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The internet, public health, and the globalisation of just about everything
  1. NANCY MILIO
  1. The University of North Carolina at Chapel Hill, Carrington Hall 7460, Chapel Hill, NC 27599, USA (nancy_milio{at}unc.edu)

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    The internet links almost a billion computers. It is both a driver and a central component of globalisation. The web is also a symbol of globalisation, signalling promise and deep problems, hopes and forebodings. While some observers see vast gains in communication, information access, commerce and new wealth, critics point to big unresolved issues: elite control over rules in marketing, production, and labour; invasions of privacy; expansion of fraud and misinformation; the shredding of ties to family, friends, and local communities, and global corporate gatekeepers to the technology and its content.

    Who will be our webmeister? More specifically, will corporate commercial interests dominate the electronic world over the public interests of planet and peoples? Are we to be atomised consumers who simply buy goods, services, and information and accept whatever guarantees the sellers might offer? Or will we be global citizens participating in decision making and entitled to call decision makers to account?

    Recent headlines confront us with attempts by transworld corporations to control both the tools for information access (the Microsoft antimonopoly ruling) and content (the mammoth merger of the entertainment giant Time-Warner with Internet Service Provider AOL, and French Vodafone with Canadian Seagrams), profitising the net. To counter this trend, critics have proposed a reserve province on the internet of the same quality and usability as that of its enlarging commercial counterpart, a cyberspace preserve for public institutions—where governments can (and should) improve the transparency of their own decision making and information systems; where non-profit service, educational, and public interest organisations can offer internet services free or at low cost with a publicly subsidised rate similar to “old media” public radio, TV, telecommunications and press.1

    In the fascination of searching through limitless worlds, the new electronic tools have so absorbed the day span of human beings, that in addition to the frenzy of pursuing more wealth, there is ever less time for family, friends, and organisational activity, including participation in public issues and policies. More of the public is audience than participant; more are observers than actors in shaping community life.2 Yet, while these early signs may be true of internet users, they leave aside their less affluent and rural counterparts in disadvantaged areas who cannot afford to enter the information and technology revolution, adding another dimension to what people—and communities—“have not”.2 3

    Issues for health proponents

    The connections between globalisation and its flagship technologies with health and health care are felt by almost all nations: growing gaps in wealth and power creating larger inequalities in health; profitisation of health care financing and delivery while public health resources face austere budgets; cutbacks in social policy and resources; loosening of governmental health, safety, and environmental protection regulatory and enforcement.4-7The issues of concern about globalisation are reflected in the internet—control, commercialisation and quality of exchanges in information, goods, and services; uprootedness of community on the ground, and exclusion (from places, people, possibilities of new technologies). Public health proponents therefore must face these issues and their implications for health information and advocacy.

    How in the webworld of the public's health will this new technology be used? To convey traditional practices and, more recently, corporate purposes? Or create new ways to use new types of information in new coalitions to challenge the patterns and priorities of corporate and bureaucratic policies when they augur poorly for health? For those who are concerned about health in the emerging picture of electronic globalisation, the issue is not only access to information technology for individuals, but also for all groups who advocate healthier living conditions, environments, and lifestyles across the globe.

    In this view, those who represent the promotion of health for planet and people, whether in or out of government, may be said to have at least two webworld responsibilities that they may or may not be capable of fulfilling. One is to be a reliable gateway, framer, and filter of information that claims to be about health and about what is needed to enable populations to achieve it. Secondly, is to use the new tools to identify issues—including policies—that affect the prospects for health and to mobilise and coordinate coherent and timely responses. This means broad based action at appropriate policy making levels—global or regional, national and local, drawing on the expertise, experience, and support of like minded groups and individuals around the world.

    Health information and commercialisation

    Health information itself has been transformed on the internet. It is now a commercial product available at over 17 000 web sites. Health is the single largest type of news sought by internet users, by 40% in the US alone. The majority of online American Medical Association journal users are not doctors, but the public. Physicians say that 60% of their patients now come to them with internet printouts, demanding further information or treatment. Not surprisingly, medical advertising will be worth $265 million within two years, as direct to consumer drug marketing takes up half of all online health advertisments.8 In a word, “health” has gained “portal” status—it is first to grab users' attention when they go online, from whence they can be lead to commercial offerings, an avenue that sellers are willing to pay for. Health has become the (spider's) web to catch the unwary information seeker.

    Questions about the quality, reliability, and security of information are endemic to the web. The web is almost by definition chaotic and its information is worth less than it might be when it is unselective and networked activity is incoherent. There are no accepted standards for purported scientific, journalistic, or other types of entries, although many options have been posed and followed by some web authors (www.scipich.org;pubs/pubs.htm;9). Thus, with almost infinite information access, uncertainty about its reliability is a constant companion.1

    Policy advocacy and organisation

    In the context of globalisation, policy making becomes more complex. As policy decisions involve larger, transnational players, occur at more levels, and change the policy choices at lower layers, the meaning of health policy making and advocacy changes drastically. To influence policy that promotes health requires new allies, tools, audiences. It demands not only “know what” (knowledge) but also “know how” (strategic/political skill) to make a difference in policy arenas. It means having action oriented, coordinated, broad based alliances as occurred at the WTO meetings in Seattle among labour unions, environmental, women's and other groups, each a kind of “ring” with its own network of groups spanning the globe and linked by the internet (for example, www.webring.org).

