVS strategic framework on immunizations presents a range of strategies (24 in total; divided into 4 thematic areas) from which countries are invited to select those most suited to their needs. Key themes are global partnership and the power of information and communication technologies (ICTs) and the mass media to spread vaccine-related information and to correct misconceptions.
Uganda was in 2003 developing wireless connections to rural communities for health care. The crucial health care need, of course, is local. (See. 2.9.3) "The structure of the health care system should shift towards rewarding doctors and health plans that that treat patients with their long-term health needs and rewarding patients who make sensible decisions about maintaining their own health." (Clinton 2004)
In a three-volume report on the global burden of disease and global health statistics (Lopez 1996) of the WHO reported that public health policy formation "desperately needs independent, objective information on the magnitude of health problems and their likely trends, based on standard units of measurement." Much of this information, however, still seems to be piecemeal. Hood (200), however, reminds those who fund science that many of the most important findings have resulted from unpromising `fishing expeditions,' often by individuals.
While data bases on medical research have not had enough to report on how to provide health care worldwide, they are probably more adequate than are those on any of the other global crises we are discussing. The U.S. National Library of Medicine has already been "a remarkable global institution, not only for our generation, but for posterity as well," Sackman said. It has been developing--and making available on the Internet--an Information Resources Map, a data base with software that will quickly find the right sources in reply to a specific query for clinical practice or for research. The response to a query can, for example, call up image databases from the Quick Medical Reference (CAMDAT corporation) and from the Visible Human Project. (2.9.4). The latter developed "factual databases concerned with genetics, protein and nucleic acid sequences, drugs, toxology and environmental health" (NLM 1996). Such research resources and services available online in one country can be interlinked and made available worldwide. So the needed system in cyberspace is coming into existence
Whole new vistas in medical research are expected from nano studies, with implications for monitoring the environment for dangerous chemicals, creating new treatments for diabetes, medical imagery and more..
Still, as Altensetter wrote in 1997, there is a great imbalance between the amount of data available and the ability to use it. Researchers already see signs that tomorrow's health problems are going to be different. More cross-indexed data will be needed on many emerging problems, such as new viruses, disease carrying insects that are moving north, bad health resulting from unexpected pollution and contamination, on mental illness and more. Such data bases--on a global scale--are crucial for "an evidence-based enlarged research strategy." There have been calls for an International Registry of healing. It would be a data bank containing information about any so-called incurable disease. It would include reports on the results of all efforts at cure, conventional or unconventional. Beyond that, will it require a world global system (2.1) to bring together all of the kinds of data necessary for a comprehensive global preventive health system? There is controversy over research priorities--there never is enough money for cancer and even less for developing world diseases--in the allocating of research funds. Could much more be done with available resources through a better coordinated research strategy?
A Web page "Medical Informatics in Developing Countries" has linked efforts in many African countries to deploy health information, including a series of working conferences on telematics in African health care. Telematics means a "marriage between telecommunications and audiovisual technologies," including high definition TV and computer networks. African universities also increasingly view such technologies as essential for research, information access and distance education in health care. Thus, interconnecting data bases on every continent can be a step toward a global health care research strategy and planetary health care management system in every neighborhood in all countries...since all are inter-related when it comes to health.
Jonietz (2003) has reported on the slow use of computerized medical records "that could have the power to transform health care." As computer systems develop more speed, power, and capacity, messy and hard to track record keeping can be replaced with a global system that can provide better support support and decision systems for physicians; can better enlist patient cooperation in preventive health and their own care; and can "provide access to patient data anytime, anywhere." That can reduce dangerous errors and speed up the delivery of care worldwide. There is, as with present medical record systems, some danger to privacy However (Farmer et al 2003) the possibility of comparing, inter-linking and researching the information in a global database--called `World Wide Med'--that makes every patient's complete medical history instantly available to doctors and researchers through the Internet will have potential benefits for the health of all humankind that far outweigh the privacy dangers. Clinton (2004) points to the efficiency, money saving and excellence that can come into health care once every person has a comprehensive and complete medical record to use in preventive health care.
