Portal de Periódicos da CAPES

Health information in the developing world

1998; Elsevier BV; Volume: 352; Linguagem: Inglês

10.1016/s0140-6736(98)90300-2

1474-547X

Bernard Lown, F. Bukachi, Ramnik J. Xavier,

Global Public Health Policies and Epidemiology

Bernard Lown is emeritus professor at Harvard School of Public Health and senior physican at the Brigham and Women's Hospital, Boston. He is the author of 450 scientific articles, three medical books, and The Lost Art of Healing (New York: Houghton Mifflin, 1996). He developed the DC defibrillator, cardioverter, and introduced lidocaine as an antiarrhythmic. He was the cofounder and first president of Physicians for Social Responsibility (PSR-USA), which is a subgroup of the International Physicians for the Prevention of Nuclear War (IPPNW), and received the UNESCO Peace Award and Nobel Peace Prize in 1985 on behalf of IPPNW~ Professor Lown is also the founder and chairman of SatetLife. Ramnik Xavier graduated from Godfrey Huggins School of Medicine, University of Zimbabwe. He trained in Internal medicine in gastroenterology an(~ molecular biology at the Massachusetts General Hospital, Boston and joined the staff there in 1996. Senior medical advisor to Satel Life, Dr Xavier is also the editor of Health Net News. Fred Bukachi is HeathNet Regional Director for Africa, and an honorary physician at Kenyatta National Hospital, Nairobi, Kenya He obtained a master of medicine internal medicine at the University of Nairobi Medical School, and has published several items in local scientific journals and newsletters on health informatics. His current research interests are telemedicine and hypertensive heart disease. In considering the health information needs of developing countries, one cannot ignore the essential fact that poverty is the leading cause of poor health across the globe.1Report of the Ad Hoc Committee on Health Research Relating to Future Intervention OptionsInvesting in health research and development (summary). WHO, Geneva1996Google Scholar, 2Beaglehote R Bonita R Public health at the crossroads. cambridge University Press, Cambirdge1997Google Scholar 900 years ago, A1 Asuli, the great physician of Islam, living in Bokhara (now Kazakhstan) wrote a medical pharmacopoeia. He divided this monumental treatise into two parts: "diseases of the rich" and "diseases of the poor". The passage of so many centuries has not made the dichotomy obsolete. As we race to a new millennium, the divide between rich and poor is widening–within industrialised nations, but more so between developing and developed countries. In 1996, 358 billionaires controlled assets greater than the annual incomes of countries representing 45% of the world's population—2′5 billion people.3Crosette B U.N. survey finds world rich-poor gap widening.New York times. July 15, 1996; A3Google Scholar In this age of potential abundance, more are hungry than ever before. Oxfam reports that a third of people in Asia, Africa, Latin America, and the Caribbean are too malnourished to lead fully productive lives.4Medical News BriefsBMJ. 1993; 306: 1147Crossref Google Scholar The disparities between rich and poor nations are prodigious. The industrialised countries (21% of the world's population), account for 85% of the global gross national product, of world trade, and of energy consumption. By contrast, the poorest quintile contribute a meagre 1–4% to the global gross national product and engage in only 0·9% of world trade.5Kevany J Extreme poverty: an obligation Ignored.BMJ. 1996; 313: 65Crossref PubMed Scopus (11) Google Scholar This formidable divide continues to grow. According to the United Nations, from 1960 to 1990, income per head increased four times among poor nations compared with an eight-fold rise among the wealthy ones. The difference in annual income is now more than 60 fold.6Crossette B U.N. World Bank and I.M.F. join $25 billion drive for Africa.New York Times. March 17, 1996; Google Scholar As of 1996, 89 countries out of 174 were worse off economically than they were in the 1960s and 1970s.4Medical News BriefsBMJ. 1993; 306: 1147Crossref Google Scholar The policies of structural adjustment, imposed on developing countries by the World Bank and the International Monetary Fund, have emphasised debt repayment based on maximising exports at the expense of agricultural self-sufficiency and domestic social programmes. These economic strictures have curtailed the already small funding for health services, education, and the environment. According to World Bank projections, by 2005 sub-Saharan Africa will, be back to levels of income per head that it had in the 1970s.7French HVV Africa resentful as Asia rakes in aid.New York Times. March 6, 1998; 8Google Scholar In Africa, as in other regions of the poor world, there is a noteworthy disparity between a mammoth disease burden and the small numbers of trained physicians. In east Africa, there is less than one physician per 10 000 people. Many African countries have far fewer physicians. The low status of women is an additional contributor to morbidity and premature death. Endless drudgery, early marriage, teenage pregnancy, high fertility, inadequate nutrition, anaemia, and chronic infections are some of the risk factors that account for the inordinate child-bearing mortality. Death in pregnancy is related to a woman's status and is reflected by her level of education.8Harrison KA The importance of the educated healthy woman in Africa.Lancet. 