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Introduction
Minamata city is now beginning a regional regeneration project which is built upon the lessons of Minamata disease, which was caused by industrial release of methyl mercury into Minamata Bay followed by the accumulation of methyl mercury in edible fish and shellfish in 1950s. Mayor Yoshii presents a message in the home page of Minamata that "In order to ensure that such tragic and foolish human disasters never occur again anywhere in the world, we in Minamata are speaking out about our experiences, and hoping to make Minamata a city that can make an internationally significant contribution to the environment". To make the tragic lessons known worldwide, the scientific and historical story must be globally available.
The information superhighway is being constructed rapidly. The increase in use of the Internet has been explosive, with a 12% growth rate in each month. It is changing the way people communicate all over the world. The key to better health in the 21st century would depend on how we complete and drive on this highway.
The Global Health Network (GHNet) has emerged to apply the Internet into public health. Improved low-cost access to information about disease monitoring and prevention can bring dramatic improvement in health. The GHNet is designed to bring the era of disease prevention onto the information superhighway.
In this paper, three major topics will be covered; 1) concept of the GHNet, 2) components of the GHNet, and 3) possible GHNet application into Minamata.
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Concept of the GHNet
In the 20th century, we have experienced outbreaks of diseases caused by Ebola virus, HIV, sarin poisoning, Enterohemorrhagic Escherichi coli O-157, mercury poisoning, and others. Is the world becoming sicker? Most certainly not. In this century life expectancy has improved more than during the entire previous span of human history. In almost all developed and developing countries there has been a 25 year increase in longevity (23). This increased life span has been almost exclusively due to public health such as sanitation, immunization, improved nutrition, maternal and child care , health education, etc. (15, 23).
Most of public health activities are up-to-date information transfer. These activities integrate basic research to applied one and provide information on sanitation, nutrition, maternal and child care, emerging diseases, and so forth which lead to improvements in health. Public health research is information research as data collection, analysis, dissemination, and research communications are all information transmission.
We are currently in the midst of information revolution that the latest telecommunication technology, the Internet, has been bringing about in 1990s. The Internet is a network of networks, interconnecting people, computers, and organizations worldwide. It reaches estimated 40 million people in more than 100 countries. The Internet allows us to disseminate and glean information much faster, cheaper and much more easier globally. It is rapidly changing almost all the areas of people’s daily living; business, education, shopping, etc..
The medical application of the latest telecommunication is termed telemedicine. The areas of discussion have centered on image transmission, medical informatics, and especially patient consultations (2, 12,25). These areas have primarily targeted on the treatment of small number of sick people with high band width connectivity in a very expensive way. What has been neglected in the discussion of telemedicine has been tele-preventive medicine (3), which probably holds the greatest promise for improvement of health in the 21st century. Tele-preventive medicine targets on the prevention of disease for large number of healthy people with low band width connectivity using the current infrastructure in a relatively inexpensive way.
The GHNet has been emerged from the grass-roots effort by experts in telecommunication and health who are actively developing the architecture for a health information structure for the disease prevention in the 21st century (8, 10, 19). In early 1993, one of the author, LaPorte R.E. from the University of Pittsburgh began to pull together a group from very divergent backgrounds with a mission to improve global health through the application of the latest cost-effective information technologies to prevent disease. Included in this group is Villasenor A., the former head of the National Space Aeronautics and Space Administration Science Internet (NSI), and the former head of the Federal Networking Council. Boostrom E. is a major leader of tele-preventive medicine at the World Bank. Akazawa S. is a developer of the World Health Organization (WHO) homepage. Gamboa C. is leading much of the effort of telecommunications at Pan American Health Organization (PAHO). Other author, Sekikawa A. is in training with LaPorte, and has been a primary person in developing the GHNet in Japan. Lee H.K. from Seoul National University has helped to guide the GHNet in Asia. We have several people in Japan who have been developing the GHNet in Japan. Tajima N. from Jikei University, Tokyo, helped to develop the early concepts of this in the mid 1980s. Satoh T. from Tokyo women’s medical college, Tokyo, has also been responsible for programs in Japan, and pushing the GHNet forward in both countries. Ochi G. from Ehime University, who is a founder of the Global Health Disaster Network and has been actively networking people for disaster preparedness (13). Director Y. Takizawa of the NIMD also has recently begun collaborating with the GHNet.