The 1998 Internet Society Summit reported health organization efforts to reach out to underserved populations and the increasing use of computer networks for worldwide research. How, it was asked, can the Internet best be used to monitor, promote and protect health? Members of the Science Panel on Interactive Communications and Health of the United States Department of Health and Human Services planned for a session at the Summit to show the importance of an evidence-based approach to interactive health communication to ensure quality and reduce harm. A large-scale research strategy might help facilitate plans for a comprehensive international monitoring network to link networks on infectious and parasitic disease, sexually transmitted diseases, disease caused by environmental factors, and many others. Note that USAid's Global Health E-Learning Center offers courses recommended for Africa, etc., at: <http://www.globalhealthlearning.org>.
The health care field seems to do more global networking than takes place in other crisis areas. In Africa, for example, as early as 1996 there was a `network of networks' meeting in Zimbabwe, the creation in Uganda of the third African essential health network, and the beginnings of an electronic conference for AFRONETS (the African Networks for Health Research.) Such efforts aim to save scarce financial resources by avoiding duplication. They seek to facilitate the exchange of information among health research networks in Africa, to maintain a joint database on the World Wide Web and they hope to "get recommendations transformed into action."
The Health and Human Relations and Resources Analysis for Africa Project (HHRAA) has sought to enlarge the use of the many connections and links among programs for child survival, family planning, for dealing with tropical diseases, and HIV/Aids education. It has sought to provide case studies country--by-country on research priorities, the equity and sustainability of health financing and many other issues including how to restructure health care.
The SDNP (Sustainable Development Networking Project) of United Nations Development has provided financial aid for appropriate technology for African networking that abides by partnership principles. These include involving all sectors of society, and avoiding duplication of efforts. Computer Networking is speeding up progress toward the international goals set by the World Summit for Children, the WHO and other United Nations health care efforts. The "Planning Network for Health Research"--to further a strategy to provide health care for everyone in the world--is a project of WHO's Advisory Committee on Health Research. The network is mandated to provide advice on global research priorities, to take a prominent part in the harmonization of research efforts on the national, regional and interregional levels, and to encourage an effective global synthesis. Its revised strategy (1997) was already clearly transdisciplinary, focusing on environmental and economic factors that affect health, human development, ethical issues, global problems and global solutions. Its creative online search for ideas involved the setting of goals similar to the now already achieved total elimination of small pox, with dates for their accomplishment; and other ideas for a more comprehensive health research planning process.
The International Health Futures Network was founded in 1991 and within a few years had members in forty countries. It has given thought to such topics as future threats to health, vision workshops, the alternative scenarios of the Committee on Future Health of the government of the Netherlands, to Japanese `bioforecasting' technology, to health care assessment in Indonesia and Nicaragua and to a WHO consultation on health futures (Garrett 1995). The Global Health Network, one of many, was established to interconnect all public health workers worldwide for disease monitoring and data collecting, for data organization and information distribution and to develop a Global Health University project.
Developing the political vision and new ideas on how to provide health care and health education for all may take place on the Internet, as researchers on five continents ask if all research projects and networks can be linked in one management system. Where else can many developing world researchers best meet regularly to help prepare preliminary blueprints for a global health care system in the cyberspace age? Providing health care for everyone worldwide may seem impossible at the moment but isn't now the time to involve many more people and disciplines in a search for ways to accomplish it? Silicon valley mentor John Doerr (Lewis 1998) has spoken of the impossible great ideas that are being realized these days. What are the implications for global health care management of Doerr's view that the Internet is like the big bang at the beginning of our universe. It is giving birth to a new universe of possibilities and great ideas. He suggested that it is going to affect and possibly transform every part of society.
