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Public Health

The Growing Global Divides


National Press Club exhibition June 1 -12, 2009

Image by Michael Foley Photography via Flickr

Information and communication technologies are rapidly changing every aspect of human society on an unprecedented global scale. These technology-driven social revolutions are fueled and funneled by the ever increasing rate of production of new knowledge and the distribution models that restrict or enable access to that knowledge. Knowledge and access to it will in turn shape humanity’s ability and willingness to effectively respond to growing populations, over-consumption, biosphere and climate destabilization, and the continued growth of wealth disparities – the key global issues that will shape human health in the next century.

Against this background, we will focus on how the widespread adoption of a single communication technology like the internet and open licensing and access models for medicine, science, and technology will enable the rapid deployment of critical health and education systems throughout the developing world.

Global Health

The first of all liberties

Billions of people suffer from diseases and disabilities that prevent them from leading productive lives. In many places, whole communities struggle without access to clean water and sanitation. Millions suffer from diseases that in other places are completely preventable or easily treatable. Each day, 100,000 people die of starvation (“Starvation,” 2009), and more than 12,000 children die from malaria, respiratory illness, or unsafe drinking water (“Health,” 2009).

State of the world’s health

There are 300 million illnesses and 5 million deaths caused by tuberculosis, malaria, and AIDS each year. As many as 2 billion people are infected with hepatitis B (“Hepatitis B,” 2009). Schistosomiasis (200 million cases per year), dengue fever (50 million cases per year), measles (30 million cases per year), onchocerciasis (18 million cases per year in Africa alone), typhoid and leishmaniasis (approximately 12 million each per year, globally), rotavirus (600,000 child deaths per year), and shigella childhood diarrhea (600,000 deaths per year) constitute only a portion of the disease burden in the developing world.

Infectious diseases kill approximately 8 million adults and 9 million children each year and are the second leading cause of death worldwide. Thirty-nine new infectious diseases have been identified over the last 40 years, and new strains of those previously known have developed, such as the H1N1 flu virus. Conversely, previously known and largely eradicated diseases have recently reemerged, such as cholera, diphtheria, dengue fever, meningitis, plague, hemorrhagic fever, and yellow fever. Concentrated livestock production, massive urbanization, and increased encroachment on animal territory could trigger new pandemics, while climate change is altering insect and disease patterns globally with unpredictable consequences.

Non-communicable chronic conditions such as cardiovascular disease, cancer, heart disease, and stroke now kill more people even in developing countries than infectious diseases. Approximately 80% of 2009’s 35 million chronic disease-related deaths will occur in low- and middle-income countries; further, non-communicable diseases are expected to account for 70% of all deaths by 2030.

AIDS is the third leading cause of death worldwide, and the leading cause by an infectious disease (“AIDS,” 2009). Among those with HIV/AIDS, tuberculosis is the leading cause of death. HIV dissemination may peak by 2012 at over 2 million per year, and is then expected to steadily decline. AIDS related deaths dropped from almost 3 million in 2006 to approximately 2 million in 2007, reflecting increased access to treatment by a third of those who need it. The Clinton Foundation has played a significant role in reducing costs of second-line drugs to $100 per year and the daily regimens to $1 per day in some high-need areas. While no vaccines are yet available, new genetic-based vaccines are undergoing trials. Radioactive anti-HIV antibodies and pre-exposure treatment are showing promise in animal models, and one controversial study suggests male circumcision may reduce infection by as much as 50%.

Global Divides

The ongoing global financial crisis has stimulated international councils such as the G-20 to rethink their basic assumptions regarding economics and finance. The worldwide trend of poverty reduction continues, and although remittance aid to poorer countries has more than doubled since 2002, it is likely to fall substantially in the near future due to food, fuel, and financial crises.

About 1 billion people live on $1.25 per day and 2.2 billion on $2 per day. If the world economic slowdown does not last longer than several years, the 1990 poverty rate will be halved by 2015. However, high population growth likely ensures that by 2015, there will still be 1 billion people living on less than $1.25.

