To learn more about GIS developments and applications in various programs around the world, and to share ideas and assist in setting priorities in health geographics at all levels, representatives of various health-related disciplines from many countries will come together Oct. 16-18, 1998, in Baltimore for the first International Health Geographics Conference.
Sponsored by the prestigious Johns Hopkins School of Public Health and Environmental Systems Research Institute (ESRI), the conference will be the first of its kind to look at GIS in the broad scope of health, both geographically and across sectors. This "think tank" approach to the geographics of global health has also attracted sponsorship from international agencies and organizations supporting health-related programs in Latin America, the Caribbean, Africa, Asia, the Middle East and Europe. Throughout the three-day conference, six keynote speakers will give presentations on a variety of applications, developments and challenging ideas. Several speakers discussed their upcoming presentations and involvement in international health geographics.
Dr. Robert Lawrence, MD, MHSc, is associate dean of the Johns Hopkins School of Hygiene & Public Health.
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GT: What will be the focus of your presentation?
RL: I am going to illustrate, from a public health perspective, how data from the recent National Cancer Institute Report on radiation exposure to the Nevada nuclear tests from 1950 to 1962 are being used to develop recommendations for requiring cancer screening of the exposed population. The illustration shows how GIS can be useful in epidemiological analysis of population risk and exposure. It also shows how GIS can be used to map correlations among datasets that have been collected for a variety of purposes.
Following each of the 90 to 100 atmospheric tests conducted in Nevada during the 12-year period, the [Atomic Energy Commission] put out sticky squares at 70 to 80 sites around the country to collect fallout. The total number of Rads contained in the sticky squares was entered as one set of data. Another dataset was from the U.S. Weather Bureau. Still another was milk consumption patterns, because iodine-135 from fallout settles on pasture grasses, which are consumed by milk cows. The iodine is then concentrated in the milk. But I-135 has a half-life of eight days, so by the time commercially-produced milk reaches the consumer, the iodine content is considerably diminished. On the other hand, milk from backyard cows tends to be consumed more promptly, so people who get milk this way get a much more intense radiation exposure vis-a- vis the short half-life of iodine-135. Using GIS to correlate these data enables us to observe patterns that would otherwise be difficult to detect.
GT: How do you see the role of GIS technology in public health?
RL: Dr. David Sackett, now at Oxford University, once made the observation that clinical epidemiology as a discipline emerged with the microcomputer. Prior to that, we simply did not have the capability of doing data analysis and statistical simulations, except for a very limited number of people who had access to mainframe computers. Today, the core disciplines of public health are epidemiology and biostatistics, and virtually everyone in the profession uses desktop and laptop computers. As the tools become more user-friendly, and GIS packages similar to the [Center for Disease Control's] EpiInfo and STATA become available, we will probably see this technology really blossom.
GT: The technology already exists for Web-based GIS. Will the school use this capability to extend training to health professionals in developing countries?
RL: We're already doing this through our Distance Education Division. We have several courses available through the Web, including a graduate certificate program initiated last July. We anticipate that our use of Web-based information sharing will continue to grow. Some of our students working on a masters in public health (MPH) spend some time on campus and the rest in their own countries. While they are away, they maintain regular contact with a faculty mentor or preceptor. Also, we have received a grant from the Sloan Foundation to develop an MPH that would be available entirely through distance education.
GT: What do you see as the role for GIS in future health-related issues?
RL: About a year and a half ago, at Johns Hopkins, we established The Center For a Livable Future. This is a university-wide center, based here at the School of Public Health. We work with people from many disciplines, examining the complex, interrelated problems of population growth, environmental degradation and resource depletion. GIS will have an important role in helping to solve such problems. For example, Dr. Grace Brush, a paleoecologist, has taken core samples from different parts of the Chesapeake Bay bottom. These samples essentially give her four- to five-hundred years of history of the changing ecology of the Chesapeake Bay. They demonstrate the disastrous collapse of the complex ecosystems over the last 20 years, as a result of nutrient runoff from factory-farms on the eastern shore, from point-source contamination and from improperly functioning sewage-treatment plants.
I anticipate GIS will become extremely important to our future, particularly as we plot strategies for trying to reduce the impact of the human population on the earth and its resources -- everything our colleagues are concerned about: global warming and greenhouse gas emissions, erosion of soils, shortages of water for human consumption, excessive irrigation, the depletion of arable land by expansion of cities and highways. All this lends itself to GIS applications in a way that will be more effective in bringing home the message to the American people in particular, and people around the world, that we are on a collision course with real environmental catastrophe over the next hundred years unless we make some major changes in our consumption patterns.
Jack Dangermond is president and CEO of Environmental Systems Research Institute (ESRI) of Redlands, Calif.