Pulido (2003) described developments in Latin America that found it difficult to keep up with changes in medical knowledge every 3 to 5 years through printed materials and video aids. There has been a drastic increase in demand for for health care instruction, not just for physicians, but also for dentists, pharmacists, nurses --over 300,000 in Venezuela alone-- and para-professionals and other health workers where physicians are not available. So first using the Internet, and then as possible Direct-TV, interactive health care instruction and question-answering is increasingly being made available through the initiative of the Pan-American Federation of Schools of Medicine and other such organizations. Such quality instruction can in time be made available in many languages and native dialects, making care possible for the less privileged as never before in various forms such as CD-Rom also.
One such `impossibly great idea' which is beginning to take shape is tele-medicine. The WHO has a plan to use telecommunications and networks to bring health care to everyone in the world. Mega-scale research is needed, however, to find how politically--through demonstrations--and financially to get it accomplished, to begin doing what is now technologically possible. Can researchers find ways to streamline a global health care system for more economy, efficiency and quality that will include tele-medicine for all who otherwise have no access to health care and for specialized consultation in rural areas? See: <http://www.thehindubusinessline.com/2004/09/26/stories/2004092601980300.htm>. on tele-medicine in rural India. Also (2.17)
A global tele-medicine system is coming into existence. In 2001 a surgeon in Argentina performed\ surgery on a patient thousands of miles away; and Imarsat, for instance, has used a global communications satellite network to provide "a cost-effective means of delivering health care to remote villages, settlements and camps" and to people aboard ships and aircraft. Tele-medicine, via satellite, can already enable doctors or paramedics to consult quickly with far distant specialists without the cost and risk of transporting ill or injured patients over long distances and rough terrain. Since the turn of the century information technology in Africa, is more and more connecting African universities for research and heath care itself. As of te spring of 2005. for example, a physician in America could send cat scan date instantly to Israel or India for analysis.
A global system could, for example, connect a nurse-practitioner in every rural neighborhood with a distant hospital, with specialists who can help in diagnosis and treatment. It is now done with television in many rural areas and is crucially important for rural and poverty areas where no doctor or clinic is within easy reach. For a start, 80-85% of medical patients in the developing world have minor injuries and needs that can be cared for by para-professional medical personnel with only eight to ten months of training. Some doctors and dentists--who spend vacation time in poverty areas where such services are not available--now look for local `barefoot' para-professionals who with some limited training and help can provide some emergency care. A tele-medicine system, such as the confecting of hospitals in Mexico with the University of Texas medical school, can also in time become two-way research projects. Whatever the ultimate standards for high quality professional health care may ultimately be, a vast population has almost no medical care . Two-way tele-medicine is not only a topic for more research but can help research. It can be used to gather case study experience from around the world and to enlist the participation of researchers in developing countries in improving the quality of what they do. Today they--and any layperson--can find `self-help medical information' on the Internet, including ways to treat many diseases. In the future anyone nay be able to ask questions of expert physicians online.
Much as a new style electronic `rural agricultural extension office' has been connected to a university agricultural school, a tele-medicine center or clinic can be connected to a university medical school. Texas Tech's medical school, for example, has been providing service for rural Texas counties where there is no physician. The mobile communications network of Japan set up a system to bring cancer treatment to isolated children in Siberia. That system used experimental mobile wireless units ("low budget high tech") to send data to distant doctors for analysis. The feasibility of global tele-medicine was also seen when USA army physicians used high-speed data systems, digital cameras and computers for medical emergencies in Croatia. New Zealand medical personnel in Bosnia have used an Internet link to Auckland to check medical databases, to get advice for specific treatments, and to communicate with medical specialists about care. Tele-medicine was used to aid earthquake victims in Armenia and to treat victims of the Chernobyl nuclear disaster from a distance. They had medical checkups and treatment from experts in Japan. There have also been successful demonstrations of robotic surgery from a distance. Expanding such demonstrations of possibility require funding and staffing which will not become available until humanity sees the health of all the world's children as one of its highest priorities.
