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Saturday, July 28, 2007

INTERNET ACCESS - IS THE EXPENSE JUSTIFIABLE?

CHILD2015 SUMMARY. INTERNET ACCESS - IS THE EXPENSE JUSTIFIABLE?

Introductory note from CHILD2015 co-moderator (Neil PW):

Please find below a summary/extracts from our recent discussion on the
subject of ‘Internet access: is the expense justifiable?’. A formatted
version is publicly available on the Resources section of the HIFA2015 web
archive: www.dgroups.org/groups/hifa2015

The discussion was held simultaneously on our two ‘sister’ groups:
HIFA2015 and CHILD2015, between 4th and 10th July 2007. There were twenty
four messages: eight from USA, seven from UK, three from India and one
each from Gambia, Colombo, Kenya, Canada, Uganda and South Africa. Names
of the 21 contributors are listed below.

As with all CHILD2015 Summaries, this is a ‘living summary’ that will be
regularly updated. Further contributions on this topic are welcome -
please send to hifa2015@dgroups.org

Our thanks to CHILD2015 volunteer Zaynab Lambat for preparing this summary
(CHILD2015 profile: Zaynab Lambat is a pharmacist by profession, and has
worked extensively in Africa, and as a Trainer and Consultant in Holland.
Her main interest is promoting health in developing countries. She is
currently based at the University of Swansea, UK, where she is working on
learning modules for International Health. feroz.gaibie AT virgin.net)

SUMMARY
This discussion was prompted by a message from Stephen Allen, a CHILD2015
co-moderator and adviser for the CHILD2015 email discussion group. He had
just attended a workshop called ‘Wales for Africa’ in Cardiff, Wales (UK).

The workshop emphasised the importance of internet access for African
partners. It was proposed that this was essential for good communication
between the partners and also for access to healthcare information.

However, a participant from Africa emphasised the many difficulties and
cost of establishing and maintaining internet access. His view was that
internet access was a luxury that could not be justified where health
institutions were short of essential drugs, equipment and staff.

Stephen Allen asked: "How can the right balance be struck between, on the
one hand, allocating scarce resources to ensuring adequate supplies of
drugs, staff etc. and, on the other, allocating resources to the
information and training required to ensure that what is available is put
to best use? Is the internet a crucial element in this - so that we should
advocate that all health institutions of a certain size must have internet
access?"

CHALLENGES
A member summed up the challenges as follows: "For most of us in
technologically advanced countries, purchasing Internet connectivity is a
no-brainer. We capitalize on generations of technological, civic, and
economic achievements and rarely think about the giants whose shoulders we
stand upon to enjoy round-the-clock power, reliable companies, trustworthy
payment methods, more-or-less predictable legal environments, and armies
of trained technicians who set up and maintain our networks. But our
colleagues in developing countries have a long way to go before they can
spend an insignificant portion of their organization's budget to have
ample, reliable Internet connections.

Even where internet is accessible, the content may be of limited value:
"At least in some countries language is a barrier. English is the language
of science and medicine but it is not managed proficiently by our
professionals and students."

INTERNET CAN MAKE ALL THE DIFFERENCE
Another member commented: "The internet has changed how we work in
development and public health. We have a number of internet-based coaching
programs that allow us to coach participants to improve how they work and
provide services in developing countries. We have found out that if people
are motivated and get valuable information and support, they do not mind
walking to the nearest cybercafй to visit our website, or get our emails
with the program materials and to send us their assignments once a day. We
also use skype to chat or talk with program participants and our default
rate is very low, and not due to the internet, but because they got busy
at work or had some other personal problem and they defer their enrollment
to the next period. I believe the internet is great and changing the way
we provide assistance to health workers in developing countries. They
learn to trust themselves and implement changes in their own terms and
according to their
strengths and talents! I think that with imagination, innovation and
creativity, we can take advantage of the connectivity the internet offers,
and accelerate reaching the MDGs."

An example of the indispensability of the internet was given by another
member: "internet access is so important: In 1998, a World Survey was
initiated, using a secure Oracle database and submission of anonymous data
via the internet....The survey has now become the World Rb Registry, with
prospective data... Internet access allows real-time consultation between
medics in resource-rich and resource-limited countries...."