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Jack Dangermond
GT: How would you describe ESRI's involvement in health care?
JD: We have formed a Health Care Solutions Group. Bill Davenhall, its manager, is one of the pioneers in using GIS in a wide variety of health care environments. Bill is joined by Bill Hoffman, an epidemiologist. We are committed to helping the health care service delivery and health care policy communities find more efficient ways to carry out their respective missions. The principal function of the group is to explore with our clients possible solutions to the critical problems they face, whether they are resource distribution issues, health-service delivery challenges or customer service/quality issues.
GT: According to Omar Kahn, the conference co-chair, the Johns Hopkins University School of Public Health is offering distance education via the Internet. Do you see ESRI becoming involved in this project or developing one of its own?
JD: We believe that distance learning will benefit greatly from the Internet. We have been experimenting with the development of the virtual campus and the tools that help those who teach expand their reach into the arena of life-long learning. We have hopes of offering at least 20-plus courses on the Web by year's end.
GT: Where do you see health care applications going, with regard to information needs and the role of GIS?
JD: We see GIS applications becoming embedded into the daily operations of health care, such as customer service. We are seeing health care providers putting physician and hospital locator maps on the Web and routing health care workers to home and work-site care locations. We see GIS applications being used more widely within health care delivery organizations, adding geographical information to their clinical data, so they can understand the relationships between demographics and diseases of the populations they serve. We see GIS increasingly impacting health care policy. The Dartmouth Health Care Atlas and the Mortality Atlas reveal the geographical disparities in both health care delivery and resource consumption.
Geographical information systems are about relationships. Health care already understands the importance of the parts to the whole, thus they will have little trouble grasping GIS concepts and putting them to work for the good of mankind. Health care will learn how to use the technology, not only to provide and deliver better health care, but to actually anticipate and intervene to prevent sickness, accident and injury. This is what GIS in health care must be about, making a real difference in our daily lives.
GT: How do you see the future of the Web in terms of getting geographic information to health workers?
JD: In terms of the Web, we are just seeing the tip of the iceberg; we don't know what all the possibilities are, because the system is evolving so rapidly. We see more geographic information on the Web every day; projects, for example, that not only distribute free health care, but also provide clinical assessment "tools" for end users -- those taking greater responsibility for their health. We see physicians putting their appointment scheduling on the Web for the benefit of their patients; and lab and test results being posted to the Web to give both care givers and patients instant access to their own personal health information.
GT: Do you have the impression that public health has been slow in embracing a technology that clearly has so much potential for this field?
JD: Public health has actually been among the vanguard of using GIS. At least 50 percent of our 5,000-plus health care customers are using the technology for some type of "public health" purpose. The part of health care that has been slow to adopt GIS has been the nonpublic health organization, and, unfortunately, this is where most of us are diagnosed, treated and interacted with.
Like so many areas, the adoption of a certain technology involves a complex set of issues, such as the perceived value of the technology, knowledge of the concepts and the willingness to change. The health care field is coming to terms on all these fronts and will embrace GIS as it has so many other technological breakthroughs
Geoffrey Jacquez is president of BioMedware -- a Michigan-based company specializing in public health research with an emphasis on disease surveillance analysis.
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Geoffrey Jacquez
GT: What will be the focus of your presentation?
GJ: Although GIS has made many contributions, health data possesses unique characteristics that are not fully exploited by existing systems. In a given health application, geographic space may be of large or small importance, but GIS currently exploits primarily the spatial dimension. This constrains applications of GIS in health to tractable problems using "generic" spatial operations, such as buffering and overlay, and are based primarily on spatial queries. My basic message is that we can do a much better job of tailoring GIS to health applications.
Another important issue is demonstrating the relevance -- the value added -- by GIS in public health. Health care providers see the value added in the location/allocation problem; the value of GIS is obvious when it comes to locating a facility so it is accessible to the client population. Vector-born disease specialists usually see the value added by GIS in relating disease occurrence to the spatial distributions of the parasite and host populations. Specialists in infectious and chronic diseases easily see the value added by identifying geographic sub-populations for cohort studies. Even so, these applications just scratch the surface. We still have a lot of work to do in terms of exploring how this technology provides unique contributions in public health.
GT: You have said that "one of our greatest needs is to provide GIS solutions tailored to public health." Hasn't GIS already shown its adaptability to this field, particularly epidemiology?
GJ: Current GIS software is primarily a grab bag -- developers have thrown everything into the product without regard to the special needs of the health care user. This has caused a steep learning curve, just figuring out what parts of the GIS can safely be ignored! Software tools for "unbundling" GIS functionalities are now available to software developers. In the near future, we're going to see GIS applications more closely tailored to the information requirements of public health professionals.
