MEDINET: A Nonprofit Initiative to Provide Internet Access for Medical Professionals in Bangladesh

Abul Kalam Azad <akazad@medinet.agni.com>
Dhaka Medical College
Bangladesh

Abstract

While the developed nations are expanding Internet access to elementary schools and rural areas, many developing nations unfortunately lack good telecommunications even in higher educational institutions such as universities or medical schools. None of the district or rural hospitals of Bangladesh has a computer. Most of the medical schools have no computers or only one. There was an acute scarcity in the supply and flow of current information related to health and medicine. A computer-minded physician came forward and initiated the establishment of MEDINET, a nonprofit and locally appropriate solution of networking to provide electronic exchange and Internet access to the medical-related professionals and institutes of Bangladesh. This paper describes the network's encouraging experiences and progress so far. The project may serve as a model of professional networking in developing countries where Internet access is limited.

Contents

Introduction

Bangladesh, like many developing countries, seriously lacks telecommunication and computer facilities. Whereas the developed nations are trying in various ways to expand Internet access to the elementary school and grassroots levels (1, 2, 3), here even the higher educational institutions do not have Internet access. There are seven government universities in Bangladesh and even among their computer science departments, only three have off-line Internet access (Tables 1 and 2 show brief country profiles). Information distribution among medical institutions and hospitals is no better. Most of the government medical schools have only one computer or none at all. None has Internet access. These institutions can hardly come by funding to purchase adequate medical textbooks or journals. Whereas the BMA library in London subscribes to around 700 journals (4), the library of Dhaka Medical College, the premier medical school of the country, may only regularly or irregularly subscribe to one or two current medical journal(s). The International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B), an international organization based in Dhaka, serves as the single source of current medical journals in the country; three other organizations provide CD-based Medline service in collaboration with the World Health Organization (WHO). But medical teachers, physicians, and students from remote locations seldom get the opportunity to use these resources. To alleviate the information poverty of medical-related professionals in Bangladesh, at least in part, we have established MEDINET (Medical Network), a nonprofit initiative to provide locally appropriate electronic exchange and Internet access.

Table 1. Country profile of Bangladesh
  • Emerged as an independent nation in 1971
  • Total area: 147,570 sq. km.
  • Population: 121.8 million
  • Population growth rate: 1.8%
  • Infant mortality rate: 78 per 1000 live births
  • Literacy rate: 37.2%
  • Per capita income: US$230 per year
  • Average gross salary of a doctor in junior position: US$100 per month
  • Average gross salary of a doctor in senior position: US$325 per month
  • Monthly house rent: Equivalent to one month's gross salary
  • Doctors required to do private practice to meet other basic needs
  • Average monthly food and lodging cost for a medical student in hostel: US$50
  • Number of postgraduate medical institutes: 5
  • Number of undergraduate medical colleges (govt.): 13
  • Number of undergraduate dental colleges (govt.): 3
  • Number of district hospitals: 59
  • Number of thana (rural first referral level) hospitals: 399

Table 2. Telecommunication profile of Bangladesh
  • Telephone company: Govt. monopolized
  • Average time required to get a new telephone after application: 10 years (5)
  • Cost for acquiring a new telephone: US$500 (actual) + US$300 (invisible)
  • Cost per local call: 5 cents
  • Cost per minute long distance call within country: 75 cents
  • Type of telephones: mainly analogue with numerous digital
  • Type of telephone cables: copper wire. Transmission speed is very slow.
  • Quality of telephone services: Worst
  • Government allowed commercial online Internet service beginning 4 June 1996
  • Commercial online Internet service providers: 6
  • Availability of online Internet service outside capital city: Nil
  • Average price of a basic 486x based clone system: US$1000
  • Average price of US Robotics 14.4 modem: US$125
  • Average price of US Robotics 33.6 modem: US$225
  • Internet access device used by providers: own VSAT
    (each provider required to pay US$8625 per month to telephone board for using VSAT).

Objectives of MEDINET

  1. To provide Bangladesh a smooth supply and flow of information related to health and medicine.
  2. To develop a reasonably reliable, fast, versatile, and easy-to-use electronic communication system unique to the needs of medical-related professionals and institutes, such as physicians, hospitals, clinics, medical students, pharmaceuticals, development agencies, nongovernmental organizations (NGOs) and research organizations working in the health sector.
  3. To develop a nonprofit system for the subscribers to communicate at the cheapest possible actual cost.