By 1997 researchers could already hand-carry an `Imarsat Mobile Earth Station' to remote areas that lacked adequate telecommunications Small terminals could either be mounted on a vehicle or carried in a briefcase weighing about four kilograms. The more expensive Imarsat-A terminal supported high-quality telephone and fax for high-speed data transmission and could send or receive information as simply as dialing a telephone number.
Medical engineering researchers have also been working on a mobile clinic, with satellite connections, and on home health stations to connect to hospitals and physicians. A New York medical school hospital has for some years electronically monitored the home care for convalescents after their release. Mentally ill patients at home have been provided with a support system that can both monitor them and enable them to take care of themselves at home. Multimedia Internet (Jones 1995) and other new technologies could thus bring a vast realm of such new services--including customized treatment and management of chronic disease--into the home. Sackman (1997) described effective house visits by this method.
Researchers now see how it can be possible to bring health care and health education to everyone worldwide, so what scale of research is needed to motivate the political will to create and fund the system? All existing tele-medicine experimentation and experience are being brought together, but tele-medicine is only a first stone in the foundation of what needs to be built in cyberspace. Existing infrastructure systems are poorly adapted to the doctors, nurses and other human beings involved in health care. Research is needed for tele-medicine blueprints in a global cyberspace system. To make tele-medicine successful worldwide, research is needed to link existing systems for smooth and predictable operation together. More research is needed on issues such as fees, licensing, liability and privacy in a tele-medicine system. (Tele 1996) There must be research on goals and objectives, ethical problems, quality evaluation, issues like abortion and preventive health. Research might propose insurance plans that give special benefits or cost reduction to people who follow preventive care instructions (exercise and diet). Universities can in other ways also move beyond scattered and piecemeal research. Meanwhile the emerging improvised system may make possible affordable costs in the developing world and may resolve many barriers to providing worldwide health care. On healthcare for women: <http://www.engenderhealth.org/> On health care videos via streaming see: <http://healthlibrary.stanford.edu/resources/videos.html>.
Several international consortia were in the late 1900's working with the WHO in research on, and the development of, a global health care infrastructure. They include: the Koop Foundation, the Global Infrastructure Commission, the Pan American Health Organization and the IEEE's Medical Technology Policy Committee. The `Leland Initiative' has had plans to extend the Internet to many of the poorest countries in Africa, thus opening doors for tele-medicine. That initiative initially was a partnership between the NASA space agency, USAid, the US Office of Communications and Information Policy, the USA Telecommunications Training Institute and international private sector partners. It was established to honor a member of congress from Texas who died on a humanitarian visit to Africa. .
At the 1995 inauguration of that program, Vice President Gore said: "Its real purpose is to help people improve their own lives." The connecting of schools, research institutions and hospitals with the Internet, Gore said, will mean "that a rural health worker in Ghana can communicate test results with a research lab in another country." Computer models of an ideal global health care system could simulate such a system to anticipate possible `bugs' and problems.
We can here only mention the potential significance of greatly enlarged computer modeling for medical research, visualization and planetary system-building. Perhaps only mega-research can anticipate and propose how to construct system in cyberspace to bring together many existing and future models. As was seen in the Visible Human Project--at the University of Colorado Health Sciences Center which used Virtual Reality to enable a researcher to examine anatomical detail in three dimensions--many possibilities lie ahead on projects which like that at the Center for Human Simulation can begin to facilitate collaboration among computer scientists, educators, bioengineers, anatomists and others worldwide. A major goal of the Center is to develop interactions with computerized anatomy in virtual space, modeling pathological as well as normal changes in the human body. The enlargement of the Virtual Human database--to add more information continually--will also involve mathematicians, anthropologists, practicing physicians, dentists, physical therapists. Such tools can also then be continually updated. At the heart of the development is a new profession: the `anatomist/computer imaging specialist.'. This anatomy project, researchers at the University of Colorado hs said, is analogous to flight simulation enabling one to participate often and repeatedly in rare and emergency procedures (CHS 1996) and many current web pages.