GT: How do you see GIS as an enabling technology for studies in health and the environment?
GJ: In the 1600s, Antony Van Leeuwenhoek used a water drop lens to glimpse at man's first view of microbes. At first, the lens was a mere novelty, and Leeuwenhoek had no idea what these "animalcules" [microscopic organisms] were, nor of their relationship to human health. It was only after the light microscope was applied within the context of the scientific method that Pasteur and Koch, the father of modern virology, and others elucidated the causal relationship between pathogens and infection. As a technology, GIS is very much like the light microscope. We're all smitten by its novelty; it gives us a new way of looking at the world. But we still haven't figured out how to use this new tool in a systematic fashion to increase our understanding of health/environment relationships. In my view, GIS is still looking for its Pasteurs and Kochs.
GT: How would you make GIS a sound financial proposition for nonprofits and health agencies in developing countries?
GJ: GIS can be an effective means of cost reduction by increasing the efficiency of health care delivery and by targeting interventions. However, in some instances, GIS has turned into a boondoggle -- lots of money spent and little return. An important first step before embarking on a GIS project is a careful, cost-benefits analysis, not just in financial terms, but also to assure the biggest "bang for the buck" in terms of human health. Basic public health measures, such as immunization, potable water supplies and sanitary sewers, may be the most effective way to spend the public health dollar. These have a strong geographic component, and GIS is a powerful tool for targeting such interventions.
GT: What are the challenges to health applications for GIS?
GJ: One of the biggest challenges is overcoming an entrenched "aspatial" mentality. We need to change the way people think, not only of health solutions, but also of the problems themselves. In many scientific fields, the importance of "space" is a given. For example, ecologists have a tradition emergent from field studies; they realize that geography mediates almost all interactions among organisms. Epidemiologists, on the other hand, come from a clinical tradition. Consequently, the geographic component of public health is often ignored. Even now, courses in "spatial epidemiology" are only rarely part of the public health curriculum. One of the big challenges is educating health workers not only in how to use GIS but also in how to "think spatially" when addressing public health problems.
GT: What do you see as the future role of the Web in terms of geographic information delivery for health workers?
GJ: This is the new frontier, and, as with most frontiers, the Web offers the greatest challenge as well as the greatest potential payoff. I have yet to see a GIS application for the Web that offers more than novelty. They are too slow, and the maps too crude, to be of any real use. However, health GIS for the Web potentially will change how health institutions "do" GIS. At present, there are two approaches: the desktop model and the department model. In the desktop approach, a researcher or small group a GIS on a desktop or small LAN. While they have good control over the GIS, other researchers at the institution have little, if any, access to the GIS and its data. The department model centralizes the data and gives "equal" access to all, but that access is through the guru who runs the department GIS. Web-GIS makes possible desktop applications with access to centralized data. This will revolutionize the delivery of geographic information to health workers.
Dr. Isabelle Nuttall is a medical officer with the WHO/UNICEF Joint HealthMap Program in Geneva, Switzerland.
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Dr. Isabelle Nuttall
GT: What will be the focus of your presentation?
IN: GIS has proved to be an essential tool for improving the management and monitoring capacities of public health programs. Our experience shows that this tool can be implemented in developing countries and can assist in the eradication of some tropical diseases. Implementation does not necessarily imply sophisticated technologies but certainly requires that time is spent on construction of the appropriate databases. We believe that 90 percent of the work involved in GIS for health is spent on data integration, management and update. This is too often forgotten when projects are being set up.
GT: What is the WHO/UNICEF HealthMap program, and what are its objectives?
IN: HealthMap is a GIS development and dissemination program in the Tropical Diseases Control Division (CTD) of WHO. Its objectives are to promote and implement mapping and GIS as an operational tool for planning, monitoring and managing priority public health programs for national ministries as well as for WHO, UNICEF and key agency partners.
GT: How does HealthMap function globally?
IN: The program was initially created in 1993 to establish a geographic information system to support management and monitoring of the Guinea Worm Eradication Program. It has since been established for 26 countries and contains geographic and other baseline information, such as village populations, school and health infrastructures and water supply information on over 80,000 villages in sub-Saharan Africa.
Since 1995, the growing demand for mapping and GIS has broadened the scope of the program considerably. It now includes the promotion and use of GIS for a diverse range of public health programs in general, and tropical disease control and elimination programs, specifically, those for onchocerciasis, trachoma, trypanosomiasis, filariasis and malaria; it includes a strategy for eliminating blinding trachoma and a prototype project for stratifying risk factors and monitoring community surveillance results for malaria in Ethiopia. Plans have also been developed to use GIS and mapping to support efforts for the global elimination of lymphatic filariasis and control of intestinal parasites. GIS for monitoring urban health is under development in the cities of Dakar and Bamako, in Africa, and a strategy framework and implementation plan for using GIS to support urban health monitoring has been developed in collaboration with the WHO Center for Health Research in Kobe. On the regional level, technical capacity has been strengthened through identification of a network of institutes and through WHO and UNICEF regional offices.
