In February 1996 , devastating floods presented a serious health threat in some areas of Washington. Within days of the flooding, authoritative flood-related disease and injury prevention guidelines from the Centers for Disease Control and Prevention (CDC) were electronically made available to anyone with access to the Internet's World Wide Web (WWW). The Washington State Department of Health posted these guidelines on its Web "home page." In the weeks following the flooding, almost 200 persons, many from flood-stricken areas such as Longview and Vancouver, used the WWW to retrieve these guidelines.
Contrast this experience to the Upper Mississippi River Valley flood in 1993, which contaminated drinking water supplies for thousands of Iowans. Then, pamphlets were the best available mechanism for distributing the CDC guidelines. Despite the hurried efforts of dozens of public health professionals, many weeks passed before the pamphlets were ready for mass distribution. By then, the need for flood related information had abated, the pamphlets were never distributed in Iowa.
The Washington experience illustrates the most obvious benefit of the World Wide Web - the ability to rapidly distribute information to millions of persons, at little incremental cost to the providing institution. The WWW has subtler benefits as well. In the Iowa Hoods, for example, public health officials had to resolve differences among experts is to how much bleach to add to bored wells before the pamphlets could be printed. Today, however, interim guidelines with appropriate caveats could be posted on the WWW while experts developed final recommendations. These interim guidelines could later be updated in a few minutes.
Problems with the WWW are often unapparent in the current excitement about this new form of communication. In this article, we offer a public health practice perspective of what is good about the Web, what is bad, and what is ugly (by which we mean, useful but clumsy, overly difficult, or not as useful as it could be). We have focused on the Web for three reasons: (1) ease of use and breadth of content is the most compelling reason - apart from email - to get access to the Internet; (2) valuable new public health information is rapidly appearing on the Web; and (3) other types of Internet applications (e.g., file transfer programs, news groups) are now accessible via standard "browsers" (the software used to find and view WWW material.
With the proper computer setup, browsing the WWW is easy, unquestionably one of the primary reasons for its success. To connect with and view a Web site, the user either types in coded address or "clicks" on a hypertext link pointing to that site.
Using the WWW is relatively cheap. Users can browse the Web for the cost of a fast modem (about $100) and a subscription to an Internet service provider (typically $15-$30 per month for unlimited access). Access to the Web for public health professionals is essentially free for those whose work sites have connections to the Internet. Browser software for the WWW is generally free or cheap.
Web browsers provide a single user interface for diverse information and data transfer activities, including document distribution, conferencing, electronic publishing, public health surveillance, message transmission, announcements, computer-based training, electronic bulletin boards, and other internal applications such as ftp (file transfer protocol) and gopher (a menu system). Web "pages" look essentially the same on all these different systems - an important advantage for information providers.
This dilemma suggests a related problem with the Web: it is completely disorganized. No one person or agency is responsible for it. Anyone with access to a Web "server" can post information of any sort, and no central authority ensures that the new information is useful, unique, authoritative, or accurate. This problem is now addressed in two ways. Those interested in a given subject often develop Web pages with organized links to other useful Web sites (see, for example, Health Links). This approach provides a structured, filtered view of relevant Web resources, but the list of linked sites is generally not comprehensive and and may not be current. Various Internet search tools represent a second approach to the Web's chaos. These free tools allow users to search for Web pages containing certain words or phrases. The search results are comprehensive and may not be current, but typically do little to help users sift the electronic wheat from the chaff. Better means of imposing order on the WWW will be needed for it to increase its usefulness. Even users who know that the Web contains a particular document can spend hours trying to find it.
Those wishing to use the WWW face technical barriers. Although Web browsers configuring all the software necessary to connect to the Web can be complex and difficult. Thus, even in corporate settings with existing connections to the Internet, relatively few users have access to the Web from desktop computers. Cost is another barrier for many public health practitioners. Although access to the WWW is much cheaper than it was only a few years ago, it still requires a personal computer, modem, and monthly payments to an Internet service provider, which puts the WWW beyond the reach of many public health workers.
The WWW raises social issues as well. Should all employees of a public health agency have full access to the Web? Browsing the WWW is interesting and often entertaining, but it can be an enormous waste of time. If we must impose organizational restrictions, on what basis should we decide who has access? The WWW presents the potential for misuse as well. If we provide data via the Web, are we responsible for its misuse of misinterpretation? We could provide only highly aggregated data, which would lessen the chance for misuse, but this would also severely lessen the value of the data to public health practitioners.
The question of accuracy and authority is also important. Some sites have claims that their information is "official" (e.g., the CDC Prevention Guidelines database), but many sites do not. Unlike the scientific literature, most information on the WWW has not had the scrutiny of peer review.
Finally, despite the dramatic increase in the number of WWW users, most people still lack access to it. As noted, hundreds of Washington residents obtained flood-related prevention information via the Web, but many thousands without access, especially those whose homes were flooded, probably needed the same information. If we accord too much importance to the Web as a means of distributing public health information and communicating with constituents, we run the risk of addressing the "haves" and ignoring the "have-nots" -- when the latter often need information the most.
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The UglySeveral aspects of the WWW are problematic or clumsy, but are likely to be improved in the next few years. The first is security. Most Web sites allow anonymous users to freely browse among the documents on their sites. This is obviously not appropriate for sensitive information such as patient records or detailed data sets. Yet, sensitive information is often the most critical to public health practice (e.g., whether a particular tuberculosis patient has been started on antibiotic therapy at another clinic). Advances in security will allow authorized clinicians to get patient-level information via the WWW. Certain Web sites (such as CDC WONDER) already restrict access to sensitive data sets while giving all users access to public-use data sets.The WWW has generally not been used for transmitting public health surveillance data. The Web is good for delivering files from a central computer to end users, but it is clumsy for moving files in the other direction. This situations is already changing, however, with the development of Web "forms" to allow users to enter information in certain specified fields on a Web page. |
Finally, the phenomenal success of the WWW threatens to clog the system. With thousands of new users gaining Internet access each month, transmission time is often unacceptably slow. Many popular sites are almost inaccessible at certain times of the day. Some experts predict the Internet will collapse under its own weight within the next few years, despite efforts to expand and strengthen it.
Recommended Reading
Centers for Disease Control: Beyond the Flood: A Prevention Guide for Personal Health and Safety Atlanta: U.S. Department of Health and Human Services, Public Health Service, 1994.
Centers for Disease Control: Public Health Consequences of a Flood Disaster - Iowa, 1993. MMWR 1993;42(34):653-656.
Lewis B: Have faith in the free market: Internet should survive the year. InfoWorld 1996; 18(13):74.
O'Carroll PW, Freide AM,. Noji EK, et al: The rapid implementation of a statewide emergency health information system during a flood disaster. Iowa, 1993, Am J Public Health 1995;85:564-567.
Balderston J: Browser makers woo CompuServe, AOL. Info World March 18, 1996, p. 51.
Authors
Patrick O'Carroll, M.D., M.P.H., F.A., C.P.M., is clinical associate professor of epidemiology and health services at the UW School of Public Health and Community Medicine, on assignment to the state of Washington from the Centers for Disease Control and Prevention.
Thomas A. Bell, M.D., M.P.H. is health officer for the Cowlitz County and Lewis County health departments and clinical assistant professor of epidemiology at the University of Washington.
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