John Mullaney <jmullaney@usa.healthnet.org>
Executive Director
SatelLife
1360 Soldiers Field Road
Boston, Massachusetts, 02135, USA
Tel.: +1 617 789 5455
Fax: +1 617 789 4471
While healthcare workers in the developing world struggle on the front lines of the world's most serious public health problems, their efforts are severely hampered by a lack of information. Indeed, information poverty remains one of the most serious obstacles to better health in the developing world. (1)
The pervasiveness of information poverty in the developing world is evidence that the revolution in information and communications technologies is a revolution of technological depth, but not of geographic breadth. While many capital cities throughout the developing world have witnessed a rapid improvement in their telecommunications infrastructures, conditions outside the capital cities have not significantly improved. For example, the average waiting time for a telephone line ranges from 5.3 years in Zimbabwe, to 10.9 years in Tanzania (2), to 48 years in Nepal.(3) Even when telephones are available, they frequently malfunction. In some African capitals, phone lines can be down up to 50 percent of the time.(4) Completion ratios for local and long-distance calls within the Southern Africa Development Community average 30 percent--and are far lower at peak calling periods.(5) Thus, while many in the developed world are traveling at high speed on the information highway, most of the world's population has never even made a phone call.
Further exacerbating this problem is the high cost of the telephone service that is available. In many African countries, the per capita expenditure for health is under US $10 annually(6), yet it costs about US $23 for a three-minute phone call from Burundi to Botswana. Faxing a six-page document from Mali to Zambia can cost as much as US $180, more than what the average African physician earns in a month. Given these statistics, it is not difficult to understand how the information gap between the developed world and the developing world has grown so formidable.
For almost ten years, SatelLife of Boston, Massachusetts has worked to overcome this information gap by creating HealthNet, an appropriate and sustainable communications network for health workers in the developing world. While the technology that SatelLife employs cannot be called state-of-the-art, it is, more importantly, cost-effective and well-suited to prevailing conditions in the developing world. Through its use of rational technology, SatelLife has made it possible for health professionals in the developing world to communicate and to share health information, thereby making an appreciable dent in the information poverty that hinders their work.
By demonstrating that technology need not be glamorous to be successful in serving the needs of health workers in the developing world, this paper will first set forth the premise that SatelLife should be considered as a model for the rational application of communications technology in the developing world. This point is especially relevant in view of the many new initiatives which are being launched with the goal of bringing information technology to Africa and elsewhere.
The second theme explored in this paper follows from the first. Over the last two years, some of the world's leading multi-lateral lending institutions that have poured billions of dollars into projects aimed at lifting the developing world out of poverty have come to the rather expensive realization that the way they have gone about their business in the past has failed. By focusing on high-profile, high-tech projects in health and other areas, they have built showpieces that have bred corruption and provided little direct benefit to communities while lavishing great financial benefit on contractors from donor countries and powerful government officials in recipient countries. Too often, these well-intentioned but misguided projects have done little or nothing to close the gap between the haves and the have-nots. Indeed, they may simply have widened it.
What does this second point have to do with a discussion about information technologies and the developing world? There is a cautionary tale to be learned from the experience of the World Bank, the International Monetary Fund, and other organizations as we assess strategies for sharing the benefits of information technology in the developing world. We ought not simply assume that wiring the developing world will close the information gap and thereby the gap between the haves of the developed world and the have-nots of the developing world. Indeed, unless we are careful to choose affordable, locally appropriate technologies and couple them with information services that serve real needs and are responsive to local communities, we could easily end up with a huge white elephant. And, worse still, we may simply end up widening other gaps. For if we focus on bringing expensive, high-tech communications technologies to the developing world, the information and economic gaps between elites of the private sector, and those who labor in the public sector--which, in the developing world, is most of the population--will grow even larger.
Much media attention has been focused recently on the growing disparity between the rich and poor in the United States. Less noted, but far more serious, is the growing divide between the rich and poor countries of the world. To illustrate: the difference in gross national product between industrialized and developing nations was eight-fold in 1950. Today it is nearly thirty-fold. During this same period, the number of countries at the lowest rung of the economic ladder has nearly doubled.(7) Nowhere is economic and social deprivation more in evidence than in Africa, where 54 percent of the population lives below the United Nations standard for absolute poverty.(8)
The number of doctors in Africa is simply not adequate to meet the continent's overwhelming health needs. Whereas industrialized countries have one doctor for every 200 to 500 people, in East Africa the ratio ranges from one doctor per 6,700 people in relatively prosperous Zimbabwe, to one per 37,960 people in war-ravaged Mozambique.(9) This shortage of doctors is becoming increasingly critical as African countries face an unprecedented health breakdown attributable to the spreading AIDS epidemic. Just a few statistics illustrate the overwhelming challenges doctors in Africa must face. About 25 percent of Uganda's 17 million people are afflicted with AIDS. It is estimated that by the year 2000, ten million African children will have been infected with the AIDS virus at birth.(10)
The mounting African health crisis relates in part to the lack of adequate information systems.(11) When African medical colleagues are asked about the type of support they most need from the North, the invariable response emphasizes access to information. Just as the world is divided between the over-nurtured and the undernourished, the same applies to information. The developing countries of the South are largely out of the information loop.
