of the American Society for Information Science and Technology   Vol. 27, No. 6    August / September 2001

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Reaching the Unreachable: The Role of HealthNet Ethiopia in Disseminating Electronic Health Information Resources

by Shimelis Getu Assefa

Ethiopia is one of the world's least developed countries. It is strategically located in the Horn of Africa covering an area of approximately 1.14 million square kilometers (444,000 squares miles), bounded by the Sudan on the West, Somalia and Djibouti on the East, Eritrea on the North and Kenya on the South.

With a population now estimated to exceed 60 million, Ethiopia stands as the fourth largest in size and the second most populous country in Sub-Saharan Africa. The total labor force of the country constitutes about 48% of the population. The country is richly endowed with huge manpower, arable land and natural resources; however, much of its potential is not yet exploited. Ethiopia is known for rich cultural and language diversities. Researchers estimate that more than 100 languages are spoken in this country. The mainstay of the economy is agriculture, mainly coffee production.

System Setting

HealthNet Ethiopia, the subject of this article, is housed in the Central Medical Library (CML) at the largest university teaching hospital in the country. The Faculty of Medicine at Addis Ababa University was established in 1963 and is the leading center of excellence in medical education, research and clinical service in Ethiopia. It now offers 16 undergraduate and postgraduate programs and several projects and research activities. The CML Library is the de facto national medical library in Ethiopia, for its doors are open to all health professionals in Ethiopia. Because of this and other expertise available, the CML is the most suitable place for hosting HealthNet Ethiopia.

SatelLife, Inc.

The SatelLife global communication network for health is an international not-for-profit humanitarian organization employing satellite and Internet technology to serve the health communication and information needs of countries in the developing world through a global computer-based communications network called HealthNet. SatelLife's mission is to improve health by enhancing connectivity among professionals in the field via electronic communications and exchange of information in the areas of public health, medicine and the environment. A special emphasis is placed on areas of the world where poor communications, economic conditions or natural disasters limit access.

The inspiration for SatelLife came from Dr. Bernard Lown. Prior to the creation of SatelLife Dr. Lown co-founded International Physicians for the Prevention of Nuclear War, which was awarded the Nobel Peace Prize in 1985. Originally conceived as a symbolic counterpoint to the "Star Wars" defense system, Dr. Lown's vision for SatelLife was to use space as a platform, not for weapons of mass destruction, but for the exchange of life-saving information among health professionals in both developed nations and the developing world.

Through the creative use of various communications and information technologies and the formation of partnerships with various medical institutions and organizations, as well as other telecommunications service providers, SatelLife surmounts the financial and technical obstacles that have kept health professionals in the developing world out of the communications loop for decades. It was intended to bridge the communication gap between health professionals in the south and north. The mission of SatelLife at its establishment was to serve as a conduit for a worldwide community, providing global electronic access to medical and public health information and through this effort to improve the quality of life. The creation of HealthNet has enabled developing countries, including Ethiopia, to have access to low-cost and appropriate communications technology and to relevant health information.

HealthNet Ethiopia

HealthNet Ethiopia was established in 1994 through an agreement reached by SatelLife, Ethiopian Telecommunication Corporation (ETC), the Pan African Development Information System (PADIS) at the United Nations Economic Commission for Africa (UNECA) and the Medical Faculty of Addis Ababa University. PADIS is now UNECA's Development Information Systems Division. Initially through technical assistance from PADIS and ETC, HealthNet Ethiopia started to connect departments and units within the Faculty of Medicine. Slowly the Medical Library took over all of the operation and started to popularize the service throughout the country. HealthNet Ethiopia has made headway in penetrating all health settings where a computer with a modem and a telephone line are available.

Indeed, working in partnership with SatelLife, HealthNet Ethiopia has been instrumental in providing a communication network for health professionals throughout Ethiopia. Currently, there are about 62 points that are connected and making use of the service. The points connected include hospitals, medical schools, non-governmental organizations (NGOs), clinics, health research centers and private health professionals at their homes or workplaces. The point distribution covers a wide area, ranging from the capital city to the north, west, south and eastern parts of the country. The Gondar College of Medical Sciences and the Jimma Institute of Health Sciences located in the northern and western parts of the country, respectively, and more than 500 miles apart are examples of HealthNet service recipients in Ethiopia. The two institutions have a total of 3000 faculty and students who heavily depend on HealthNet Ethiopia for their electronic communication and information search. In these two institutes, the library is the major node for the HealthNet service.