1997; 349: 844Google Scholar Although science and technology promise a way out from poverty, it is difficult to be optimistic on that score. In the decade of the 1970s, the increase in the number of scientists per million population was 637 in the industrialised countries compared with 42 (<0·1%) in the developing world (tables 6 and 10 in 9UNESCO Statistical Yearbook, 1985. UNESCO, Paris1985Google Scholar). Only 10% of the US$55 billion spent globally on health research is allocated to the needs of poor countries,10World Health Organization Ad Hoc Committee on Health Research, Relating to Future Intervention OptionsInvesting in health research and development. WHO, Geneva1995Google Scholar where more than 90% of the years of potential life is lost. The grim coin also has a more hopeful side. While the north-south gap has widened in terms of income and higher levels of education, as judged by basic indicators of human development, significant advances have been registered in health care. In the past three decades average life expectancy has increased by 16 years, adult literacy by 40%, and per head nutritional levels by more than 20%. Child mortality has been halved during this period. Developing countries have achieved in 30 years what it took industrialised countries nearly a century to accomplish.11State of the World Year Book. UNICEF, New York1996Google Scholar A further basis for hope is the continuing information revolution-a social transformation of epic proportions. The scaffolding is in place for an electronic total information environment that is becoming an important source of wealth and power. In public imagination the information age is embodied in the internet, promising new vistas for democracy, education, and personal enrichment. Indeed, nothing in human history has provided a potential for making readily available more information for more people at lower cost. As with A1 Asuli's pharmacopoeia, the divide between rich and poor applies also to the sphere of health information. The industrialised north is awash with new information technologies transforming the way health care is delivered. At the same time three-quarters of the world's population are starved of the most basic nutrients of the mind. Of Africa's 700 million people, only 800 000 to a million (0·14%) are users of internet services and of these about 80% live in South Africa.12 Whereas one in six people use the internet in the USA or Europe, for Africa (excluding South Africa) there is one internet user for every 5000 people. Information poverty is a substantial impediment to better health in countries. Medical libraries are supplied with a few worn books and dated journals.'3 Whereas a medical library in the USA subscribes to about 3000 journals, the Nairobi University Medical School library, Kenya (long regarded as a flagship centre for medical literature in East Africa) receives only 20 journal titles today compared with 300 to which it subscribed 10 years ago.14Bukachi F Primary health care and Health Net.Whydah Newsletter Africa Acad Sci. 1996; S: 3Google Scholar In the 1960s, the Albert Cook Medical Library at Makerere, Kampala, Uganda, boasted over 2500 medical volumes and journal subscriptions; one of the largest libraries in east Africa, today it receives fewer than 40 medical journals. A number of libraries have received no new books over the past decade, have no computer, have no access to databases, and have no money for stamps to write for material (Irene Bertrand, WHO Library, Geneva). A major reason for this sorry state has been attributed to the failure of parent bodies or institutions to finance libraries.13Rosenberg D Can libraries in Africa ever he sustainable?.Inform Develop. 1994; 10: 247-251Crossref Scopus (20) Google Scholar The uneven state in neighbouring countries is striking. The library of the University of Zimbabwe still obtains between 600 and 900 books per year, about half as donations. As of 1996, it had a journal collection of 170 titles, compared with 500 in 1984. The library issues a health digest (Current Health Information Zimbabwe-CHIZ) containing abstracts relating to Zimbabwe's principal health problems, which is circulated free to 1200 health professionals (Helga Patrikios, Librarian, University of Zimbabwe Medical School, Harare). Similar digests are produced in six other African countries. Various programmes are beginning to make a difference. Among the most successful is the African Index Medicus (AIM) sponsored by the Association for Health Information and Libraries in Africa (AHILA) and supported by the WHO Regional Office in Africa and by Network Organization for Research and Development (NORAD). This and other programmes define the possible when constrained by scarce resources. The larger picture, however, is of stunted health-information systems due to inadequate infrastructure and lack of initiative on the part of governments and health-professional associations. Internet connectivity and its abundant databases, reference material, journals online, and library-search programmes hold great promise for the information-starved poor countries. The cyber highway may mean that the acquisition of costly traditional medical journals can be bypassed. At present, internet connectivity is growing rapidly in developing world countries, including Africa. Public access to internet services is now available in the capital cities of 42 of the 54 African nations.12Leon F Use of the Internet is growing in Africa.