Global technological dualism

Rapidly growing disparities in the creation, utilization, expenditure, and availability of technology between rich and poor countries has been described as the global digital divide (Pick & Azari, 2008, p. 92). Further, the global digital divide involves “economic, educational, and social aspects” (Pick & Azari, 2008, p. 92) that differentially influence the levels of ICT (information and communication technology) infrastructure in developing nations. The knowledge divide describes a second aspect of global technological dualism as the increasing disparities between those who can access, navigate, and apply knowledge and those who cannot.

Global digital divide

The global digital divide includes both the disparities in access to ICT within countries (digital divide) and the uneven development of ICT among countries (geographical divide), causing less developed nations to fall behind in technology, education, labor, democracy, and tourism (Guillen & Suarez, 2005).

Interestingly, Foulger suggests that the most striking facet distinguishing the global digital divide from the four millennia of media divides proceeding it is the willingness of the privileged group to make an issue of it. In this spirit, he proposes solutions to seven distinct obstacles: “Social and Legal Constraints”, “Economic Priorities”, “Basic Infrastructure”, “Literacy and Language”, “Network Infrastructure”, “Computer Resources”, and “Choice” (Foulger, 2002).

Digital divide

The digital divide describes differential access to technology as well as inequalities in requisite knowledge and skills needed to effectively participate as a digital citizen. Chen and Wellman argue that while diffusion trends are slowing and even stalling in many developed nations, the digital divide is growing in almost all countries, especially in developing countries where access is most strongly correlated with socioeconomic status (Chen & Wellman, 2004).

Geographical divide

Drori and Jang have mapped the global digital divide by country and blocks of countries to determine correlations between IT penetration and national characteristics. Their research suggests that cultural features more strongly predict IT penetration than political climate or economic capabilities (Drori & Jang, 2003).

Global knowledge divide

The scientific, technological, and information post-industrial revolutions made possible the information and knowledge societies that characterize developed nations in the modern information age. However, many of the assumptions made by global digital divide analysts ignore the social and cultural factors that determine how and to what degree information and new knowledge are valued in developing societies (Rumiany, 2007). These values in turn may influence ICT penetration by defining access as a private (rather than public) good and therefore as a commodity to be profited from. The growing knowledge divide is therefore the more subtle yet fundamental aspect of global technological dualism – information is both the content distributed by communications technology and that which informs ICT development decisions.

Information / knowledge societies

Information Society is one of the broadest and most inclusive terms used to describe the society-wide consequences of the post-industrial information revolution. Within this broad category one may identify supporting concepts such as Information Age, which describes the three-decade period between the widespread adoption of computers and the emergence of the knowledge economy in post-industrial nations, and the knowledge era, which describes the nature of content rather than socioeconomic processes.

In specifically economic terms, the information and knowledge economies emphasize the content or intellectual property being traded through open markets. The digital economy focuses on the trading of bits rather than material goods. The network economy describes businesses as interdependent ecosystems rather than isolated agents. Social networking refers to global-scale, many-to-many collaboration systems. The Internet Economy focuses on the nature of markets that are enabled by the Internet.


O’Hara argues that “profound changes to established patterns of life, root metaphors, necessary expertise and habits of mind” are accompanying the global shift to knowledge societies (O’Hara, 2007). Increasingly, especially in developing nations, graduates of western-style Enlightenment-based socializing systems such as colleges and universities are poorly prepared for the leadership challenges of transitioning to a globalized knowledge society. This misalignment may be addressed in part by deeper collaboration and integration between telecenters (ICT development) and universities (R. D. Colle, 2005; Royal D. Colle & Roman, 2003), and by reorienting traditional academic-industry-government relations to facilitate the emergence of entrepreneurial universities (Etzkowitz, Webster, Gebhardt, & Terra, 2000). O’Hara goes furthest in insisting that for colleges and universities to meet the needs of the life-long learner in the 21st century,

… revolutionary changes are required in mission, curriculum content, pedagogy and modes of inquiry. The purpose must become explicitly aimed at producing a shift in the deep structures of consciousness and towards the development of trans-disciplinary expertise—entirely new literacies and new approaches to learning that both fit the current economic realities and are more attuned to the … needs of an emerging global knowledge society (O’Hara, 2007).