The agency also maintains a library of digitized basemaps of every country in Africa and selected countries in Southeast Asia. These are available via the Web as interactive maps for assessing distribution of population settlements in relation to health and social infrastructure.
GT: What issues of GIS/GPS sustainability have your group had to address in working with developing countries?
IN: There are several: the maintenance of GPS and the computers; the possibility of solving technical problems when they occur; the impact of high staff turnover within institutions, and the maintenance of databases. However, once people are working with computers on a regular basis, adding GIS in the package of tools they use is not a problem. The operation can be sustained if there is enough training and awareness provided at the technical and decision-making levels.
GT: How does GIS improve the health/development process?
IN: When setting up a GIS that could be further used for public health
planning, the first step is to get the geographic coordinates of the villages, link them with census data and provide information on the location of the basic infrastructure -- health facilities, schools, water supply. All this information and the subsequent maps that can be drawn can tremendously improve the health/development process through better planning.
GT: The United Nations has made possible -- via the U.S. State Department -- computers, GPS receivers and GIS software to assist in mine clearing operations in Bosnia. Will the United Nations be able to provide similar technologies to assist
in the eradication of endemic diseases in developing countries?
IN: Yes, definitely. It is already happening with guinea worm disease. GIS and GPS are being used to monitor the results of the village-based surveillance system over time, to facilitate cross-border monitoring of the disease and for better planning and targeting of intervention activities. Interruption of the transmission of the disease is targeted for 2005. The same approach is also taken for polio eradication.
Patrick Gerland is a population software specialist with the United Nations Statistics Division (UNSTAT), which is responsible for collecting and disseminating economic and social statistics for member states and assisting them in improving statistical capabilities.
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Dr. Patrick Gerland
GT: What will be the focus of your presentation?
PG: PopMap software and its applications to population activities in developing countries. PopMap is a sustainable, user-friendly tool, designed primarily for statistical and geographic database development on the local level. It was developed for geographic information management and decision support for population activities. It integrates a geographic database for statistical data with desktop GIS mapping capabilities in one software package. It is compatible with all national versions of Windows and multilingual character sets, and is distributed free of charge to governments and population programs in developing countries.
UNSTAT has also developed a new product called MapScan, which reads and converts scanned maps into vector format, ready to use with PopMap and other CAD/GIS packages.
GT: Does PopMap have applications for epidemiology?
PG: The software does not offer specific features for epidemiological applications, but several projects and health organizations in different countries use it to store, organize and present health data. It can be used to map reproductive health and family-planning resources in relation to their spatial context, population and socioeconomic infrastructures.
GT: Why did UNSTAT develop PopMap software when off-the-shelf GIS packages are readily available?
PG: Commercial relational database systems and state-of-the-art GIS on true client-server architecture offer optimum solutions for the most advanced countries. However, commercial, high-tech options are unrealistic for many less-developed countries. The key issue is database sustainability; limited capabilities and frequent staff turnover combined with scant resources make it difficult, if not impossible, to rely heavily on training and support for high-tech applications. It is more beneficial to choose a simple and robust design that many more users can easily understand and maintain and that can be transferred to software packages independent of any hardware platform.
GT: What are some of the challenges the United Nations and its partners face in terms of data and analysis?
PG: There is little or no commercial market for maps and data in most developing countries. In some areas, these products are either nonexistent or not suitable for GIS applications. In addition, many existing paper maps are often outdated or incomplete. It will take a massive effort to cross-check and convert data and digitize the maps. Most of these countries are facing rapid changes; urbanization, migration and population growth impose frequent revisions. Datasets need constant revision to take these changes into account.
GT: How do agencies obtain PopMap?
PG: United Nations Population Fund-supported programs, government agencies and academic institutions can obtain PopMap for Windows free of charge. Requests for software should be addressed to the Statistics Division, United Nations, 2 United Nations Plaza, New York, NY 10017. Fax: 212/963-4116.
E-mail:
Dr. Robert Lawrence is one of the architects of the school's ground-breaking distance learning program in public health. He and Omar Kahn, co-chair of the International Health Geographics Conference and affiliated with the Johns Hopkins School of Public Health Center for Communication Programs, assisted the author with this story.
Bill McGarigle is a writer specializing in communication and information technology.
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