In 1987, SatelLife began addressing this problem by creating HealthNet, a global information and communications network for health workers. The particular needs of health workers in the developing world informed the development of HealthNet's technology: it was imperative to identify technology that would be both cost-effective and reliable despite the inadequate telecommunications infrastructures in the host countries. Low earth orbit (LEO) satellite technology met these criteria. SatelLife purchased two LEO satellites, built by Surrey Satellite Technology Ltd. of the UK, and commissioned their launch from Arianspas, the European space agency. The first of the two, HealthSat 1, was launched in 1991. HealthSat 2 was launched in 1993.
Each satellite, roughly the size and shape of a small refrigerator, orbits the earth in a polar trajectory at an altitude of 800 kilometers. Circling the globe every 100 minutes, they pass over every point on earth at least three times daily. Because of their polar orbit and the rotation of the earth, ground stations at the equator have the least access, with an average of four passes daily, while sites near the poles have as many as 14 over-flights per day. Because the satellites are relatively low altitude and employ sophisticated modulation and coding techniques, the connections to ground stations are strong and virtually error-free, despite the relatively low effective radiated power.
Ground stations can establish contact with the satellite for about 15 minutes during each pass of the satellite that permits a connection. Compression software permits data transmission at a rate of about one page of text per second. Messages composed on computers can be uploaded to the satellite where they are stored until the satellite passes over the addressee's ground station. Then the message is forwarded to the recipient. This type of communication is aptly known as store-and-forward and it is at the heart of what makes SatelLife an affordable technology for those in the developing world.
While the ground station technology continues to serve extremely remote medical facilities, improvements in the quality of international telephone connections to capital cities enabled SatelLife to shift the greater volume of its e-mail and information throughput from satellite to telephone lines in the early 1990s. Despite this shift, it is important to note that SatelLife has continued to rely on store-and-forward technology, as it is extremely well-suited to the poor quality of telephone service which still plagues many HealthNet users working in district hospitals and remote clinics outside of capital cities.
The costs to be saved by eschewing real-time communication in favor of store-and-forward technology--used in conjunction with either the satellite or telephone lines--are considerable. A recent communication with the HealthNet system operator in Tanzania informs us that the Internet is coming to that country. Connect time promises to be cheap: only $100 per month! With an income of approximately $150 per month, a public health physician in Tanzania can hardly afford to connect to such a service. With HealthNet, this same physician pays only the cost of a local phone call to send all e-mail and receive HealthNet's value-added information resources.
As real-time Internet connections become increasingly available within HealthNet countries, SatelLife is employing PC-based Unix software to enable users to link into existing connections, but only when ensured that such connections remain reliable and affordable to HealthNet users.
HealthNet now serves approximately 4,000 healthcare workers in 25 countries, and the network is expanding rapidly. In each country where HealthNet operates, a local "HealthNet Users Council" works with SatelLife to define the country's health information needs and to develop appropriate communications solutions. A local "network management team" administers the system in each country.
While HealthNet users are able to send and receive e-mail to each other, and to any point on the Internet as well, providing reliable communication is only half of SatelLife's mission. Equally important is providing health workers in the developing world with a wealth of health information not found anywhere in the Internet. HealthNet provides access to the most current information on clinical research, clinical practice, and public health for doctors, researchers and other health professionals in Africa, Asia, and Latin America. The constantly expanding range of HealthNet services enables users to:
One of these conferences, the Program for Collaboration Against AIDS and Related Epidemics, made possible by the support of the AT&T Foundation and collaboration with physicians from the Massachusetts General Hospital/Harvard Medical School, the Harvard AIDS Institute/School of Public Health, and other project partners in Europe, Africa, and Asia, is the first electronic global conference on HIV/AIDS and sexually transmitted diseases. This project will be announced at the XI International AIDS Conference in July, 1996.