ICT as poverty reduction

The current digital divide is more dramatic than any other inequity in health or income (Edejer, 2000). With the formation of a global market largely controlled by institutions with entrenched inequalities, McElhinney addresses the role of vested interests in determining access to and application of information and communication technologies in the emerging global knowledge society (McElhinney, 2005). Castells takes this further by articulating the important role of the public voice (public diplomacy) in the emerging global public sphere to act beyond “the strict negotiations of power relationships” and build broad coalitions of human interests based on shared cultural meanings (Castells, 2008).



The Internet is a global network of networks that use a standardized Protocol Suite (TCP/IP) to serve digital information. It consists of millions of private and public, academic, business, and government networks carrying a vast array of information resources and services. It is also a revolutionary tool that enables the efficient and instantaneous transfer of information among users. This globally accessible information system can be used for international trade, online digital libraries, online education, telemedicine, e-government and other applications that would solve critical endemic problems in the developing world. Norris states, “in poorer villages and isolated communities, a well-placed computer, like a communal well or an irrigation pump, may become another development tool, providing essential information about storm warnings and crop prices for farmers, or medical services and legal land records for villagers” (Norris, 2001, p. 40).

Nearly 1.67 billion people are connected to the internet – approximately 25% of humanity (“World Internet Usage Statistics News and World Population Stats,” 2009) – with more internet users in China than citizens in the United States (“List of countries by number of Internet users,” 2009). There are over four billion mobile phones currently in use, 60% of the global population (ITU Corporate Annual Report, 2008). Mobile devices are evolving into personal electronic companions, combining the traditional functions of computers, telephones, cameras, music players, TVs, and libraries. These dynamic smart phones can connect to the internet, are location aware and capable of adapting to individual users. The built environment is being connected via the internet and low-cost nanotech sensors, cameras, and transceivers for myriad purposes. Humanity, ubiquitous computing, and the built environment appear destined to become intractably interconnected.

Internet bases are being constructed in remote villages, internet-ready mobile devices are being designed to enable educational access by low income groups, and new business models are being created to connect the poorest two billion people with the rest of civilization via the internet. Emerging e-government systems are capable of supporting civil rights, education, democratization, and economic development by delivering needed services, creating citizen feedback channels, and facilitating public-private collaborations. Significantly, the Internet can connect developing country professionals learning or working internationally with the development processes in their home nations.


The internet increases economic expansion and decreases child mortality in the developing world (Bradshaw, Fallon, & Viterna, 2005). Public health and education are key beneficiaries of ubiquitous open information access. Documented examples include real-time epidemiological tracking (Curioso, Peinado, Rubio, Lazo-Escalante, & Castagnetto, 2009), development and deployment of open-source information systems for public health data (Qian Yi et al., 2008), and increased rural education opportunities (Zhao, 2008). Participatory government and cosmopolitan values are also increasingly correlated with internet penetration (Guillen & Suarez, 2005).

Accessibility: Penetration and Usage

As of June 2009, approximately 1.67 billion people worldwide use the Internet (“World Internet Usage Statistics”, 2009). Africa has some 50 million Internet users, for an Internet penetration of just 5%. Europe’s Internet penetration is 8 times higher (“ICTs in Africa” 2009). The quality of information available via the internet, including critical health information, is inconsistent, and high costs, English language dominance, lack of relevant content, and lack of technological support are barriers for disadvantaged communities. Edejer advocates maximizing internet penetration, decreasing the socioeconomic and cultural barriers to access, and exploiting the full potential of the internet to continuously translate universal information into useful knowledge (Edejer, 2000).

