This is an article that appeared in the August, 1995 US Medicine Magazine, "Creating an Epidemic of Health with the Internet" by Tom Munnecke and Heather Wood Ion

“It is possible to create an epidemic of health,” said Jonas Salk. The convergence of the Internet, global communications, and medical technology have created an environment from which dramatic new advances in health care and enhancement may emerge.
The contagion for this epidemic is healthy people. In any population, there will be some who have maintained their health, and serve as role models for those who have not adapted as well. These people may be healers, or simply people who exude enough vitality that others can benefit. Healthy people are contagious in face to face settings. The Internet can leverage their presence around the globe.

The vector of this epidemic is information. It can build electronic communities, share research, communicate knowledge, locate resources, share needs, and build an evolutionary path to cope with future needs. In order for this to be shared, access to the network must be global.

The world can be the population affected by this epidemic. As a result of the herd effect, even those without direct access to the network can benefit.
The virulence of the epidemic of health can be assured because of the universal need for health. Improving health can be a win-win situation for all concerned. Health is not a commodity subject to supply and demand curves; neither is information.

The hospital, said Peter Drucker in 1973, is “one of the most complex social institutions around.” Systems of hospitals are even more complex. The intervening twenty-two years of technology, health care reform, and cost pressures cause even greater complexity. Compounding these levels of complexity are global issues which make the problem of global health care seem insurmountably complex. From a traditional point of view, perhaps they are. This complexity can be addressed by innovative techniques. By combining the dynamics of an epidemic with global communications, major changes can occur. To quote Salk: “Only a few are needed to visualize and to initiate a process that would become self-organizing, self-propelling, and self-propagating, as is characteristic of evolutionary processes.”

The Internet as a Role Model
The Internet serves as a role model for a self organizing, self-propelling, self propogating system of immense complexity which has grown rapidly over the last 25 years. It connects an unknown (30 million?) number of people from over 100 countries with millions of computers. The World Wide Web is a particularly active portion of the Internet (see sidebar), and is currently growing at about 1% per day. All indications are that the rate of growth of the Internet is accelerating.

The Internet grew from a small set of universities, and developed with a (then) unique design attitude. Rather than convene committees and authoritative bodies to write white papers and standards, they adopted a philosophy of “rough consensus, running code.” As new ideas emerged, they would be discussed in various task forces. When the idea was deemed reasonably well formed, someone would program it and place it on the Internet. The good ideas survived and propagated; the bad ones died away. The Internet’s complexity evolved over the years from a simple initial condition and a well defined fitness function: replicating good ideas.

A traditional approach to managing complexity, which harkens back to the “Clockwork Universe” thinking of Isaac Newton and his contemporaries, is to break things down into components, and resolve the complexity of each subcomponent. This cognitive divide and conquer approach has worked for many problems which are mechanistic or factory-like. For the sake of discussion, we contrast two types of systems: policy based and adaptive.

A policy based system is controlled by an external set of rules, policies, or other control mechanism. The system is governed by negative feedback: operations which are against the policy are punished. The IRS tax code, driving laws, and bureaucratic organizations are examples of this approach. The complexity of these systems is restricted by the complexity of the policy; stability is generally considered a virtue. The more complex the system, the more complex the policy. The system is supposed to be predictable and behave repeatably, according to linear mathematical models. The role model for behavior is the policy, and authority is an abstraction of the hierarchy. In general, the goal of policy based systems is complex initial conditions, simple operation.

An adaptive system is controlled internally by positive feedback. Successful operations are replicated. The system is assumed to be continuously changing and growing. The system is its own definition, and complexity is a characteristic which evolves over time according to the evolutionary “goodness” of the behaviors of the system. Adaptive systems are not necessarily predictable, and display emergent properties, in which the whole is greater than the sum of the parts. These systems are non-linear, and display patterns of chaos. Any living thing, evolution of the species, and the Internet are examples of adaptive systems. In general, the goal of adaptive systems is simple initial condition, complex operation.
Consider the complexity of two problems: building a factory and tending a garden. A factory (policy based system) is a very complex system, with many rules and procedures for producing its products. If everything goes well, it will produce exactly what it was designed for, no more, no less.