These libraries have put in place separate computer and access rooms for their users to send and receive e-mail, check their discussion lists, download the electronic publications they subscribe to and copy the website information they receive through e-mail. The library staff in charge of HealthNet service at these locations is also responsible for keeping track of the electronic publications and other relevant announcements and information distributed through the Net. They print and display these materials, which have now become important resources in their periodical holdings.

The HealthNet Ethiopia System

The HealthNet Node software, based on FidoNet technology, comprises a few DOS-based Fido applications customized to allow electronic mail bundle exchange between two computers over modems. These exchanged mail bundles or packets that are sent and received at the HealthNet node essentially contain two types of electronic messages: (1) personal mail and (2) electronic publications and conferences in the form of Fido conference mail. In FidoNet terminology these two types are called netmails and echomails, respectively. The overall configuration of HealthNet Ethiopia is shown in Figure 1.  For more detailed information on the equipment, software, protocols and procedures for the primary and subsidiary HealthNet Ethiopia nodes please see the accompanying sidebar.

HealthNet Ethiopia Services

HealthNet Ethiopia is one of the beneficiaries of SatelLife's Communication and Information Service. Through HealthNet Ethiopia thousands of users, both in major cities and remote locations, have access to a wide range of information services as shown in Figure 2. These services are frequently used. As a system administrator, I have made several mini-surveys on use and users of the Network. The results may be summarized as follows:

  • Hospitals: Users from clinical settings exchange disease related information, get consultations and collect and send epidemiological data. They heavily use the e-mail service to schedule consultations and referrals, making it unnecessary for ill patients to travel long distances with no guarantee of seeing a physician.
  • Medical Schools: Students and faculty subscribe to many of the electronic publications, search information through GetWeb, post specific questions in search of answers and views, and exchange project documents, theses and other scholarly articles with foreign counterparts.
  • NGOs: NGOs use HealthNet Ethiopia mainly to exchange reports on their activities and on-going projects with their head offices in other countries or with a main office in Addis Ababa.
  • Societies: Societies use HealthNet Ethiopia to collect news items and advances on specific topics for use in their publications. They also use it for other purposes including distributing announcements for upcoming events and receiving articles from members.
  • Private persons: Individual health professionals make use of HealthNet mainly for e-mail, to participate in discussion groups and to subscribe to electronic publications.

Public Health Channel

Finally, HealthNet Ethiopia has been selected to be involved in an exciting pilot project and has received a World Space Foundation Digital Radio with multimedia adapter. World Space Foundation and SatelLife initiated this program to create the first public health channel for the entire African continent. Through this channel health professionals in Ethiopia will receive a steady stream of material to assist them in the diagnosis, prevention and treatment of diseases that are ravaging the continent. It is hoped that this unique new service, called the Public Health Channel, will overcome the barriers of poverty, geography and unreliable communications infrastructures to help stop the decimation and maiming of Africa's population from such diseases as HIV/AIDS, malaria and tuberculosis.

The addition of the Public Health Channel (PHC) on top of the HealthNet Service will undoubtedly increase the volume and quality of health information our health professionals will obtain. This service is again situated in the CML where the HealthNet service is. We will be downloading materials and any other content broadcast through the PHC, information that will eventually be distributed to all HealthNet users through their e-mail addresses.

    For further information, please also see the websites at www.healthnet.org and www.telecom.net.et.

Shimelis Getu Assefa is Chief Medical Librarian and System Administrator, HealthNet Ethiopia, PO Box 150237, Addis Ababa University, Addis Ababa, Ethiopia, and can be reached by e-mail at medicine.aau@telecom.net.et or shimelis.getu@eth.healthnet.org Sidebar

HealthNet System Specification and Operation

The HealthNet Ethiopia boss node operates on a dedicated workstation with the following specifications:

  • E-machines, E-tower 400i3 PC
  • Intel Celeron processor 400 MHz
  • 32MB SyncDRAM/128 KB L2 Cache
  • 4.3 GB Hard Drive
  • 40x Max CD-ROM Drive
  • 56k ITU V.90 Data/Fax Modem