    How able then are those concerned for public wellbeing and health to be reliable electronic gateways, framers, and filters to health know what and know how, and coordinate action for health policy advocacy? In many countries, including the US, local and national public health agencies, voluntary and community groups have limited access to the internet. Where access exists, there are many problems, including

    • Information excess and unguided searching

    • Lack of awareness of non-traditional information sites

    • Over reliance on traditional types of information (for example, epidemiological and fiscal)

    • Persistent traditional uses of information (for example, staff education, trend analyses, planning, data to support program development, evaluation)

    • Traditional use of electronic tools (for example, distance learning, videoconferencing, telemedicine, disaster response systems; cost effective health care purchasing and communication within state agencies)4 10 11

    In other words, the new is being used to better perform the historical and still essential tasks to protect the public health within the frameworks of conventional practices and law. Yet, however important these information systems and uses are, they do not begin to tap the potential of the new electronic tools for facing the health related challenges ahead. To do so entails firstly, moving beyond delivery of local programmes to knowing what policies are important to population health—ranging from foreign policy like economic sanctions to tax policy for tobacco control to promotion of planet friendly fuels, universal education and health services. Secondly, it concerns how to advocate them effectively. This clearly moves beyond presenting data that uncover health problems and offering health promoting advice and services. New information is needed, what may be called “strategic information”. Such policy relevant information is abundantly available—somewhere—on the internet.

    In summary, the issues are twofold, the quality and scope of information usefully available to health proponents (encompassing both traditional and strategic types) and how to use it for policy development and advocacy.

    An agenda for action

    The task then entails a two pronged effort: to provide an electronic gateway, useful frameworks and filters for substantive health knowledge bases and to create a usable strategic knowledge base and coordinating framework for health advocacy

    Here, collaborative leadership among health proponents would foster agreement on voluntary standards, including selection criteria for content, accessibility, and reliability, such as identification of an authors' affiliations and purposes, web site sponsors' aims and addresses; other underwriting, commercial interests, or conflicts; use of verifiable attributions and copyrights; and correct dating of content and updates. It would also seek ways to monitor and report adherence through independent review and oversight of sites.

    Beyond supporting the quality of health related information for users, a second and less traditional prong involves developing a new knowledge base for promotion of policies that encourage healthy livelihoods, environments, and lifestyles. Much of the what and how of policy effectiveness exists, for example, in policy studies, reports on interest group activities, public and media opinion and polls, governments, international organisations, think tanks, media investigative reports, and exemplar analytic policy action case reports—otherwise known as the “gray literature” (compared with the peer reviewed journals typically used). The gray literature is more likely to demonstrate and analyse how policies get adopted (or defeated), implemented, and sustained, including the multi-varied and enlarging play of the media in the process. This would be an essential step in moving health promotion to policy actions that assure health through reallocation of resources and organisational change, a step that goes beyond traditional programmes that motivate individuals and groups to change their personal behaviour. It would build the policy capacity of health promotion entities in and outside of governments and support mobilisation of groups and individuals on any level of decision making .

    Interlinked nodes of networked individuals and groups in each country or other regions might take on the necessary leadership for strategic knowledge-base development and collaborative action, to gather, frame and array a wide spectrum of information for policy development. They might jointly develop an internet home page or gateway to selected reliable and comprehensive web sites that encompass such information as the health impact of problems and current policies, analyses and examples of effective and failed efforts to change health threatening policies, proposed policy solutions for improving health prospects through mining the “gray” literature (the research literature is already available at such sites as the US National Library of Medicine), as well as resources for expertise in relevant areas. The electronic tools and links that would produce a “satisficing” amount of information—that is, an amount within the time, budget, and political requirements of users. These nodes of groups and knowledge bases would then be linked among themselves for information and collaborative action at many levels of policy making within regions and across the globe.

    The information might be framed to support policy action, a work in progress to be tested in use. That is, it could be configured to document, demonstrate, analyse, evaluate, and suggest ways to tackle the following “how to” problems that must be faced for effective collaboration to promote health friendly policies, including how to:

    • Set aside individual interests to advocate for a specific issue, to acknowledge differences, and then agree to disagree

    • Identify targets among policymakers, professional and community organisations, the press, and public, and use rationales specific to each audience

    • Summarise key points and make recommendations, such as model policy language

    • Use reports on economic and social costs of delayed prevention, evidence of public opinion, media, and organisational support

    • Demonstrate administrative and technical feasibility

    • Illustrate concepts with actual examples

    • Avoid complexity

    • Create public debate to help “unfreeze” previously held opinions through the media, the public, and community organisations

    • Use old and new methods of communication, persuasion, and mobilisation, taking advantage of the media as gatekeeper to public and political minds.

    • Monitor a wide range of public, media, legislative, and opponent activities and respond to misleading statements

    • Act in timely ways and coordinate efforts

    • Make early and sustained personal contacts with policymakers and staff

    • Not over rely on experts at the expense of public/community support

    • Continuously assess progress and revise tactics

    Conclusion

    Traditionally, health policy development has been confined to legislatively determined issues within specific jurisdictions and accomplished by offering proposals that are usually based on the public health sciences. A second, less taken step, based on the first, is needed now more than ever. It is a political one. It extends to how to use information to develop policy and how to get a health supporting policy, once formulated, into the appropriate arena and have it adopted and adequately implemented. It is here that the new information technologies can support this effort and create a synergy among those who work to make the prospects of health for all a prominent and permanent feature of globalisation. But to realise this potential, the debate must move beyond the luxury of dialogue to organisational sponsorship and early joint action to begin a usable work in progress that, like the internet, can grow and mature with use in policy action and advocacy.

    References

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