A garden, as an adaptive system, can be a very simple system. With the proper amount of water, seeds, nutrients, and sunlight, a respectable garden may appear. The results of the process are far less certain, and biological surprises may often appear.

The simplicity of the garden, however, hides an incredible complexity of the chain of life. Even the smallest cubic millimeter of the garden holds immense scientific complexity and evolutionary information. Those tending the garden, however, are free to deal with simplicity.

So it is with the complexity of global health. Rather than considering it to be a problem solved by the policy-based “factory” paradigm, it can seen as an adaptive problem akin to tending a garden. The immense global diversity of health care needs, resources, and models dictate that a highly adaptive and continuously growing system is necessary.

A formula for designing adaptive systems might be:

• Start simple, and let the system grow in complexity over time
• Allow it to evolve based on positive feedback. Replicate success.
• Decentralize to allow many points of view
• Support lateral communications for operations, training, and the evolution of the system
• Assume that the system is constantly changing; expect the unexpected.

Alvin and Heidi Toffler wrote, “global competition means that we cannot go back to the conformity, uniformity, bureaucracy and brute force economy of the assembly-line era. But the Third Wave is not just a matter of technology and economics. It involves morality, culture and ideas as well as institutions and political structure.”

The Internet as an Infrastructure
As we move towards a global information infrastructure, we will once again experience the sensation that the world is shrinking. Concepts of distance, time, geography, borders, nationality, and community will all shift radically as we deal more and more with bits of information instead of atoms of matter.

Globalization means much more than “Internationalization.” For the purposes of this article, we will define globalization as the process of dissolving borders. Connecting two medical facilities in the same town in the United States or connecting United States and Zaire are two variations of the same problem of globalization. (Although the Zaire problem is probably simpler.)

The Global Health Care Environment

There are three major aspects to the challenges of the globalization of health care:

• the definition of “health," and the pragmatic understanding of implications for care
• the diversity of health care models
• the different drivers of health care

The Definition of Health

The World Health Organization states “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” The problem with this definition is that by including the words ‘complete’ and ‘social well-being’ it turns the enduring problems of human happiness and social interaction into one more medical problem to be treated by specific, scientific, interventions. Coupled with the mechanistic and reductionistic expansions in technologically-driven capacities, this opens a Pandora’s box of demands for ‘fixes’. Further, the definition’s interpretation has removed the responsibility for such complete well-being from the individual and placed it on the shoulders of the medical professional.

This definition does not convey the common world-wide assumption that health is a functional state which makes possible the achievement of other goals and activities of living. Comfort, well-being, and the distinction between physical and mental health differ in social classes, cultures and religious groups.

Attached to the definition of health is the consequent health policy in any given community. If health is defined as a right of all people, access to health care is mandated. If it is defined as a market-driven commodity, or as an individual’s responsibility, access to health care services varies widely.

Models of Health Care

In 1990 Americans spent $10.3 billion on alternative health care modalities. In 1992 Congress created the Office of Alternative Medicine as part of the National Institutes of Health. Even as we cannot assume that there is only one medical model used within the US, we cannot assume that globalization through communication will dissolve the boundaries between definitions and models. 48% of the world’s population is at risk for the biggest international killer, malaria, and over 200 million people live in areas where malaria is endemic. Yet for most of these people malaria is a condition of life, a given, and thus not a reason to seek any model of care.

Major models of care around the world include:

• Model /Region

• Allopathic or diagnosis-based therapies Western, professional medicine
• Homeopathic or likeness-based therapies European
• Meridian or energy based therapies Asia, and increasingly in the US
• Manipulative or treatments by the hands World-wide
• Shamanistic or treatments by priests Indigenous peoples, and folk healers
• Ayur-Veda or balance restoring therapies India
• Herbal or plant-based therapies World-wide

Even within one of these models of care, such as Western diagnostic medicine, various interpretations of the disease process and of the healing or curative process mean that specialists may differ not only in what they do, but in their perspectives on what constitutes disease, health, and an ethically justified intervention. Where the medical model has coexisted with highly scientific societies, the habitual ‘need’ for certainty has insured a ‘need’ for specialized technology which has created a ‘need’ for specialized personnel.