[email protected],nea.ieGoogle Scholar Numerous agencies are promoting this development, such as the World Bank's InfoDEV (Information for Development Program), which seeks to fully integrate developing nations into the information economy. There is also the UN System-Wide Initiative on Africa, one of whose key areas is harnessing information technology for development. The Group of Seven and many other international organisations are launching similar programmes. This computerised technology has the potential of promoting dramatic social, political, and economic change in poor countries. The promise, however, is fraught with serious difficulties. When everyone is talking at once, sense and nonsense become indistinguishable. To locate the nuggets one needs to search for a needle in the proverbial haystack. With the cyber highway growing into a shopping mall, it becomes ever more difficult to separate advertising hucksterism from relevant information. As the information highway becomes privatised and commercialised, cost limits access; this is already evident in the USA, a country with the richest global economy. It is estimated that two-thirds of all personal computers in the USA are bought by those with annual incomes of $40 000 or more, or by less than a third of American households15Lohr S The great unplugged masses confront the future.New York Times. April, 1996; Google Scholar The problem is an order of magnitude greater for poor countries. In the major cities of Africa, direct real-time access to internet lines can be obtained through a growing number of internet service providers. However, hook-up, access fees, and training costs are financially out of reach for most health professionals. A direct internet line to a ministry of health, for example, may cost between $15 000 and $35 000 per month,16Lown B Mullaney J MacArtnur S Lighting a small candle: SateLife.Sci Med. 1996; 3: 8Google Scholar which is far beyond the budget allocated for the communication needs of medical schools, research institutes, or hospitals. Facing oppressive debt burdens, poor countries have curtailed investment in improving healthcare infrastructures or in upgrading telecommunication networks for the public sector. The impact of limited fiscal resources is reflected by the experience of the Witwatersrand Health Sciences Library, Johannesburg, South Africa, which serves some 30 000 users a month and is one of the most advanced in Africa. Although it is capable of delivering electronic information to its clients, it cannot connect up with users in urban hospitals a few kilometres away. The reasons are a lack of money for hospitals to be networked, a telephone system so inadequate that high-speed modems do not function, or cables that are damaged by rain, theft, or vandalism (Glenda Myers, Medical and Dental Librarian, Witwatersrand Health Sciences Library, Johannesburg, South Africa). Although many capital cities throughout the developing world have witnessed a rapid improvement in their telecommunications infrastructures, conditions outside the capital cities remain dismal. In many African countries, expenditure for health per head is less than US$10 annually, yet it costs about US$10 for a 4 min telephone call from Burundi to Botswana.17Mullaney J SatelLife: pioneering the path for electronic communication and health information in the developing world.Clinical Prefor & Quality Healthcare. 1997; 18: 38-44Google Scholar While the affluent travel at ever greater speed on the information highway, a majority of the world's population has never even made a telephone call. Donors have focused largely on the conduits, but the network is clearly not an end in itself. Technical progress demands the training-up of a cadre of individuals who can master the technology. The rate of technical progress invariably depends on the emergence of such expertise. Medical curricula in most developing countries offer little, if any, training in informatics. The result is low computer literffcy among health professionals.18Akinde AD Soriyan HA Adagunodo ER A philosophy for health informatios education in developing countries: Nigeria as a case study.Meth Information Med. 1997; : 131-133PubMed Google Scholar, Furthermore, women–essential to the upgrading of health care in poor countries-are largely left on the sidelines. The problem is made more intractable by the absence of an information chain and an underdeveloped information culture. How can it be otherwise when most medical and nursing students in many poor countries have no textbooks of their own and have little access to medical journals. The sweep of the internet presents additional anxieties. Poor countries have amassed a wealth of locally produced health information that is often highly valued and pertinent to the unique medical problems distinctive to their countries, though inaccessible and not widely known.19Shaw JG Report from Brazzavile.SatelLife/News. 1997; 14: 1Google Scholar How will this raw information be processed by outsiders who may have little appreciation of its relevance? Furthermore, the latest medical knowledge frequently concerned with tertiary-care problems may be remote from the needs of those in poor countries lacking primary health care. The issue of appropriate health information gains urgency as non-communicable disease, endemic in rich countries, increasingly takes a firm hold in poor countries. More than two decades ago, WHO warned that cardiovascular disease, including hypertension, stroke, and coronary artery disease, was emerging as a key public-health