How the idea came about

Because of my opportunity to work directly with computers since 1989 in my philanthropic organization, Sandhani International Eye Bank, which campaigns for posthumous eye donation and effective eye banking in Bangladesh, I developed a natural weakness for computers and began subscribing to the locally available computer magazines to learn about developments in the field. Thus, when a commercial firm started offline e-mail and BBS service in late 1994, I subscribed at the first opportunity. At the time, I was an assistant professor at Dhaka Medical College. I was looking for ways to use e-mail to make current medical information available for my professional colleagues and students. I decided to establish an organization for this purpose and also to process other locally available health information. Because of natural inertia, I found little interest among my senior colleagues, but my students encouraged me a lot. Thus, in April 1995 we started the Medical Information Group with 40 student members, of which 20 were active. It was my unique opportunity to witness a live demo on the Internet given by Andrew Robinson on behalf of the Ford Foundation in October 1995. Mr. Robinson, a U.S. citizen and Internet activist, visited Bangladesh to create awareness of the Internet. I asked him to hold several demos for medical professionals, and accordingly three live demos were held through long-distance international telephone calls: one at Dhaka Medical College, the second at the Directorate of Health Services and the third at the Bangladesh Association of Pharmaceutical Industries. All the programs were attended by large numbers of professional people in various capacities. The very positive reactions of the audiences stimulated us to design the concept of MEDINET.

But things were not so easy

As soon as the concept had been designed, I began looking through e-mail both at home and abroad for possible software and hardware support with a view to establish MEDINET. I received a shareware version of a BBS software from one of my friends in the United States, an Application Form of INET 96 from Professor Mark Musen at Stanford University, U.S., and a commitment for necessary hardware support from the local Pharmaceutical Association. At that time Bangladesh had to pass through a phase of prolonged political unrest with consequent strikes, and effective local liaison for immediate solutions was not possible. As alternative I built the necessary setup and started initial MEDINET service based on a 486SX Compaq Contura Aero notebook computer that I was using as part of my involvement in a research project. It was May-June 1996 and thanks to the Internet Society I received a scholarship to join INET 96 in Montreal and receive training in Network Technology. I returned home in a very enthusiastic mood and found that the notebook computer had been taken away by the research project with no hope to get it back. I contacted the Pharmaceutical Association in different ways but it showed reluctance. However, a local diagnostic service company provided us with a computer and we resumed service through my own home telephone. But fortune betrayed us; the donor claimed commercial use of the project including its own share. When we refused, it took the computer back. Then we decided to invest the money from our own sources. We purchased two computers, one for the server and another for our first information distribution center in Dhaka Medical College. We also purchased one telephone; 70% of the amount was contributed by me from my hard-earned savings (really difficult in this country) and the rest by my student members. We issued some press releases in the local newspapers and also circulated request letters to the potential clients explaining MEDINET's nonprofit nature and benefits. We also launched a basic computer training program to enhance computer literacy amongst medical students and professionals and conducted other promotional activities within our limited resources. With all sincere efforts, we began to gradually gain ground and MEDINET started progressing steadily.

The Structure of MEDINET

  1. MEDINET has a round-the-clock operating computer server (AMD 586 based clone system worth US$1200) located in Dhaka and connected with two digital phone lines.
  2. It is an offline Internet access system which connects with Internet every hour through dial-up Unix-to-Unix Copy (UUCP) with a local commercial Internet service provider.
  3. MEDINET stores information in several areas under different subject headings (Table 3) and all users can share information, messages, electronic books, articles, journals, newsletters, software, and so on to enrich MEDINET's electronic library.

    Table 3. Message and file areas of MEDINET
    Message areas
    • Local e-mail (private)
    • Internet e-mail (private)
    • Synapse for physicians
    • Interaction for pharma people
    • Anastomosis for NGOs (health)
    • Plexus for medical students
    • General for all issues
    • Health digest
    • General digest
    • Journal information
    • Newsletter
    • Announcements & events
    • Buy, sale, trade
    • MEDINET support
    • Computer support
    • New proposal
    • Online survey
    • soc.culture.bangladesh
    • Medical advice
    • Other Internet newsgroups
    File areas
    • Databases
    • Telephone directories
    • Drug reference guide
    • Books
    • Journals
    • Software
    • Etc.

