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ProMED-mail, a program with the International Society for Infectious Diseases, is the iconic example of how the Internet is advancing public health. Launched in 1994, it arrived at a moment when CompuServe and AOL were fueling personal email, and when scientists were becoming aware of the intensifying emergence of new infectious diseases, such as Ebola hemorrhagic fever. It was also a time when government health officials still tightly guarded information on disease outbreaks. According to Larry Madoff, M.D., ProMED’s current editor, the thinking among its founders was: “Wouldn’t it be great if people who had access to the Internet in far-flung places, and were seeing something unusual, could send an email to this list? We wouldn’t have to wait for a public health laboratory to notify the Under Minister of Public Health, who would notify the Minister, who would notify the World Health Organization. We would all know at once.”
ProMED’s virtues are those of the Internet itself: It is fast, nimble, egalitarian, bottom-up, open, and transparent. These are also the hallmarks of an effective public health campaign: delivering the facts swiftly to those who need to know. China’s SARS epidemic actually surfaced in November 2002—three months before the fateful ProMED posting. If a ProMED subscriber in Guangdong had written directly to the listserv in, say, mid-December—by which time the epidemic had spread to three cities—who knows? Perhaps the scourge would never have vaulted beyond the country’s borders.
Despite the explosion of web innovation, ProMED remains conspicuously low-tech and hands-on. Individuals feed outbreak information into the system through email, while ProMED’s small staff gleans material from its own searches of media and official reports. The seven or eight daily postings, available through email or on the website, are thoughtfully moderated and commented upon by a panel of experts—a unique step that adds meaning and context to otherwise unmediated facts or assertions. Each posting is limited to 25 KB bandwidth—to ensure that it slips through an old-fashioned dial-up modem in the most remote areas of the world (where new infectious threats tend to smolder). “We use technology that was state-of-the-art in 1994. We use email—plain-text email at that. We don’t use fancy fonts,” Madoff says. “The power of the Internet is its ubiquity and speed; it’s not necessarily in all the neat things you can do.”
More technologically awesome is GPHIN—the Global Public Health Intelligence Network, part of the Public Health Agency of Canada. GPHIN is a secure Internet-based early warning system that gathers preliminary reports of public health significance in nine languages, round the clock. Launched as a prototype in 1998, it relies on news aggregators to scour 20,000 media sources—from wires to websites to blogs. Every 15 minutes, its software pulls articles and assigns them a relevancy score based on keywords and syntax. Non-English articles are machine translated. Expert analysts further parse the material, which ranges from infectious diseases to natural disasters to product safety.
Each week, GPHIN sends hundreds of reports to its main client: the World Health Organization, as well as to government officials, NGOs, and other subscribers, who pay tens or hundreds of thousands of dollars annually. Unlike ProMED—which operates on a shoestring, is free of charge, and is open to the public—GPHIN is government-affiliated, pricey, and restricted to organizations with an established public health mandate: the loaded Lexus compared to the stripped-down Corolla.
Both services face the challenge of “noise.” Flooded by disease news—some vitally important, most not—what to publish? GPHIN actually snagged and sent out early Chinese-language news items about what later became SARS. In November 2002, it posted a report that an unusual number of people were showing up in an emergency room in Guangdong, appearing to suffer from atypical pneumonia. In January 2003, GPHIN’s computers found an English-language financial report from a pharmaceutical company, describing a spike in sales for its antiviral drugs, which the firm conjectured was due to an unusual outbreak in the Chinese province.
At the time, these reports didn’t stand out; only after SARS was front-page news did investigators comb the record and discover these unheeded warnings. In the massive daily GPHIN trawl, stories about respiratory symptoms during flu season in a country of 1 billion people were understandably overlooked.