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Components of the Global Health Network
The main object of the GHNet is to bring telecommunication into public health for disease prevention. It consists of eight components (1).
1. Connectivity
The GHNet has been pressing for the connection of all public health agencies in the world, from local public health departments to international ministries of health. The GHNet has been working with the World Bank, the United States Agency for International Development, and NASA to bring Internet connectivity to Africa, where only five countries had direct access to the Internet in 1995.
The GHNet has also determined the status of connectivity of public health in Japan and the US and are starting to connect them. For Japan, the connectivity to the Internet at public health related departments at medical school was surveyed during 1995 to 96 (20). Almost 90% of the facilities had access to the Internet. More than 70% were connected to the Internet past two years. Almost all had an electronic mail access. Only 8%, however, had a homepage for their facility.
We are actively developing training courses to bring public health workers onto the information superhighway. The first and second WHO/GHNet joint program Internet training courses were held at an annual meeting of Japanese Society of Public Health and Japanese Society of Hygiene respectively (18).
2. Telemonitoring of Diseases
In August 1996, Villasenor A. from NASA and Libman I.M. from University of Pittsburgh were invited by the Division of Emerging and Other Communicable Diseases Surveillance and Control (EMC), WHO and proposed the global information system using telecommunication technology for emerging disease monitoring. In this proposal, the GHNet is to provide technical and operational support services for dissemination of information, disease monitoring and response, and antimicrobial resistance monitoring. The proposal was accepted by the WHO. Once established this could form a backbone for monitoring of conditions world wide, especially for non-communicable diseases.
Morbidity statistics are obtained by surveillance, cross sectional studies, disease registries, and other various sources. However, disease monitoring systems are not yet sufficient in any developed countries. This is mainly because of incomplete ascertainment rates which yield undercounting (14) and the high cost of establishing health statistics. Recently, new statistical approaches, capture-recapture methods (5), designed to evaluate and to control for undercount in the field of ecology, are being applied to count diseases in human (4, 17, 24). Using these techniques with a telecommunications backbone would allow timely and accurate monitoring of morbidity statistics for both communicable and non-communicable diseases alike.
3. Global Health Network University
Distance education is a general term covering the broad range of teaching and learning events in which the student is separated from the instructor, or other fellow learners. The earliest form was through correspondence courses which date back to 1890's. Instructional radio and television have become popular since 1950's. The major drawback of them for instruction was the lack of an interactive communication channel between teacher and student. In 1990's, the old correspondence course has stormed into the high tech age. These new media are mainly tools of the Internet, such as electronic mail, mailing list, gopher, and the World Wide Web.
The GHNet is developing international distance education programs to train public health workers where teachers in Tokyo, Pittsburgh, Moscow, and Santiago train students in Seoul, Beijing, and Melbourne. In 1995 students from 16 countries participated in the e-mail based program, where they discussed in mailing list and submitted their assignments through e-mail. In 1997, e-mail and homepage based program is being held, where lecture slides, syllabus, and reference materials are up on the homepage, discussions are on the mailing list, and students are supposed to submit their final papers as a form of homepage.