What have these services meant to HealthNet users? Two examples are typical. A physician at a remote location in Zambia was presented with a patient with mysterious growths in her mouth. Normally, an arduous journey of several days to a district hospital--one this patient might not have survived--would have been the only course of action. Using a SatelLife ground station, however, the physician was able to send an e-mail message describing the symptoms to the country's leading teaching hospital. Several hours later, the electronic reply came with the recommended treatment--a surgical procedure that could be performed on-site. In 1995, when an outbreak of Ebola virus in Zaire caused concern throughout the world, healthcare workers in neighboring countries were able to monitor the latest information from physicians at the scene, the World Health Organization, and the Centers for Disease Control via an electronic mail conference co-sponsored by SatelLife.
HealthNet services will continue to expand in the future. Among its potential applications are:
HealthNet's services are proof that when applied rationally, new technologies do not necessarily serve to widen the gap between the private sector, which can afford them, and the public sector, which cannot. Today, most subscribers to HealthNet pay only the cost of periodic local telephone calls and a nominal monthly subscription fee to help cover the costs of operating the network in the their home country. In many cases, SatelLife underwrites the cost of the hardware needed to access the network as well. SatelLife will continue to explore the uses of a variety of communications technologies to find the most inexpensive, but reliable methods of keeping its network users in touch.
There is no doubt that the Internet can play an important role in improving communications and information sharing in the developing world. But whether the Internet becomes a positive force or a negative one will depend on how much it costs to access, how well people are trained in its use, how carefully we choose from among the many types of functions one can perform on the Internet, and what perceptions accompany its inevitable introduction into the life of many developing world countries. If the Internet becomes the latest high technology status symbol, and if it is presented and perceived as a panacea for the information needs of the developing world, the outcome is going to be disappointing at best, and truly harmful at worst. If, on the other hand, its potential is harnessed in locally appropriate ways, at a cost that is affordable to ordinary people, it will be a force for good. In this regard it is useful to look at how new technologies, including medical technologies, have traditionally been introduced in the developing world to see if there are lessons to be learned about the introduction of communications technologies.
For decades, multi-lateral assistance to the developing world favored enormous infrastructure projects such as hydroelectric facilities, highways, and sophisticated tertiary care hospitals--high-profile projects that were frequently counter-productive, often unnecessary, and rarely sustainable. Too often in the health field, according to a 1993 World Bank report, too little goes to low-cost, highly effective programs such as control and treatment of infectious diseases and of malnutrition.(12) In many of the showpiece tertiary care facilities, for example, it is not uncommon to see high-technology medical equipment such as CAT scanners and other advanced diagnostic equipment. In countries where lack of access to potable water accounts for much of the preventable disease, and where children die by the tens of thousands from diseases which could be prevented by simple, inexpensive vaccines, it is questionable whether a CAT scanner should be a big priority. To quote a recent publication of the World Bank:
In Tanzania the richest fifth of the population use more than twice as many government hospital beds and more than four times as many outpatient services as the poorest fifth. In Cote d'Ivoire less than one-quarter of the rural poor who were sick received any form of medical care, as compared with half of the urban rich. In Peru only 20 percent of the poor received care, versus 57 percent of the rich. In general, when government expenditures are concentrated on urban areas and on hospitals rather than on basic services, the results are highly inequitable, governments are essentially subsidizing the rich.(13)
Ironically, much of the expensive equipment provided through high-profile initiatives is not even functional because funds are not available for maintenance, repair, and training. The World Health Organization estimates that half of all medical equipment in developing countries is unusable. In Brazil, for example, an estimated 20 to 40 percent of the $2 to $3 billion worth of public sector medical equipment is not working. In Kenya, sterilizers work for about two years instead of the expected six, and incubators for two rather than eight because maintenance budgets are too low.(14)
To some extent, the leading multi-lateral aid agencies are learning from past mistakes. Both the United Nations Development Program and the World Bank are now shifting their focus from big enterprises to skill-building projects which promote professional training and basic education for ordinary people. The new watchword is "capacity building."(15)
Unfortunately, in the area of telecommunications, the lessons of the past are being ignored. The emphasis--by the multi-laterals and by developing world governments--is on the latest, hottest technology, regardless of whether the system is appropriate, affordable, or sustainable. The rush is on for real-time Internet access and the infrastructure that will support it. As a result of this emphasis on importing costly, high-bandwidth communication lines that only the upper echelons of the private sector can afford, there may actually be a delay in closing the information gap between the North and the South, despite rapid improvements in telecommunication infrastructures in developing world countries.
For some in the health sector in Africa, direct, real-time access to Internet lines is obtainable through a growing number of commercial e-mail providers, especially in the major cities. However, hook-up, access fees, and training costs are financially out of reach to the large majority of health professionals. A direct Internet line to a ministry of health, for example, may cost between $15,000 to $35,000 per month.(16) At these rates, Internet access is far beyond the reach of medical schools, research institutes, and hospitals whose budgets for communication needs are extremely limited.