Again, such research on many new ideas is only beginning. Mega-research can model entire disease systems. It can model the enlargement of the global network of collaborating laboratories to create an effective global surveillance system for early detection of viruses and infections. Simulations can examine the idea of a network to coordinate medical research with social, political and financial issues. Health care cannot be separated from political priorities since much sickness results from malnutrition, dirty water and toxic wastes. Efforts to vaccinate all the world's children and to totally eliminate some diseases have been limited by politics.
So computer simulations can help politicians--as well as medical ethicists and scientists--visualize the nature of a crisis and what might be done about it. A planetary health care management research strategy needs "a way to map quality" of care as well as quantity (Fishback 1997). Although modeling and simulation receive widespread attention from the research community, (Kortwright 1997) there is concern that these efforts are not directed towards solving the most significant and practical problems. There is need here, as in all research, "to revise basic principles, to identify the fundamental problems and emphasize those most urgent, and to set clear directions for research." This will require the collaboration of many researchers worldwide. To prepare for a global plague every emergency room in the would should be able automatically send out a warning and receive information about what to do.
Designing a larger research strategy is likely to be the job of one or more international co-laboratories that assume the task, moving beyond the limitations of shoestring systems. Existing co-labs were illustrated by a 1997 global Internet colloquium for medical research, based at Yale Medical School. Underwritten by UNESCO, Sprint, the WHO and the Lounsbery Foundation, it was in part an experiment in using multimedia technology. Its purpose was online research collaboration on emerging infectious diseases. Background research papers and software could be downloaded from the Internet. Yale researchers were available to answer questions. Special efforts were made to accommodate participants whose language was not English. This project was proposed as a model for `Grand Rounds'--across biomedical and public health fields--where leading universities would each take responsibility for designing one such global research discussion on one or another specialty.
The planners of this project had in mind some future ways to build support for an international research community that would "give everybody a common cognitive map." This colloquium began with about 3,500 researchers in 110 countries, Its numbers continued to grow, in part because current information technology kept the cost for participants down to an unexpectedly low level. One evaluator of the seminar, the Director of the International Scientific Network Project, called it an important step in an international revolution in the organization and conduct of scientific research. Should such projects move beyond medical schools alone? Research adequate to enable global scale health care must be transdisciplinary, mobilizing collective intelligence in political and other fields? In 2005 `bird flu' activists and researches were online together all over the planet.
When Turoff and Hiltz (1997) early looked for successful uses of computer empowered collective intelligence, they found that the processes used were not adequately described in many experiments. One exception was "in the medical field" where they found well-documented descriptions of the way collaborative judgments about complex issues were formulated; for example, in the production of guidelines on medical practice and decision-making used by Viral Hepatitis researchers in preparing guidelines for physicians. The medical researchers had to review five thousand or so documents and reach a complete consensus on what to propose.