  4. We regularly procure and update valuable information from the Internet. For example, we subscribe to HealthNet news, ProMed, EDrug, ProCarre from SatelLife, MedPulse from Medscape, and the soc.culture.bangladesh newsgroup from Internet.
  5. We help our users get articles from medical journals through our own online account or via e-mail.
  6. Users are encouraged to prepare and read messages offline for efficient use of limited telephone lines and to reduce waiting time for getting connection. Thus, it is a great saving to use MEDINET from remote locations outside Dhaka.
  7. Currently, services are distributed through 60 individual users, 17 organization users, and 6 distribution centers. The remote subscribers use the store-and-forward technology and receive/send all the information in one or two dial-up connection(s) a day. Distribution centers are mainly located within institutes where we could not build a formal MEDINET connection. We have organized local volunteer groups to display information in a suitable place for public viewing. Interested persons may submit responses for transmission via e-mail. We arrange sending/receiving messages to/from distribution centers on a daily basis through bicycle messengers or courier mail service. Thus, a public transport system for health information has been created for places where there is no computer or direct Internet. We also encourage our individual users to render services to their friends and colleagues. These two systems are unique, and hundreds of professionals and medical students who do not have personal computers or telephones are getting benefits.
  8. To procure computers for remote health centers is difficult. Thus, we are planning to establish at least one sub-host server in each medical college, so that users in those places can maintain personal e-mail accounts and create local discussion groups. To create access from the district and rural thana towns, we have recently decided to provide free connections to the local Computer Training Centers subject to the condition that they will arrange distribution of health information at a rational price. However, we emphasize the concept of distribution centers. At the same time, we never ignore the importance of online Internet and are actively working to render online service on a cost-sharing basis by hiring a separate leased line.
  9. For service, we take a nominal monthly maintenance charge (US$2.50 per user) and actual cost for per Kb e-mail transmission in Internet. We are actively thinking to remove the monthly service charge to encourage more users. Table 4 shows a comparison of bills between MEDINET and other commercial providers.

    Table 4. Comparison of bills between MEDINET and other commercial providers
    Description MEDINET Other providers
    Registration fee Nil US$250
    Monthly subscription US$2.50 (We will omit monthly subscription soon.) Nil
    Access limit Unlimited Costs 7.5 cents/min. + 15% VAT
    Service area Whole country Within capital city
    Local discussion groups Plenty and active Nil
    Storage of Internet information Plenty Nil
    Allows public distribution center? Yes No
    Encourages subscribers to provide service to others? Yes No

Conclusion

Doctors, pharmacists, and other health care workers, wherever they are, should have up-to-date knowledge on medical research and development. But this is often difficult in a developing country situation, which is rightly expressed by the Economist earlier this year, "While the lucky few million in the rich world amuse themselves in cyberspace, half the human race has never made a telephone call" (5). Those in the world's rich northern countries could happily chat among themselves by post, telephone, fax, and e-mail, but very few doctors in the poorer countries of the south could join in. MEDINET is a less glamorous system than online Internet, but it is a locally appropriate, simple, and inexpensive system that combines the power of information technology with a traditional information distribution system. Moreover, it provides the opportunity for users to discuss and share information on local issues that are rarely available on the Internet, which is largely occupied by northern affluence. MEDINET may be considered as a developing country model of professional networking where Internet access is limited.

References

  1. Emerson, M. Facilitation of the CMC learning collaboratory in K-12 education. Presented at INET'96.
  2. Egnatoff, W. Preparing teachers for effective use of Internet in schools. Presented at INET'96.
  3. Holbrook, P. Extending Internet access to rural areas and small communities in the midwestern United States. Presented at INET'96.
  4. Groves, T. Information sharing: Getting journals and books to developing countries. BMJ 1996; 307: 1015-7.
  5. Tele-haves and have-nots. Economist 1996; 18 May: 19-20.