4. Global Health Network Information Server
The GHNet has been particularly interested in the use of the Internet for research communications. The GHNet has written a controversial article in the British Medical Journal (BMJ) titled the "Death of Biomedical Journals" in which we predicted that in 10 years journals will die (9). The GHNet has recently published several other papers questioning the need for the current copyright policies in light of the Internet. One of the papers was published in the BMJ, and was commented upon by the head editors of the BMJ, Lancet, Annals of Internal Medicine, and JAMA (11). The GHNet also wrote a paper titled "Scientists assassinate journals". This was put on the Internet (http://www.pitt.edu/HOME/GHNet/publications/assassin/index.html) in various different formats, including a lay version, a scientific version, an editor version, and a hypertext comic book. In addition, this was presented in English, Japanese, Portuguese, and Spanish. Once one comes into the page they can call up a form to rate the paper, as well as to provide a critique. This is the first time to our knowledge that a single scientific communication has been developed into multilingual and multi-version research communications with a peer review.
5. Networking Non Governmental Organizations (NGOs)
Health related organizations outside the government, such as Red Cross and medical associations provide much of the care and health information to people and doctors worldwide. The problem is that there is little discussion among these organizations. The GHNet has been networking for example, the Latin America Diabetes Association, Minority Health amongst others to increase efficiency of information transfer and to reduce duplication of effort.
6. Cyberdocs
Public health and preventive medicine have grown independent of information and telecommunication sciences. Information transfer has been becoming an extremely important component to health. A cyberdoc is an individual trained in medicine/public health and information sciences and telecommunication. Health workers in general need to be trained on telecommunication, and people in telecommunication need to be trained in health to become cyberdocs. The GHNet has four students who are being trained in both public health and telecommunications. The GHNet is proposing to establish training programs in telecommunications for public health.
7. Homepage
A GHNet homepage (http://www.pitt.edu/HOME/GHNet/GHNet.html) has been constructed as a one-stop shopping mall for health information (6). Included on the home page are world wide directories of professionals involved in global health, job listings, and medical information from valid sources on such topics as laboratory, population and reproductive health, women's health, emergency and disaster medicine, minority health, physical activity, molecular epidemiology, etc. Some parts of the homepage are available in Japanese, German, Portuguese, Spanish and will soon be translated into Chinese. In Japanese version, each homepage in English is summarized in Japanese so that Japanese researcher can easily surf the health resources on the Net. To a homepage in languages other than English, summary document and an e-mail address of a contact person will be put for English readers. Thus, communication on world health will be globalized (21). The home page is monitored closely and updated frequently so that information is timely and useful.
This web site has received several major telecommunications awards such as PC Magazine's Top 100 Web Sites and Point Communications' Hall of Fame. During the past year over 100,000 individuals world wide have come to visit our page. In addition the homepage and our work have been identified with the top 6 global health projects in part of the global information infrastructure award.
8. Limited access server
In the editorial of the January 11th issue of the BMJ, the editors argued that the primary cause of death in developing countries is information deficiency and that the Internet can prevent information deficiency (16).
In response to this editorial, the GHNet proposed free online journals with an Internet targeted access server (7). In this way, health workers in developing countries will be able to get the information for free as well as the journals can avoid to lose subscribers in developed countries. In addition, opening the door will allow information to flow from developing countries as well. The GHNet has already contacted more than 70 leading journals in health such as BMJ, the Lancet, JAMA, Journals of Canadian Medical Association, and Annals of Internal Medicine, and all of them have agreed to start the electronic flow of journals to developing countries.
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Possible GHNet application into Minamtata
Minamata disease was officially discovered in 1956. In 1968, the national government recognized it as pollution caused by methyl mercury poisoning. In 1978, National Institute for Minamata disease (NIMD)was established to carry out multi-disciplinary studies on the disease to clarify the mechanism of methyl mercury poisoning and to improve medical care for the victims. The results of the research conducted at the NIMD have been very well received in Japan and other countries. In July 1996, the NIMD was inaugurated in order to enhance its research functions and to make an international contribution through telling the world of the lessons learned from Minamata disease (history of Minamata Disease).
In consideration of the recent advancement of the telecommunication, the time has come to disseminate the information on Minamata disease worldwide through the Internet.