Licensing and Access Models

“Shortly after a large-scale clinical trial in 1955, the first inactivated polio vaccine was being injected into tens of millions of people around the world – possibly the most successful pharmaceutical product launch in history. Asked why he had not obtained a patent on the phenomenally successful vaccine, Jonas Salk reportedly replied, ‘That would be like patenting the sun.’ A few decades later, this view seemed laughably quaint.” (Dove, 2002)

Knowledge revolutions in science, medicine, and technology have made possible unprecedented levels of wealth, health, and education. But both physical access to ICT and the skills requisite to use it are highly concentrated in developed countries, leaving much of the world’s population at a growing disadvantage. According to the National Research Council for the National Academies,

“Data and information produced by government-funded, public-interest science is a global public good caught between two different trends. On the one hand, the Internet provides valuable new opportunities for overcoming geographic limitations and the promise of unprecedented open access to public information for research. The synergistic aspects of the availability and access to such information result in a broad range of positive externalities and network effects that increase exponentially with the addition of new Internet users. On the other hand, there are growing restrictions on the availability and use of public data and information arising from the privatization and commercialization of such sources. This countervailing trend undermines the traditional scientific cooperative and sharing ethos. It diminishes the public domain and open access to such global public goods and leads to a host of lost opportunity costs at both the national and international levels.” (Esanu & Uhlir, n.d.)

Trends in Intellectual Property Law

Until recently, both US intellectual property law and the property laws of most developed countries did not allow raw facts to be patented or copyrighted as property. Commercial proprietary ownership was limited to a finished product entering the marketplace. The data upon which the product was based remained free and open (“What is Intellectual Property?,” n.d.).

Further, US law required all federal government works appropriate for copyright to fall directly into public domain – reflecting the major role government resources play in scientific, medical, and technological research. This practice in federally funded research was designed to encourage the broad dissemination of data at or below cost, in the belief that the investment of public resources should yield public benefits. Each of these tenets evolved, at the slow rate of change inherent to the legal system, from concepts originating before the industrial revolution.

Modern ICTs have rapidly and permanently changed the way information is collected and disseminated. In many fields, data are published nearly as quickly as discovered. Juxtaposed, copyright law, built on the assumptions appropriate to analog technology, has failed to keep up. In response, a large and active global community has formed to support open access — that is, making data, information and knowledge “digital, online, free of charge, and free of most copyright and licensing restrictions.” (“What is CC?,” n.d.) Major research foundations have adopted policies to require open access to research results. For example, the NIH now requires open access to funded research. Faculty at colleges and universities are passing resolutions to ensure that their work is published openly (“Cornell Faculty Senate Resolution” 2005; “Faculty Senate Passes Author Rights Resolution,” 2007; “US07/08-17” 2007). And most major journals have granted their authors self-publishing rights.

Legislatively, there are alarming trends toward greater privatization, even of databases and basic research. The EU has adopted a “database right” that grants intellectual property protection to facts (“EUR-Lex – 31996L0009 – EN,” n.d.). Under the Bayh-Dole statute, researchers using federal funds are encouraged to patent and commercialize their research (Leaf, 2005; Roseman, 2008). In some cases, the commercialization has moved upstream to the levels of research and data, creating complex legal quandaries. While often providing immediate financial returns to the researchers and research institutions, privatization also stifles innovation, as the usefulness of information increases when connected with other information, and decreases when segregated by law.

Therefore, ironically, at a time when technological advances permit global access and distributed processing of data, legislation is increasingly favoring the privatization and isolation of new knowledge.

The Commons: An Open Movement

The open non-ownership model will almost certainly be a key component in tomorrow’s global economic system. However, intellectual property issues, compensation for creatives, and equitable policies to regulate competition among communication models are as yet largely unresolved.

Open source

Open source is an approach to the design, development, and distribution of software, guaranteeing certain practical rights such as to copy, to distribute, to access source code, and to change source code (Perens, 1999). The principle of “open source” has been adapted to many other fields important to international development, including content, architecture, science research, education, and health.

Open access

Open access describes toll-free online access to articles that have traditionally been published in toll-access scholarly journals (Suber, 2007). Ten to fifteen percent of all peer-reviewed journals are open access journals (“Directory of open access journals,” n.d.).

The major national and international research funding institutions are beginning to require open access standards for the research they support. Seventeen have adopted Green OA self-archiving mandates (“Access to Research Outputs,” n.d.), and four more have proposed mandates (“ROARMAP,” n.d.).