issue in developing countries)20WHA 29·49(1976). Handbook of resolutions and decisions of the World Health Assembly and the Executive Board. Vol II. WHO, Geneva1985Google Scholar For the first time, cardiovascular disease is the leading cause of death globally, and other non-communicable diseases are not far behind.21Christopher JL Murray CJL Lopez AD The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard School of Public Health, Cambridge, Massachusetts1996Google Scholar In 1990, two-thirds of the 14 million deaths due to cardiovascular disease worldwide occurred in developing countries. Incidence and premature death can be expected to continue to rise because most of the people are under 35 years of age and risk factors are already prevalent among the young.22Wielgosz AT The decline in cardiovascular health in developing countries.World Health Statist Q. 1993; 46: 90PubMed Google Scholar At the same time, tropical disease continues to be a relentless scourge complicated by the AIDS epidemic, antibiotic resistance, and a breakdown of essential public-health services. The promotion of modern conduits of information is unlikely to reverse these changes. In responding to the health transition, will governments in developing countries succumb to the model evolved in rich countries? The pattern seems to be largely set since the public-service sector of poor nations is shrinking while health-care facilities are being rapidly privatised. In capital cities, one witnesses new, well-equipped tertiary-care hospitals, fully stocked with cutting-edge technologies to service the country's elites. These investments consume large proportions of health budgets at a time when funds are in short supply to deal with elementary public-health problems such as safe drinking water, nutrition, sanitation, and literacy among women. This approach has less to do with a moral failing of the developing world than with the irresistible pressure of the global economic system, the deluge of information, and the pressures of new technologies.23Woolhandler S Himmelstein DU Labar B Lang S Transplanted technology: third world options and first world science.N Engl J Med. 1987; 317: 504Crossref PubMed Scopus (20) Google Scholar Nonetheless, the experience of the industrialised world is highly relevant in cardiovascular disease. A wealth of epidemiological observations points to the role of clearly identified risk factors that can be modified by public-health policies and individual lifestyle changes, thereby reducing the burden as well as the outcome of cardiovascular disease.24Reddy KS Yusuf S Emerging epidemic of cardiovascular disease in developing countries.Circulation. 1998; 97: 596-601Crossref PubMed Scopus (954) Google Scholar, 25Cooper RS Rotini CN Kaufman JS Muna WFT Menash G Hypertension treatment and control in sub-Saharan Africa: the epidemiological basis for policy.BMJ. 1998; 316: 614-617Crossref PubMed Scopus (111) Google Scholar These lessons are especially pertinent in relation to the role of tobacco consumption, which is now gaining a substantial foothold in poor countries. The available health information obviates the need to re-invent proverbial wheels. However medical journals in the rich countries necessarily mirror their own health-care practices. Unsifted information from these sources could further distort the already strong tendencies away from population-based health policies. Many medical journals are already posted on the worldwide web, but we need new information institutions that are closely tuned to the health problems of poor countries. Such tuning requires a partnership of equals between health professionals of the two worlds, so that the shared information is scientifically sound, reliable, pertinent, and affordable. Among novel institutions, SatelLife, though a tiny organisation by any measure, is already making a dent in the information poverty that afflicts the developing world. This Boston-based non-profit organisation was founded in 1987 to provide communication links among physicians and health workers in the developing world and to constitute a source of relevant information.26Lown B A dream deferred. Final plenary session fifth congress international physicians for the prevention of nuclear war. IPPNW V Congress Report. Hungary, BudapestJuly 1, 1985Google Scholar, 27Groves T Further down the information highway: SatelLife.BMJ. 1996; 313: 1-4Crossref PubMed Scopus (7) Google Scholar It has focused on low-cost, yet appropriate and highly functional, technologies capable of delivering critical information where it is most needed. Its electronic network, HealthNet, was initially based on low-earth-orbit satellite (LEO) technology, providing cost-effective and reliable technology for reaching remote areas with inadequate telecommunication infrastructures. The LEO satellites (Surrey Satellite Technologies Ltd, UK) were launched in 1991 and 1993 by Arianspas, the European space agency. Each satellite, roughly the size of a small television set, circles the earth in a polar orbit at an altitude of about 800 km. It passes every point on earth at least four times daily, circumnavigating the globe in 100 min. Since telephone lines have improved, health information can be moved more quickly and efficiently with standard telephone dial-up networks, and high-speed modems. Today, over 95% of the HealthNet information flows over telephone lines. However the LEO satellite remains indis pensable for communication with a number of remote sites that