Software Specification

The HealthNet Node software, based on FidoNet technology, comprises a few DOS- based Fido applications customized to allow electronic mail bundle exchange between two computers over modems. These exchanged mail bundles or packets sent and received at the HealthNet node essentially contain two types of electronic messages, namely personal mail and electronic publications and conferences in the form of Fido conference mail. In FidoNet terminology these two types are called netmails and echomails, respectively. The main components of the HealthNet Node software are

  • Intermail: the primary mailer program
  • Gecho: the one-pass netmail and echomail processor
  • NetManager: the header rewriter for messages flowing from Fido to the Internet and vice versa
  • Message Track: the traffic log tracker

These various software components along with some batch and control files, namely the imrun.bat and unpack.bat, control the running and operation of the HealthNet node.

For the points side, the system uses mailer software called Marimba. Marimba allows the user from the remote side to perform such tasks as composing, editing and sending messages, creating private folders and managing addresses, and replying and forwarding.

How the HealthNet Node Operates

Whenever the HealthNet Node communicates with another system the Intermail software exits after exchange of the mail bundles with an error level 50 to give control to another batch file, namely unpack.bat.  This exchange could be either with the main Fido gateway system, hosted at SatelLife, Boston, or with one of HealthNet's point or routing node systems. Unpack.bat runs the related programs in sequence on the mail bundles received before giving control back to the main Intermail application.

The unpack.bat program takes control whenever mails or files are received from any system. It starts by invoking the Gecho toss function that decompresses the received mail bundles and packets in the inbound mail directory. The messages contained in the mail bundle could either be destined to other Fido systems (local or outside) or to the Internet world. In the case of mail destined to the Internet world and Fido systems that are not local to the node the mail gets routed to the main gateway from which it is distributed. The NetManager (netmgr) program, which runs after the Gecho toss, essentially rewrites the "To Header" field. Once netmgr is done with scanning and rewriting the message base, it gives control to the Message Track program, which does the tracking, renumbering and logging. Finally Gecho takes control to scan and pack the mail messages, whereby mail bound to specific systems is packed and held at the node to be picked up. Finally, control is returned back to the Intermail application, which waits for an incoming call.

In the HealthNet Node software netmgr is used primarily for two purposes. The first is to rewrite messages bound from the Fido systems connected to the node to the Internet world. That is, for the outbound traffic from the node to the Internet, the messages are rewritten to be routed to the gateway system. The gateway periodically polls the node system for mail exchange. The second use is to rewrite the headers of messages addressed to users connected to the node system, that is, for inbound traffic reaching the node system from Internet and other Fido systems for users connected to this system.

BOX

Description of Services Shown in Figure 2

A. E-mail: Electronic mail

B. Electronic Publications:

  • HealthNet News: A weekly publication that features summaries, editorials, abstracts and occasional full-text articles from several leading medical journals, including the British Medical Journal, New England Journal of Medicine, Tropical Doctor, Pediatrics, American Journal of Public Health, South African Medical Journal and East African Medical Journal. Items featured in HealthNet News are carefully selected by the physician-editor for scientific integrity and relevance to clinical practice in the developing world. Topics covered include women's health, infectious diseases, cardiology, general medicine, HIV/AIDS, STDs, diabetes, pediatrics, oncology and more. And HNN-AIDS: HealthNet News HIV/AIDS Supplement: Published monthly, the HIV/AIDS supplement carries selected abstracts, summaries and occasional full text articles selected.
  • WHO-DIGEST: WHO Library Digest for Africa is a monthly publication compiled by the World Health Organization (WHO) office of library and health literature services in Switzerland. It features recent WHO press releases, new WHO publications from headquarters and regional offices, and publication information from WHO newsletters and periodicals. WHO Library Digest for Africa is oriented towards medical librarians and others interested in promoting health information in the developing world.
  • HEALTH ACTION is published four times a year by HealthLink worldwide and emphasizes international implementation of primary health care. Health Action features practical information on such public health issues as emergency management and quality control of health services. It frequently includes input from health workers in the field concerning the challenges they face and the solutions they find to work.
  • AIDS ACTION: This quarterly publication examines and provides practical information on HIV/AIDS prevention and treatment. HealthLink Worldwide, formerly known as the Appropriate Health Resources and Technologies Action Group (AHRTAG) in England, publishes AIDS Action.
  • Child Health Dialogue, published quarterly by HealthLink worldwide, concentrates on international child health and disease prevention. It provides a forum for information exchange on five key pediatric conditions acute respiratory infections, diarrhea, malaria, malnutrition and measles. Each issue offers practical information on a range of subjects such as barriers to treatment, staff management and clinical guidelines.
  • CBR NEWS: Community-Based Rehabilitation is produced three times a year, CBR News from HealthLink Worldwide is an international newsletter on community-based rehabilitation and the concerns of disabled people. CBR News provides practical solutions to enable disabled individuals to work within and successfully contribute to their community.