Health Care Drivers

Delivering care involves a complex interaction among individuals, providers of care, payors and communities. In some models, the individual receiving the care is not the payor. In some models the patient is not the object of the care. In some models the physician or provider of care must satisfy at least three masters: the patient, the payor, and the community. Different groups balance these influences in contrasting ways. Some of the drivers of health care services are:

• population
• economics
• social responsibility or humanitarian concerns
• environment including sanitation, water, natural resources
• war
• culture, beliefs, values
• innovation
• fear and legal systems of protection

These factors influence the content of care, the compulsion or impulse to seek it, and the responsibility to pay for it.

In the US the movement to reform health care must somehow balance the demand for universal access to care, and the demand to limit the costs of care. Both problems may be clarified by better understanding of the definitions of health and of disease and the consequent demands for care itself.
Our Shrinking World

The challenge to global health care is a volatile mix of pressures from population, poverty, new and drug-resistant pathogens, natural and man-made catastrophes, wars, environmental degradation, mass travel, and extraordinary demand for medical solutions to non-biological problems. HIV, hepatitis B, Ebola bacteria, or new threats to global health exist independent of society’s differing health care models.

Partly due to these pressures, the health care community has been scaled up to proportions greater than any nation-state or economic organization. In some countries the health care delivery system is the largest employer, and the largest recipient of hard currency. The World Bank has become the major external funder of health sector investment in developing countries.

Simultaneously, multinational companies are looking to developing markets with major consequences regarding health care. Since 95 % of world leaf tobacco is controlled by six transnational corporations, their power can often overwhelm countries which do not have a clear tobacco policy, or where significant revenue is gained from tobacco sales or exports. The tobacco company viewpoint is clear: “Until recently perhaps 40% of the world’s smokers were locked behind ideological walls. We’ve been itching to get at them--and we’re much relieved and excited that this 40% is now open to us. That’s where our growth will come from."

With global marketing has come global consumerism. From consumer action, the International Code regulating the marketing practices and promotion of infant foods was passed by 118 countries at the World Health Assembly in 1981.

There is no single, stable point of view in this expansion of activity, need, and awareness on which to base a policy. With the huge numbers of degrees of freedom and the explosion of human needs, a complex, adaptive, interacting web approach is necessary to address the global commonality of concern for health.

Decentralization and Replications of Success

A transition to adaptive systems would provide an opportunity to evaluate policies which effect global health applied at the local level. Enteric disease remain rampant worldwide, and the safety of water supplies is a problem relevant in both the developed and developing worlds. For almost two decades, solar disinfecting studies have confirmed that bacteria from fecal sources which contaminate water are susceptible to destruction upon exposure to sunlight for an adequate period of time. Drinking water can therefore be rendered safe using clear plastic or glass bottles when exposed to sunlight for 85 minutes. Communicating this simple solution to highly motivated local users of the Internet and World Wide Web, would create the opportunity to save the lives of over 25,000 children per day, by transformation of a “push” effort by world bureaucracies and external organizations to a locally empowered “pull” operation of relevance.

The practice of medicine is an application of local knowledge. While a physician’s discrimination will be informed by aggregate numbers of efficacy of test results and appropriate drugs, the more local his attention to the circumstances of illness and health, the more relevant the care provided will be. Decentralization of communication means immediate comparisons of the local conditions of care without the diluting, and often distracting, delays of the centralized systems of distribution and approval or codification of validity.

How can the decentralized worldwide communications technology effect policy change? Greater knowledge means greater informed choice, and the connectivity of a global information infrastructure indicates that choice can be based upon the fitness function of efficacy. What works best? What does no harm? Centralized policies can now subject to the democratic and informed scrutiny possible with shared knowledge based on an intellectual commons which accelerates and enhances our ability to correct error and revise health care delivery on the basis of what is known to have positive effect without negative consequence.