From the scientific and epidemiological points of view, Minamata disease is the most significant incident of mercury pollution and the investigation of the incident has been the most thorough and are still in progress (22). Recently, the importance of studying environmental methyl mercury pollution and its effect on human health has been increasingly recognized, and methyl mercury pollution has become a global concern.
The Minamata disease has been taught at almost all public health schools in the world.
In addition to the information dissemination, the Internet could make the NIMD an excellent model for an information efficient biomedical research center. The NIMD comprises several departments from basic medical sciences, epidemiology to clinical medicine. Each department would develop its own network in the cyberspace and the Internet backbone will link together the network of each field. Furthermore, the city municipal has just opened its homepage (http://www.qqq.or.jp/tenant/minamata.city/english/me_top.htm). The Internet backbone will link together work from basic scientists, epidemiologists, clinicians to lay public.
As a possible GHNet application to the NIMD and Minamata disease, we propose several specific items.
1. Connectivity and Internet training
The NIMD will get connected to the Internet in summer 1997. What is critical will be to have the staff trained for the use of the Internet. The GHNet personnel could assist in training. Moreover, GHNet training materials on the Internet could also assist in training.
Once the staff is trained, each would obtain a personal electronic mail address. Electronic mail is the basis of communication on the Internet. People can communicate personally and as a group using a mailing list. The mailing list offers a way for a group of people with a shared interest to send messages to each other and hold a group conversation. For example, researchers interested in ataxia caused by methyl mercury would develop a mailing list named "M-ataxia".
2. Center for mercury poisoning and other environmental health surveillance
The NIMD can become the center of information on mercury poisoning. The identification of places is reported to the NIMD as was discussed in the meeting, such as from Philippine, Brazil, Tanzania, and Indonesia. The NIMD can glean, analyze, and disseminate the global information and can branch out other environmental issues.
3. Center for distance learning for Minamata Disease
The NIMD could provide distance learning on Minamata Disease to students and faculty at public health schools through the Internet. Many would visit the site through the Internet as almost all public health schools in the world could teach Minamata disease in their lectures on environmental health.
4. Network of people and organization
The NIMD would provide a framework for networking other groups and organizations dedicated to prevention and treatment of mercury poisoning. The NIMD has department of basic medical science, clinical medicine, and epidemiology. Each department would establish a network in the cyberspace and these networks would be pulled together to facilitate the prevention and treatment.
5. Homepage
Sekikawa A. for the GHNet constructed a demo version of a home page for the NIMD (http://www.pitt.edu/~akira/mina/mina.htm). This page is a general overview of the NIMD. Much more precise ones could be constructed. One way for doing that is to establish a public site and a password protected site. A public site would contain general information, summary of projects, educational information, etc. A password protected site would contain manuscripts and data among investigators worldwide.
6. Limited access server for environmental health
As the GHNet is planning to develop the limited access server in order to meet the needs of health workers in developing countries, the NIMD could apply the same idea in the field of environmental health such that environmental health journals would be made available ot developing countries.
7. Training Center of the Internet and environmental health
Once the staff gets trained, the NIMD could provide an Internet training course for other facilities, both through training at the NIMD and distance learning.
8. Cyber-Environmental Docs
A joint program of training could be established where environmental specialists would learn from experts of telecommunication, and vice versa. These individuals, for example, would respond to environmental disaster through developing information system at the home of a disaster.
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Conclusions
| We made this paper along with the slide presentation
available on the Internet so that people all over the world can reach the
document and enjoy the slide show as a collaborative work between the NIMD
and the GHNet.
Click this image here to go to the Slide Presentation |
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The NIMD, where Takizawa serves as a director general, which has been a WHO collaborating center since 1986 and the center in Pittsburgh where Sekikawa and LaPorte belong which has been also a WHO collaborating center are located far distant, yet, through the Internet it is like they are next door.
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