C. Global Electronic Conferences:

    1. PROMED-MAIL: Program for Monitoring Emerging Diseases electronic network was inaugurated on the Internet in August 1994 by the Federation of American Scientists (FAS) to serve as a prototype for the communications system needed to monitor emerging infectious diseases globally. A central goal of the ProMED initiative has been to establish a direct partnership among scientists and doctors in all parts of the world. Sharing current information and discussing emerging diseases further that goal.

    2. E-DRUG: Essential Drug supports the concept of essential drugs by improving and speeding up communications among health professionals working in the field of essential drugs. Often, colleagues in developing countries cannot afford telephone and fax lines. Normal postal services are too slow and unreliable. Many have already discovered the usefulness of e-mail as an affordable tool for communication. E-DRUG is a free service of HealthNet. The only cost is the normal one associated with sending/receiving ordinary e-mail messages.

    3. ProCAARE: Program for Collaboration Against AIDS and Related Epidemics is a program initiated by SatelLife in cooperation with colleagues from internationally recognized research institutions, including the Harvard AIDS Institute. The goal of this conference is to provide a forum for discussion on HIV/AIDS and related topics among researchers and clinicians both in the industrialized and in the developing worlds. ProCAARE enables physicians, policy makers, researchers and other health care providers in the developing world to have rapid access to current information and to a body of experts from around the world.

    4. ProCOR: Cardiovascular Health in the Developing World addresses emerging epidemics of cardiovascular disease in the developing world. Its goal is to create a dynamic international forum where health care providers, researchers, public health workers and others may share timely information and participate in raising the awareness about this emerging public health challenge. Expert moderation of ProCOR helps to ensure the quality of the discussion and the rapid dissemination of current information relevant to developing countries.

    5. AFRONETS: The African Networks for Health Research for Development in Eastern and Southern Africa conference facilitates the exchange of information among the different networks of health-research-for-development professionals active in the eastern and southern African region. It is a forum for discussion that supports collaboration among those in the fields of capacity building, planning and conducting research, and the transforming of research recommendations into action.

    6. INDICES: International Network for Drug Information Centers is an electronic conference meant for colleagues working in drug information and drug information centers. It provides a forum for discussion of issues pertaining to the setting up and running of drug information services and centers. It is also hoped that this conference will provide a network of support for those colleagues working in the developing world.

D. GetWeb is offline access to the World Wide Web. This service enables users to request the text content of Web documents via electronic e-mail.

E. Global Database of Health Professionals provides access to the electronic directory.

.. Linux gateway polls respective HealthNet Nodes at scheduled times to exchange mail bundles

      _______ User systems call the host node system for exchange of mail bundles using the modem and telephone

Figure 1: Configuration of the HealthNet Node

Figure 2: Information Services Offered by HealthNet

Text for Figure 1 (The graphic exists only in fax format at this point!)

Internet

Linux Ifmail Gateway

FIDO Systems HealthNet Nodes

Kenya

Ethiopia

Bolivia

FIDO Polls User Systems

GCMS

JIHS

GTZ

Hospital

Text for Figure 2 - graphic exists only in fax format

Information Services

E-mail

Electronic Publications

HealthNet News

WHO Library Digest for Africa

Health Action

AIDS Action

Child Health Dialogue

CBR News

Global Electronic Conferences

ProMED

E-DRUG

ProCAARE

ProCOR

AFRONETS

INDICES

GetWeb

Offline access to the WWW

Global Database of Health Professionals

Electronic Directory

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