lack adequate telephone services. HealthNet now serves about 4000 health professionals in 25 countries. These programmes are structured to be cooperative, interactive, and driven by the needs and resources of users. A local "User's Council" works with SatelLife to define the health-information needs and develop the appropriate communications solutions for each country. A network manager oversees operations. Through e-mail, electronic conferencing, and electronic publications, HealthNet has become a critical link for many on the frontlines of the major public-health battles being waged in poor countries. A basic tenet is that sustainability relates not to the sophistication of the technology but to developing human capital. SatelLife, with World Bank support, is currently sponsoring "a regional centre in Nairobi, Kenya, for training health professionals in information technology. Subscribers can receive electronic publications such as the weekly HeahhNet News, which provides current abstracts from leading peer-reviewed medical journals as well as full-text articles, which are selected on the basis of their sound science and relevance to health problems in developing countries. Royalty-free arrangements with 18 leading medical journals, including The Lancet, afford a wide range of high-quality communications. A special software package, relying on simple e-mail, enables subscribers to engage in remote electronic searches of 21 abstract databases at the National Library of Medicine in Washington and to receive relevant abstracts. SatelLife recently has developed GetWeb, an electronic tool to retrieve documents on the worldwide web for health professionals in developing countries that do not have a direct internet connection. In collaboration with the American Physiological Society (APS), this programme has been configured to interact with the weekly online notice of research articles and abstracts scheduled for publication in the APS Journal. Through this service, more than 30 000 documents are obtained monthly by health workers worldwide with only e-mail access. The expert-moderated international electronic conferences are the mainstay of HealthNet-information services; these are on both the internet and the store-and-forward SatelLife network. ProMED-mail, founded and directed by Jack Woodall in cooperation with the Federation of American Scientists, monitors the emergence of infectious disease in man, animals, and plants.28Mitchell P Pro MED-mail: outbreak intelligence or rash reporting.Lancet. 1997; 350: 1610Summary Full Text Full Text PDF Google Scholar ProCAARE, launched in cooperation with the Harvard AIDS Institute, provides communication and peer-reviewed information on diverse aspects of HIV/AIDS with particular emphasis on meeting the needs of practitioners. Afro-Nets, a conference dedicated to African health research and development, deals with capacity building, resource mobilisation, and the application of research in east and South Africa. A recent addition, ProCOR, in partnership with the Lown Cardiovascular Center of Boston, addresses the emerging epidemic in cardiovascular disease in poor countries.29Lown B Health technology in the developing world and SatelLife ProCOR February.www.healthnet.orgDate: 1997Google Scholar This novel programme aims to raise global consciousness of the surge of cardiovascular disease. A major focus has been on the tobacco wars of the next century that will increasingly be waged among vulnerable populations of developing countries ill-equipped to cope with the slick marketing techniques and the dirty tricks perfected by the tobacco industry. ProCOR also intends to promote a dialogue on the experience of industrialised nations that can translate into population-health cost-effective prevention. The communication revolution, which affords an opportunity for bringing ordered structures with reliable information to the internet, is especially essential for poor countries as they enter the global dialogue. Wiring the poor world, however, will not close the information gap between the haves and have-nots. Improving information access will require a far more equitable global world Order. The prosperity of industrialised countries over longer stretches of history relates in no small measure to the cheap products obtained from poor countries. Transfer of this wealth to Europe and North America continues and is expanding. Those who live in affluence deplore the situation, but turn away from the moral challenge. As Tolstoy complained about the state of dispossessed serfs in Russia, more than a century ago, "I sit on a man's back, choking him and making him carry me, and yet assure myself and others that I am very sorry for him and wish to ease his lot by all possible means except by get ting off his back" (What Then Must We Do? 1886). The annual servicing of Africa's debt of $300 billion exceeds the funds available for health and education combined. An AIDS-afflicted country such as Uganda spends US$2·50 per person per year for health and $15 on debt servicing30Logie DE Benatar SR Africa in the 21st century: can despair be turned to hope?.BMJ. 1997; 315: 1444-1446Crossref PubMed Scopus (13) Google Scholar To usher in the new millennium, cancellation of the colossal debt from poor to rich countries would do more for improving health care than providing free subscriptions to leading medical journals for every health professional in developing countries. The time is appropriate for the health profession to speak out.