The Canadian Institutes of Health Research (CIHR) adopted a mandate in September 2007, the first North American public research funder to do so (“OA Self-Archiving Policy: Canadian Institutes of Health Research (CIHR),” n.d.). The U.S. National Institutes of Health Public Access Policy; the US Federal Research Public Access Act; the Wellcome Trust’s Position Statement in Support of Open and Unrestricted Access to Published Research; the Canadian Institutes of Health Research (CIHR) Policy on Access to Research Outputs; and the Howard Hughes Medical Institute have all made significant investment in open access policies for the research they fund.

However progressive North America may be described as being in its recent embrace of open access policies, Europe has produced more results: For example, sixteen major Dutch universities have cooperatively launched DAREnet, making over 47,000 research papers open access (Libbenga, 2005). By the end of 2009, NARCIS will provide access to 185,000 open access publications. The European Commission has recommended that research funding agencies mandate published articles arising from EC-funded research be made available in open access archives.

Open content, open knowledge

For content or knowledge to be regarded as “open”, it must meet certain basic requirements. It must be socially accessible without technological restriction; allow for redistribution and reuse; be free of discrimination against persons or groups, or fields of endeavor; and the open license must be distributed with the work without package limitations or restrictions upon the work of others (“Open Knowledge Definition,” n.d.).

Open design

Open design is public sharing of design information – for physical products, machines, or systems. The process is generally facilitated via the Internet and without monetary compensation. The goals and philosophy are identical to those of open source, though different in object of application.

More than 80% of the world’s human population lives in countries where income disparity is widening, while just less than 80% of the world’s population lives on $10 a day (purchasing power parity adjusted) (“Human Development Reports,” n.d.). The U.N. Millennium Development Goals aim to “achieve improvement in the lives of 100 million slum dwellers by the year 2015”, addressing the nearly 1 billion currently living in slum settlements (“United Nations Millennium Development Goals,” n.d.). Architecture for Humanity, Design for the Other 90%, and the Open Architecture Network are high-profile open design projects seeking to use the open source model to provide cost-effective, sustainable design for the developing world. The design focuses are meant to address the needs of the nearly 6 billion people with little or no access to the majority of products and services available in developed countries, and the billions of those without regular access to adequate shelter, basic health services, clean drinking water, primary education, or necessary transportation services by networking tens of thousands of international designers in collaborative, systematic efforts.

Open research

“Over the past 20 years, the culture of science has undergone what is arguably its most radical change since World War II: instead of being seen as a strictly public good, basic research is now a patentable commodity. The money is nice, but of course it has strings attached. As university budgets have come to rely on the massive revenue streams gushing from faculty patents, pressure is increasing for administrators to turn laboratory findings into cash cows.” (Dove, 2002)

Most scholarly journals don’t purchase from or pay royalties to authors. Researchers have historically given their work to publishers in exchange for visibility, prestige, career advancement, and to establish their priority. Most science-focused journal articles are based on publicly funded research. Willinsky argues for the logic of providing public access to the results of publicly-funded research with the contention that scientific research carries with it a responsibility to circulate the results as widely as possible (Willinsky, 2009). Further, scholarly articles published under an open access model have been found to have a greater research impact (Antelman, 2004) and are twice as likely to be cited (Eysenbach, 2006), adding value to the work and in turn contributing to its claim as knowledge. Open access, argues Willinsky, is in the self-interest of the researcher-authors who create knowledge and increases the return on investment to the public in whose interest research is ostensibly conducted.

The benefits of open access research publishing models are not unnoticed by the researcher-authors themselves: a 2006 survey of the attitudes of UK and Nederland authors commissioned by JISC and SURF found that nearly a third of authors preferred a joint rights model under a Creative Commons license (Hoom & van der Graaf, 2006), a growing trend.

Open science

Scientific research depends on access to and use of factual data, and is becoming more data-intensive in almost every discipline. The Mertonian tradition of open science has historically discouraged the proprietary exploitation of research data by requiring that the datasets on which research is based be made available as a precondition for publication.