The mechanistic paradigm driving Western medicine has proven inadequate for preventive care, chronic conditions, and behavioral medicine. Market-based values of cost have not reflected the human and long-term impacts of this inadequacy. The complex adaptive systems approach of communications technology makes it simple to relate what we now know to our choices of what we must and can do. Communications connectivity thus restores to medicine its moral role, and restores medical judgment to primacy above measurable evidence. An informed patient, just as an informed community, or country, can assume cooperative responsibility with the physician and scientist to choose optimally, instead of passively expecting the physician or medical profession to provide complete well-being. In such areas as infant mortality, the use of prenatal care, and the coordination of community resources, dialogue among providers offers potential improvement through alternative approaches known to be successful.

Connectivity and Diversity

Another opportunity provided by the globalization of a complex adaptive information technology, is the connectivity of shared interests and the harmonies thereby created among diverse users, from diverse cultures and perspectives. One of the most expensive consequences of the mechanistic paradigm in health care is its compulsion for certainty. Not only does interactive connectivity educate us regarding other possibilities, but in doing so it increases our tolerance both for diversity and for the uncertainties of organic and adaptive systems. Such an attitude could radically change cross-cultural health care, and the delivery of support or compassionate care.

This tolerance and mutualism is enhanced by another function of digital communication--the exploration of free movement between generalities and specifics. As the depth/breadth problem disappears with hypertext, traditional accusations of “inadequate” or ‘insufficient’ regarding data become irrelevant, as the user can at once see the fitness function: what works, where, when and how much is known about why. In all aspects of health care this creates an accessibility for experiment, evidence and evaluation. Research will no longer be an additional luxury, but intrinsic to the process itself.

Simultaneously, connectivity eliminates the boundaries between knowledge of need and knowledge of resources. In global health care this is particularly significant since we know that most famines, some epidemics and many untreated septic infections result from distribution problems (information) not by lack of knowledge. By using the electronic web connecting common concerns, we can better respond both more rapidly and more appropriately than the hierarchical paradigms of the past have allowed.
How to create the epidemic of health on the Internet

The first signs of this epidemic are already appearing on the Internet. Patient support groups, for example, have been shown to have a life extending effect in cancer therapies, chronic illnesses, HIV positive individuals, and chronic heart disease. Extending these activities to on-line communities on the Internet could provide vast benefits.

The BRAINTMR Internet support group, for example, was started by a young woman who had a brain tumor successfully removed. As a survivor of this traumatic experience, she is a powerful communicator to a group of people facing similar problems. This group of 600 people from all over the world “meets” via electronic mail and shares their experiences and emotional ups and downs as they struggle with this common problem. The group simply emerged: it has no formal sponsorship or funding.

Geriatric medicine has struggled with the fact that a significant portion of elderly patients seek medical care due to loneliness and boredom. Linking isolated, often home-bound elderly patients to each other via the Internet could have a significant impact on social interaction, a sense of worth, and the related sense of well-being.

1. Start Simple. Couple a simple mechanism with a grand vision.
2. Devise a mechanism for communicating and replicating success.
3. Provide universal access to the global information infrastructure.
4. Build connectivity and virtual communities for health-related activities.
5. Support Patient Support groups on the network.
6. Publish medical knowledge on the Internet, make it freely available to all.
7. Create a health “metacenter” on the World Wide Web to serve as a focal point for the evolution of the epidemic of health.

We believe that global communications can initiate an epidemic of health which can be self-organizing, self-propelling, and self-propagating. In the event of a global biological emergency, global communications could prevent or mitigate a catastrophe. As a means of improving one of humanity’s intrinsic needs: health, it could become a powerful source of positive reinforcement. As a means of aiding and comforting those suffering from disease, it could build community where none was previously possible. All that is necessary is to trigger this are those few people to visualize and initiate the process.


The authors wish to recognize the review and contribution of Dr. Jonas Salk to this article.