THE EXPENSE OF INTERNET IS NOT ALWAYS JUSTIFIABLE
One member commented: "The answer must come from those who are using or
trying to use the internet."

Another: "There is an important difference between researchers and
specialists who cannot thrive without broadband and the average health
professional in poor countries - not every healthworker needs - or has
time - to trawl the web for appropriate medical information....How
wasteful of human resources if every practitioner, every clinician (North
or South) had to check the Web to keep up with best practice and most
effective and efficient therapies. Should it not be the responsibility of
the country's or region's central health authority or medical school -
and/or of the WHO national or regional office - to distribute such
information - centrally gathered and synthesized from Internet or other
current sources - to all health workers for whom it is relevant?" The
author gave examples of the Zimbabwe quarterly digest CHIZ - Current
Health Information Zimbabwe and the CME Uganda newsletter that is
distributed by email.

Another CHILD2015 member commented that internet connectivity is the most
cost-effective source of knowledge for some situations. Not every facility
could have it but tertiary centres should not go without it. The amount of
money need to buy every new edition of a text book will certainly be more
than that needed to maintain an internet line. Patients in developing
countries need the best care with the right skills and knowledge just like
anywhere in the world.

SOLUTIONS

1. MAKE THE INTERNET MORE ACCESSIBLE AND AFFORDABLE
"Once wireless internet access becomes available (thus obviating the need
for land lines), I am hopeful that more medical institutions world-wide
will gain access to this valuable resource."

"Open access principles where applicable should be applied."

2. PROMOTE INTERNET ACCESS WHERE IT IS MOST NEEDED
"While many individuals do not have access to the internet, most training
facilities do. By making paper-based self-help learning courses available
on free websites, training facilities can access the material and then
print their own education manuals for local use. This is an easy, cheap
and effective way of enabling local, regional or national healthcare
authorities to get a wide range of appropriate learning material to all
professional health care workers in their service. For the past 12 years
we have used this method of empowering groups to very successfully manage
their own continuing education and professional growth without the need of
formal trainers and online internet access.

3. USE ALTERNATIVE METHODS
"Are there other, better, less expensive ways to get information into
people's hands?... If computers are to be used, what kinds of information
can we deliver without Internet bandwidth? What kinds of information can
ONLY be delivered via the Internet? These are worthwhile distinctions to
make as we construct information dissemination strategies that meet the
needs of the varied practitioners in the field. In March I visited the
medical school in Liberia. A student there related how he had parked his
car next to a hotel that had wireless Internet. He "poached" some
bandwidth and downloaded a physiology textbook over the course of a couple
hours. He then copied this textbook to a flash drive and shared it with
his classmates. After a couple of months, everyone in his (small) class
had read or copied the book from the flash drive. We can capitalize on
these kinds of innovative knowledge sharing activites."

"Mobile phones may be a more useful medium."

"I think it's important that we continue to look for more cost effective
ways to deliver knowledge... The eGranary Digital Library is one (see
http://www.egranary.org) but there are others (like simple CD-ROMs and
flash drives.)"

"Freedom Toasters are conveniently located, self-contained,
computer-based, 'Bring 'n Burn' facilities. Like vending machines,
preloaded to dispense confectionery, Freedom Toasters are preloaded to
dispense free digital products, including software, photography, music and
literature. The Freedom Toaster project began as a means of overcoming the
difficulty in obtaining Linux and Open Source software due to the
restrictive telecommunications environment in South Africa." (Source of
preceding text: http://www.freedomtoaster.org). These "kiosks" can
substantially bring down the costs of connectivity if (a) they can then be
combined with some kind of delay tolerant networking systems to join with
each other (network of kiosks, the wider the better and we totally bypass
the conventional internet connectivity at no cost beyond the cost of one
time set up), and (b) key personnel in hospitals and small communities be
taught how to do wireless networking in their own homes and communities."