Open science is a hypernym for technological tools, many of which are Web-based, that help scientists communicate about their findings (Lloyd, 2008). Information available to researchers, as far as possible, is made available to absolutely everyone. Open Notebook Science, the practice of making the entire primary record of a research project (including the so-called dark data) publicly available online as it is recorded, is the modern embodiment of both the Mertonian tradition and the extreme implications of the open access movement.

Open health systems

ICTs have the potential to reduce health disparities by providing access to information otherwise and previously unavailable, and by providing a broad range of other health-related Internet-based resources, including the location of and subsequent communication with health providers (Kalichman et al., 2002). Unfortunately, those who have preventable health problems and lack health insurance coverage are the least likely to have access to such technologies (Eng et al., 1998). Barriers to access include cost, geographic location, illiteracy, disability, and factors related to the capacity of people to use these technologies appropriately and effectively. The current digital divide is more dramatic than any other inequity in health or income (Edejer, 2000).

Many developing and emerging nations’ governments are seizing on the opportunities provided by the internet by implementing open access health projects. Health departments are able to leverage open-source software to implement low-cost information systems for access to modern data analysis and visualization tools (Qian Yi et al., 2008), and web-based geospatial data (GIS) (Kamadjeu & Tolentino, 2006). India, for example, has launched a new open source initiative for developing drugs to treat diseases such as tuberculosis, malaria, and HIV (Singh, 2008).

“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 industrialized 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. … 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.” (Lown, Bukachi, & Xavier, 1998)

Yach and Bettcher argue that the transnationalization of disease and health risks means that new forms of transnational collaboration between developed and developing nations are required to minimize risks and build on opportunities. For countries and communities to successfully navigate the globalized health landscape, the point of departure must be at the convergence of enlightened self-interest and altruism (Yach & Bettcher, 1998).

Separate from the issue of access to the internet and the information it transmits, medical research is in many cases barred from internet publication by the vested interests of the traditional publishing model and copyright laws (Barbour, Chinnock, Cohen, & Yamey, 2006).


The Information Era has created bold challenges and unique opportunities for improving global public health via telemedicine, distance education, and home care. But a truly universal information super-highway has an economic price, which has not, as yet, been properly evaluated. Detailed studies are needed to prove the cost and medical effectiveness of these technologies, especially for developing nations that lack the technological infrastructure and cultural capital to implement and therefore benefit from full ICT penetration. The transnationalization of disease and health risks requires new forms of transnational collaboration between developed and developing nations to minimize risks and build on opportunities.

Both physical access to ICT and the skills requisite to use it are highly concentrated in developed countries, leaving much of the world’s population at a growing disadvantage. Ironically, at a time when technological advances theoretically permit global access to data, legislation is increasingly favoring the privatization and isolation of new knowledge. This trend, if unchecked, will lead to a host of lost opportunity costs at the international level (Esanu & Uhlir, n.d.), especially for developing countries. In contrast, a vibrant open access, non-ownership model has emerged in crucial areas such as software, research data, and design. Linux, the WikiMedia Foundation, and the Science Commons exemplify the open source and open access philosophies. Architecture for Humanity, Design for the Other 90%, and the Open Architecture Network are high-profile open design projects seeking to use the open source model to provide cost-effective, sustainable design for the developing world.

To date, the quality of health information available on the web is inconsistent, and the visibility of research from developing countries is limited. Many argue that the way forward is full universal ICT penetration as a platform to exploit the full interactivity of the internet, which ideally allows rapid feedback and change to continuously mould information into useful knowledge, ostensibly to the benefit of all. However, the countries least prepared to bridge the digital divide have average life-spans much lower than those in developed nations; they have the highest infant mortality rates and the highest rates of HIV infection; they have average GDPs per capita an order of magnitude lower than developed nations; and their literacy rates are often lower than 20%. Therefore, bridging the digital divide is an effect, rather than a cause, to strive for. Until more basic problems are remedied, many of the world’s poorest citizens will remain fundamentally excluded from the internet and its benefits, even if it were to be made physically available to them.


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