One particular problem of real-time Internet access for those in the developing world is the costly combination of usage fees and the extraordinary breadth of information on the Internet. Searching the Internet can be time-consuming because the vast quantity of information available is not organized coherently. Trying to locate a specific piece of information for a health worker can be the proverbial hunt for a needle in the haystack. Yet for every minute the user is picking away at the haystack, he or she is running up usage charges. This is a problem exacerbated by the scarcity of useful information for healthcare practitioners in the developing world. While there are hundreds of World Wide Web sites containing information on cancer or heart diseases, there exist very few sources of information on diseases like leprosy, malaria, or cholera that have major consequences outside of the industrialized West. Even sites that deal with tropical diseases are often cursory and unhelpful to clinicians dealing with the disease in hospitals and clinics in the field.
Without really understanding its limitations, ministers of health and doctors in big hospitals perceive the World Wide Web as essential to their work. Though already facing oppressive debt burdens, some ministries of health and principal teaching hospitals may reject more cost-effective means of communication in favor of real-time Internet service for much the same reason they opted 10 and 20 years ago for building well-equipped, tertiary care hospitals in capital cities, even as district hospitals and other primary care facilities which delivered healthcare to most of the population withered on the vine. Like the big, expensive tertiary care facilities funded by the World Bank and others, direct, high-speed Internet access is a national status symbol. But, as the World Bank itself concluded in a report two years ago, the tertiary care facilities increased costs without increasing quality of care:
In virtually every developing country, facilities, equipment, human resources, and drugs are skewed towards the top of the health pyramid [specialized hospitals]. Yet the cost-effective public health and clinical interventions...are best delivered at the level of the district hospital or below. That they are often delivered through tertiary hospitals simply increases costs without improving quality. This problem is found in poor countries in which the principal tertiary teaching hospital in the capital city consumes a large proportion of the total resources available for health.
In many countries public investments are concentrated unduly on tertiary services, and public spending subsidizes high-end facilities, equipment, and human resources for private markets.(17)
It is fair to think of direct, real-time Internet connectivity as the communications equivalent of a tertiary care facility, especially in countries where the vast majority of people have never made a phone call. For healthcare workers on the front lines at district hospitals, health centers, and clinics or making rounds in the bush, such connectivity is simply far removed from their communications needs. Nor, as noted above, is the Internet writ large likely to prove a useful information source. If investments are to be made in communications technology for the health sector, there are simpler, cheaper, far more effective tools than direct, real-time Internet connectivity--tools that will be of far greater value to most developing world health workers and the populations they serve.
The point here is a cautionary one. The same misjudgments that have characterized choices made about the delivery of medical care and investment in medical technology could be repeated when it comes to communications and information technology. Investing in expensive high-bandwidth technology for the purposes of bringing Internet access to the developing world is seductive. However, it is hard to fathom how such a system will benefit the vast majority of those in the developing world when telephones are widely unavailable and frequently dysfunctional. Before huge investments are made in state-of-the-art technology, we must first work with the communities we are trying to serve to determine what their needs are and which technology will best meet those needs.
SatelLife has made a commitment to do just that. We are not interested in providing technology for technology's sake, or in unleashing a torrent of unsifted, and therefore virtually unusable, information on health workers in the developing world. SatelLife's short-term plans include harnessing all available communication technologies to the service of improving the availability and quality of health information for all people. To do that, SatelLife will continue its effort to build affordable and sustainable national health networks that penetrate to the jungles, mountains, and deserts where people live, and where physicians heal them when they are ill.
SatelLife addresses the Internet Society with a call for reflection on its own mission.
We propose that the health sector be given priority and discounted access to direct Internet connections. The connection sites should be located at discrete locations such as medical libraries, medical schools, and HealthNet nodes. HealthNet users could connect to the node via Unix-to-Unix Copy (UUCP) or Fido connections when telephones are available, and by satellite when appropriate.
As new initiatives are established with ambitious goals such as continental connectivity in Africa, we hope that the accomplishments and contributions of existing projects such as HealthNet will be recognized and built upon. Having pioneered much of the technological frontier in the developing world, we are well-placed to advance the aims of projects like the Leland Initiative. Cooperative relationships will ensure that limited resources are used effectively, and that previous efforts are not duplicated. Cooperation will also ensure that skilled individuals are encouraged to transfer their skills and knowledge to others. As a result, initiatives which have made tremendous investments in training a cadre of technicians will be in less danger of losing them to larger, seemingly more glamorous endeavors. If new projects such as the Leland Initiative work closely with existing networks such as HealthNet, everyone stands to conserve time, resources, and energy. And, let us not forget the biggest winners of all: those people whose lives are improved by the services we provide.