CONTRIBUTORS
Patricia Abbott is the Co-Director of the PAHO/WHO Collaborating Centre
for Nursing Knowledge, Information Management and Sharing at the Johns
Hopkins School of Nursing in Baltimore, USA. She is also a member of the
Board of Directors for the American Medical Informatics Association (AMIA)
and serves on the Editorial Board of the Journal of the American Medical
Informatics Association (JAMIA). Patricia is a Fellow of the American
College of Medical Informatics and the American Academy of Nursing. Dr
Abbott’s primary area of research is in connectionist machine learning
techniques/data mining. Additionally, Dr. Abbott serves as the
Secretariat for the Global Alliance of Nurses and Midwives Communities of
Practice effort; a WHO initiative to address the crisis in the global
health workforce. pabbott2 AT son.jhmi.edu

Stephen Allen is a co-moderator and adviser for the CHILD2015 email
discussion group. He is a Reader in Paediatrics and Honorary Consultant
Paediatrician at the School of Medicine, Swansea University, UK. He is the
Overseas Director for Africa for the David Baum International Foundation,
and a committee member of the International Child Health Group, in
association with the Royal College of Paediatrics and Child Health, UK. He
has 4 years experience in Papua New Guinea and 6 years with the Medical
Research Council, The Gambia, involved in training, research and clinical
paediatrics. He has developed eLearning in international health in
partnership with colleagues at the University College Hospital, Ibadan,
Nigeria (see
http://www.medicine.swan.ac.uk/inthealth.html). s.j.allen AT swansea.ac.uk

Ike Anya is a lecturer in public health at University College London.
ike.anya AT gmail.com

Arindam Basu is a Consultant in Ear Nose and Throat Diseases and
Epidemiologist, at the Guru Tegh Bahadur Medical Center in Kolkata, India.
He is also currently working as the Associate Director of the Fogarty
International Training Program of the University of California at
Berkeley. He is keenly interested in evidence based medicine,
meta-analysis and systematic reviews. He works as an author of the
Clinical Evidence topic, "Earache in air travelers" for the secondary
evidence journal, "Clinical Evidence". His current area of interest is to
create a web service in Ruby on Rails to enable healthcare researchers to
quickly collect and appraise best evidence. He has been a member of the
evidence based health discussion group since 1996. arin.basu AT gmail.com

Elvira Beracochea is a medical doctor and President and CEO of MIDEGO,
Inc, based in Fairfax, USA. MIDEGO is a global health care consulting firm
whose mission is to help partners to reach the Millennium Development
Goals. MIDEGO offers health care management consulting, capacity building
and coaching services for health professionals and managers that want to
achieve outstanding performance consistently and efficiently.
www.midego.com elvira AT midego.com

Anuradha Bose is a paediatrician working in the departments of Community
Health and Child Health, Christian Medical College, Vellore. She has
interests in Infectious Diseases and in Injury Prevention. The Department
of Community Health is primarily committed to demonstrating the role of a
medical college towards achieving health for all in Vellore district
through a participatory approach that empowers the people. Her interest is
in issues related to child survival in India. Anu's department has a
varied teaching programme, including teaching courses on International
Health. abose AT cmcvellore.ac.in

Daisy Dharmaraj is a medical doctor specialised in Public Health, from
Christian Medical College, Vellore, India. She heads the AIDS desk of the
National Lutheran Health and medical board and TEST (Techno economic
studies and training) foundation in India. Both organisations are involved
in Primary Healthcare, health related action research and advocacy, and
gender issues. Presently her focus is on HIV/AIDS prevention, care and
support especially in the rural areas, and her primary concern is to make
health care accessible to them.www.aidsindia.in
www.peopleshealthfoundation.org daisy.dharmaraj AT gmail.com

Matthew Ellis is a consultant paediatrician at Southmead Hospital,
Bristol, UK. He is also a Senior Clinical Lecturer Child Health, Centre
for Child and Adolescent Health, Bristol University. His research
interests include the public health of birth asphyxia in low income
countries and the epidemiology of neurodevelopmental disorders of
childhood. He is course director of the International Health BSc for
medical students at Bristol University and convenor of the International
Child Health Group of the Royal College of Paediatrics and Child
Health.m.ellis AT bristol.ac.uk

Cynthia Flynn is Associate Professor of Nursing at Seattle University,
USA, and President-elect of the American Association of Birth Centers. She
is interested in training midwives throughout the world. FlynnCNM AT
aol.com