Marien (1998), reviewing some research on health systems and policy, found public health defined as "the collective action taken by society to protect and promote the health of entire populations," where clinical medicine deals with individuals. Both, he reported, were failing to fulfill their potential to improve the public's health. Both focused too narrowly on disease. Strong leadership is needed to refocus their efforts on global issues, "policy linkages and a broad perspective of foundations for health." Reforming the existing system will be a formidable task. Co-laboratories that undertake it must involve the developing world where the most serious problems are, illness complicated by malnutrition and poverty that eventually will have serious consequences for the health of the rest of the world. Increasingly important, as suggested by Goetz (2003), will be the use of Open Source software development as illustrated, for example, by a team-developed inexpensive IV system for cholera victims
Only 5 percent of global health research expenditures
have been used for the developing countries that provide up to 95 percent of medical problems, according to the Commission on Health Research for Development. Larger-scale research is necessary on how best to use limited resources; and that research
"must be context-specific." Cultural issues are involved, for example, on how to bring
tele-medicine and modern medical technologies into developing world cultures without seriously disrupting traditional health care support structures; also when researchers investigate all kinds of plants which may help provide needed medicines. Such research in and with the developing world may become so wide in scope, the data created so large, that it can be
managed only with computerized mega-systems. (MacBride 1997).See:
was established to be a nonprofit organization to use satellite, telephone and radio in the developing world. Its experience
showed how to make research partnerships possible in areas of the world where access has been limited because of poor communications and poverty. It
has sought to improve communication and the exchange of information in areas of public health, medicine and the environment. It has
had connections to many kinds of networks related to particular diseases and
to various regions of the world. Such projects begin the process of technological development to make it possible for developing world researchers to participate actively in the research for and the development of health care for all. <http://www.aed.org/health.html>
More and continuing attention must be given to assisting medical and nursing schools in the developng world--and perhaps everywhere--in finding ways to train and assist midwives and others who provide health care where hospitals and physicians are not available. German medical students have taken videotapes to show to midwives and pregnant women, and perhaps computer and video games can provide automated instruction in which nursing students learn and rehearse emergency procedures.
Now that the technology exists to provide health care for everyone in the world, we propose that livelong education for all via the Internet may be the key to providing political leaders and the public with the vision and political plans to make it a high priority. So far, presenting the need and the facts to a limited audience has not been enough, although success in eliminating smallpox aroused limited enthusiasm. The United Nations World Children's Fund reported in 1995 that over nine million children under five years of age die each year from causes that could be easily and cheaply prevented. Research in preparation for the 1995 Copenhagen International Summit on Social Development found that millions more will each year be physically or mentally disabled from lack of care that could now be affordably provided.
Presenting a great, imaginative vision of global health education and health care has not been enough to move an inadequately educated public and political leadership. The failure of the WHO to achieve its scheduled goals and vision has perhaps weakened its influence and potential. No one knows, until it is tried, whether mega-research could find ways to persuade the public and political leaders. Once local area studies are integrated into a total world health database and issues map--with graphic models to demonstrate possibility to political and other leaders--perhaps the need can be dramatized in ways that highlight the helpful impact of proposals and possibilities for each local community to begin to do what it can.
The "Hanford Dose Reconstruction Project," for example, focused on ways to increase public awareness and participation in understanding the effects of radiation doses. One interesting aspect of that research was the involvement of twelve tribes of Native Americans in gathering data on their reservations. Could a mega-research project initiate something like that in every community worldwide; then interconnect them in a network that seeks to help every neighborhood become a healthy place? Family medical histories might be gathered into an intergenerational health profile. What might be learned if each person's and each community's medical records could be automatically processed as part of a global medical history, country by country, disease by disease? Technology could now make it possible for records to be compiled and compared without endangering privacy; for example omitting names in comprehensive statistics.
It is often suggested that much more could be accomplished in medical research, and much sooner, if more money could be provided. However, as research continues to enlarge and develop, it also provides a warning that large-scale projects are not guaranteed to produce better results. Efforts at international collaboration in cancer and AIDS research, for example, have resulted in conflict and controversy. Is this to some extent because the international research system/strategy is still primitive, without a system to automatically connect a scientist's discovery to his name?
New crises may provoke both researchers and politicians to develop a larger research and health care management system. Global data bases and networking make possible a global monitoring system to track the rapid spread of new viruses and more drug-resistant forms of old diseases like tuberculosis and cholera that are moving towards becoming a new global crisis. The U.S. Institute of Medicine has called for a long-term program to increase knowledge about sexually-transmitted diseases that have become a hidden global epidemic; and for more research on new dangers such as drug-resistant malaria. Lynn (1996) warned of genetic diseases caused by increased radiation and the use of chemicals in modern society which indicate more dangers to com
A planetary health management system, however, must include many other systems. One of many global problems that are inseparably related to health care is the lack of clean water for a billion people. (See Wolfram: 2.18) Even before their population doubles, fifty countries are now unable to provide safe and adequate water for all their people. And eighty percent of all diseases are waterborne. In the world's largest city, for example, a third of its declining water supply is lost through cracked pipes. Much contamination from sewage and industrial waste leaks into those pipes.
