From tracking outbreaks of new infectious diseases with the potential to spread at jet speed to reminding HIV-infected patients to take their medications, information and communications technology (ICT) has become an indispensable part of global health.
Different Fogarty program areas are finding new ways of using communications hardware and software to enhance research projects in hard-to-reach regions, and the Center is examining success stories in order to make ICT an integral part of its new strategic plan to foster a "sustainable research environment in low- and middle-income countries."
At an international conference on e-health, sponsored by the Rockefeller Foundation in Bellagio, Italy, in July, Fogarty Director Dr. Roger I. Glass said most of the new money in global health is disease-specific but each of those programs needs interoperable databases so they can be properly evaluated.
"If I go to any part of Africa, I can use my bank credit card in any bank or ATM. I can buy a Coca-Cola in any little city. But I can't get a health record or immunization card," he said in urging ICT programs to seek corporate partners. "I think the private sector has a lot to teach us about logistics, about Internet broadband access and they are in a position that they could well want to fuel what we're doing."
Photo by Eric Miller
ICT is a broad concept that encompasses computers, cell phones, broadband, video-conferencing and distance learning - and Fogarty grantees are at the forefront of the movement, trying to adapt fairly standard Western technologies to low-resource settings.
"The use of cell phones and Internet applications for health research and surveillance is one of the most exciting tools in public health on the horizon," says Dr. Pamela Johnson of Voxiva, a global health telecom company that works with some grantees.
The cell phone, she says, has been used for disease surveillance, health program management, patient monitoring and personal health as well as for global health research.
Attach a camera that turns a cell phone practically into a microscope, and "The public health implications of this (for example in diagnosing malaria or tuberculosis remotely) are stupendous," say Dr. Krishnan Ganapathy and Aditi Ravindra in a Bellagio conference paper.
The promise of ICT overall, says Dr. William Tierney of Indiana University is that "we have critical tools for maximizing the benefits provided by the limited financial and human resources available." From a small Fogarty grant, Tierney created the first electronic medical record system in Kenya, and he was instrumental in developing similar systems based on low-cost, open-source tools now in use in more than a dozen countries on three continents.
After visiting a Fogarty program in Haiti, Dr. Rebecca Dillingham of the University of Virginia Center for Global Health and a former grantee herself, replicated the idea of using cell phones to communicate with HIV-infected people in rural parts of her state. Landline phone service is spotty and consists of party lines in those countries, HIV carries high social stigma and the nearest clinic is, on average, two hours away by car.
Under her pilot project, free phones are given to patients to remind them through text messages to take their medications, refill their prescriptions and remember their next clinic appointment.
And although not all her patients have used or even seen a cell phone, focus groups of likely users made it clear "everybody wants one," she says.
In Peru, grantee Dr. Walter Curioso has built an interactive computer system using cell phones not only to promote adherence to antiretroviral treatment and encourage risk-reduction but for real-time collection and transmission of adverse events involving the administration of metronidazole as a possible treatment for vaginosis.
"Cell phones are ideal tools for a mobile team, and the equipment is less likely to be stolen compared with laptops or personal digital assistants," he says.
Echoing Dillingham's observation that "everybody wants one," the fastest growth in cell phone use has come in Africa, where, by the end of this year, Voxiva's Johnson says, there will be more of them than in North America. According to the company there are now 3.5 billion cell phones in the world, and by 2010, 90 percent of the world will have coverage.
Forty years ago, the idea of teaching a college course by television was a necessary evil at overcrowded American college campuses.
Today, with leading universities freely making their courses available on the Internet and with teleconferencing technology relatively cheap "distance learning" is being used to save lives in low-income, high-illness countries.
After a consultation with leading experts in the field this summer, Fogarty is taking steps to incorporate technology into its programs to help grantees connect students, clinicians and patients with both general information and research data via the Internet itself, the noncommercial academic-based Internet2, the OpenCourseWare movement and devices called "Internet in a Box™ and "Virtual Hospital". Even Second Life® is being looked at as a teaching tool.
Although distance learning has been a staple of many universities' academic and public outreach for years, the Center's focus is on using it to train researchers how to build sustainable health infrastructure in their countries.
"The countries with the greatest need for health resources are the same countries with the fewest Internet resources," says Dr. Thomas Cook, a professor and environmental health grantee at the University of Iowa.
Cook helped develop an offline method of transferring medical information called the E-Granary Digital Library, which stores more than 700 CDs-worth of educational resources from 1,000 Web sites and is shipped to institutions in Africa, India, Bangladesh, Azerbaijan and Haiti for installation on their computers and local networks without need for an Internet connection.
They can even send back local content for inclusion on the next iteration of the CDs. The cost is $750 for the 750-gigabyte digital library and $2,800 for a server.
Cook also is an advocate of Web conference software, such as Elluminate, which can be cost-effective in regions where classrooms or faculty are few and far between. Elluminate is available to all Fogarty grantees for use in their programs.
A Tufts University program under Framework grantee Dr. Jeffrey Griffiths collaborates in curriculum development with Makerere University and the University of Dar es Salaam and relies heavily on a digital library that can link to computers in resource-poor areas.
The program seeks culturally appropriate responses to health problems; one example being the realization that a Ugandan sanitation solution dependent on school children taking turns cleaning new toilets would not work in Indian schools because of caste-related prohibitions on such a chore.
A Harvard program under Fogarty grantee Dr. Richard Mollica focused on natural-disaster-induced mental health trauma brings students together for two weeks in Italy followed by five months of Web-based training with close faculty supervision and strong peer learning. Requirements include each student participating in two small-group assignments--a clinical or policy case detailing a current work problem and a video.
Mollica says that preliminary results reveal that this model has resulted in an increase in networking and decrease in isolation; confidence and competence in technical topic; an empathetic climate and trusting community for learning; and high levels of both student and faculty satisfaction with certificate training.
Some coursework can be taken by "self-learners" using packaged material, says Fogarty informatics program officer Dr. Flora Katz, but other courses that require laboratory or field training are best conveyed person-to-person. "The hands-on part of science cannot be self-taught, and we don't know yet where the edge is for distance learning."
ICT and distance learning have the potential to transform health systems, says Dr. Ariel Pablos-Mendez, managing director of the Rockefeller Foundation, but there are still huge disconnects: computer interoperability and the relatively low financial investments ICT and health companies are making in each other.
He says bringing the talent of information technology professionals and corporations to serve public health needs in the developing world should be "the higher order vision...I think this is going to happen, and I think it is going to be an incredible revolution for the next 10 years."