Michael Gibbs is a publisher of clinical textbooks and open-access
journals. Sherborne Gibbs Ltd (Birmingham, UK) publishes the following
titles: Cardiovascular Journal of Africa; British Journal of Cardiology;
British Journal of Primary Care Nursing; The British Journal of Diabetes &
Vascular Disease; Diabetes & Vascular Disease Research; Journal of the
Renin-Angiotensin-Aldosterone System; and Primary Care Respiratory
Journal. mgibbs AT sherbornegibbs.co.uk

Abubacarr Jagne is a junior doctor at the Royal Victoria Teaching
Hospital, Banjul, The Gambia. abubacarrjagne AT gmail.com

Saroj Jayasinghe is Consultant Physician at the National Hospital in
Colombo and Associate Professor at the Dept of Clinical Medicine at the
University of Colombo. He is also Coordinator of the Postgraduate Diploma
in Health Development and was the first Director of the Medical Education
Development and Research Centre. His current research focuses on the areas
of poverty, health determinants and health policy. sarojoffice AT
yahoo.com

Jorge Maldonado is a senior physician, former Full Professor of Medicine
at the Mayo Clinic, from Colombia with an interest in health information.
He works on Saludhoy.com and Iladiba.com and cursosiladiba.com websites,
which deliver health information to health professionals and the general
public in alliance with Colombia's National Academy of Medicine and
National Institute of Health. jorgem AT emsa.com.co

Clifford Missen is director of the WiderNet Project, a non-profit
organization at the University of Iowa, USA, that works to improve digital
communications in developing countries. Cliff has over 20 years
professional experience in computers, networking, multimedia design, and
applications development. He combines this with his long-term interest in
international development. The eGranary Digital Library is a program of
the WiderNet Project, and provides an 'Internet in a Box' to the
unconnected majority, by storing huge amounts of information on hard
drives on internal networks. It contains books, websites, journals, movies
and audio files from hundreds of contributing authors and
publishers who freely contribute to help bridge the digital divide.
missenc AT widernet.org

Paul Mwanzilo is the Librarian of the Faculty of Health Sciences Library,
Egerton University, Kenya. He holds a diploma in Information and has over
20 years in academic library work. mwanzilo AT yahoo.com

Brian Ostrow works with the Office of International Surgery, University of
Toronto, Canada. His interests include the Ptolemy Project
http://www.ptolemy.ca/ which provides surgeons in the developing
world with online access to the University of Toronto library; and Surgery
in Africa http://www.utoronto.ca/ois/SIA.htm which publishes reviews on
the topic. brian AT bookshelf.ca

Helga Patrikios is an independent consultant based in Newbury, UK. She is
currently working on the history of leprosy. She recently retired as
medical librarian of the University of Zimbabwe. helgoid AT yahoo.com

Lenny Rhine is University Librarian Emeritus at the University of Florida,
USA. His interests include: delivery of health information in developing
and transitional countries; electronic health information; Internet
resources; and training for identifying, filtering and using Internet
resources. rhinel AT ufl.edu

Paget Stanfield is a retired paediatrician with an interest in the
availability of learning materials and textbooks for medical students and
postgraduates in developing countries. He has a long experience in Africa,
particularly with the Makerere University, Uganda, and AMREF. Paget is
editor of the textbook, Diseases of Children in the Tropics.
welcome.stanfield AT c-pac.net

Abby White is co-founder and coordinator of Daisy's Eye Cancer Fund, an
Oxford (UK) and Toronto (Canada) based charity that takes a global
approach to the needs of children affected by retinoblastoma, an
aggressive but highy treatable childhood eye cancer, which kills over
7,000 youngsters each year. Abby is based in Oxford, UK.
http://www.daisyseyecancerfund.org/ abby AT daisyseyecancerfund.org

Dave Woods is emeritus professor in neonatal medicine at the School of
Child and Adolescent Health, University of Cape Town, South Africa. He is
Chairman of the Perinatal Education Trust and Eduhealthcare, both
not-for-profit non-government organisations that develop appropriate
self-help distance learning material for doctors and nurses who care for
pregnant women and their children in under-resourced communities. He has
30 years experience as a clinical neonatologist, with particular interests
in perinatal care and training of health professionals. He is currently
developing paper-based continuing learning material in maternal care,
newborn care, childhealth, and care of adults and children with HIV/AIDS.
He is also participating in the design and development of wind-up
appropriate health technology for poor countries. www.pepcourse.co.za
pepcourse AT mweb.co.za

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