See Twaddle and Hessler, 1987 and Andrew Twaddle, Health Care Reform Around the World, 2002) for more detailed information on (1) the crucial need to address poverty. malnutrition, sanitation, pure water needs along with the lack of health insurance, and (2) and on what to do about the trend towards for-profit care that eliminates the poor as it also focuses on expensive high tech. The aggressive movement towards market-solutions, privatization and competition in providing health care is leaving out much of the developing world. This approach is shown to be undermining the plans and possibilities for effective, equitable health care for the impoverished of the world. (3) Research and experimentation is needed to design new kinds of health insurance that is affordable to all, even the poorest. If a cooperative banking system can do so for villagers in Bangladesh, a focus on low-technology, high impact solutions can be possible wherever needed. How? We end here as the chapter began, with a reminder that nurse and `barefoot doctor' paraprofessionals can be inexpensively trained to take care of more than 80 percent of medical needs in isolated and rural areas, and they can be connected by radio to doctors and hospitals for advice on where to send more serious cases. Also see 2.17)
If a network of researchers have mega-plans ready, a new crisis--like a new plague that might kill tens of millions--might give political leaders the motivation to put a planetary management system into place. Nations can have early warning systems for possible epidemics, and individuals (as Stikeman 2002) tiny sensors that "could provide early warning of heart attacks" and other health dangers.
Neurosynaptic Communications, India, is part of the TeNeT group working towards making affordable and quality healthcare available to the villages with the help of ICT. "We have developed a comprehensive telemedicine solution `ReMeDi(TM)' that integrates various aspects of rural healthcare delivery. It has a medical data acquisition system that captures 12 Channel ECG, Blood Pressure, Heart Sounds, Temperature and pulse of the patient located in the village, and a complete software which includes videoconferencing, electronic patient records and communication capabilities. The whole solution works real-time with the audio, video conferencing and medical data transfer beautifully over the low bandwidth networks, and has been deployed and operational in many villages in the southern part of India." <http://www.neurosynaptic.com/>.
Perhaps the results of even larger-scale research can persuade the public and officials of the necessity of a holistic-world approach. Holistic? By that we mean collaboration among researchers in agriculture, environment and natural resources, social science and the humanities, engineering, and all varieties of medicine: health professionals, veterinary, nursing and others, "to improve the quality of our food, health and environment." (Pai 2002) There must be "a convergence of disciplines, and opportunity for cross-fertilization of ideas, expertise and research methods." Research is prepared to move forward at an astonishing rate, with less human error and vast new quantities of data. From Geonomics will come more information about `life's blueprint;' from Protomics, a next step beyond genome research; from Nanotechnology, `diagnostic devices' that are better for the human body; and from Bioinformatics, better means to manage `torrents of data' that are more than a human being can handle, plus security in storing it. "The more great minds you can get together, the more strengths can be combined the more medical and all other research can be empowered.
Freeman Dyson (2003) has called for "a bold new initiative in biology; a planetary genome sequencing project to identify all the segment so all the genomes of all the millions of species that live together on the planet." Also, perhaps the public can be motivated by dramatic media presentations of needs and dangers, tied in with the ecological health of the planet that is discussed in the next chapter.
Meanwhile what political leaders an citizens will call for a vision of global health care system--and whatever must be accomplished in the 21s century to bring health care to everyone for the planet. A global political planning process needs to be enlarged now that electronic technology makes possible much more effective networking and planning..
The Future of Higher (Lifelong) Education: For All Worldwide: A Holistic View