In a knowledge society of the sort existing today, being a “technological citizen” requires that one understand how to use current technologies as well as be able to learn how to use new ones that appear. Ensuring that the poor have access to these technologies and the knowhow to use them may require design of new approaches. Some speakers suggested that a curriculum to teach people how to use the new media in the most informed way should be developed and tested. As well, they believed it would be essential to develop rapid evaluation methodologies to ensure that interventions are evidence-based and successful. Several participants noted that as information and communications technology (ICT) moves forward, people should look for innovative ways that the old and new media can be used together.
COMPUTING POWER AND SPEED OF TRANSMISSION
Today’s technology is characterized by an increasingly rapid transmission of information and large datasets that can be stored and mined. Speaker and planning committee member Jody Ranck of the Public Health Institute discussed the effect of more pervasive computing power. He noted that the mobile phone of today is more powerful than NASA’s computing power in the 1960s.
As the use of mobile technology in the practice of medicine and public health has become more pervasive, it has evolved into a defined field known as mHealth. SMS, which can be used on all mobile devices, is the most common platform for mHealth; however, as the prices of smartphones decrease
it will be important to think about their design and uses as well.1 In 2009 the number of smartphones imported to Africa was equal to the number of SMS-only phones. Citing Cisco’s estimates that by 2020 there will be more than 50 billion things connected to the Internet, Dr. Ranck spoke of the coming of an “Internet of Things.” These things may be, for example, sensors looking at air and water, and connected through a smartphone. Dr. Ranck noted that access to the Web is becoming more mobile, with most connections to the Web now being made by mobile phones. Because smartphones are also designed to collect data, this increasing connectivity raises the question of who is collecting data, what data are being collected, and who owns the data.
The proliferation of social media platforms is changing culture. Small numbers of people can raise the profile of the issues they care about by generating content for social media platforms and connecting to more people. There are a large number of mHealth deployments worldwide, ranging from HIV prevention messages and information via text to diagnostic tools and peripherals that can attach via Bluetooth wireless for remote diagnostics, acute treatment, and drug adherence. Dr. Ranck predicted that more democratic engagement in public health will result from the growth of peer-to-peer mHealth implementation, making it imperative to address “technological citizenship” in greater detail.
Dr. Ranck also cautioned that an intervention that worked well in one setting may not work in the same way in another cultural context. The issue of power often may be ignored in the development of mobile applications. He mentioned that there are some examples of domestic violence applications, successful in one area, that actually increased the level of domestic violence in other areas because of gender and control issues over the mobile phone.
PRIVACY AND MISINFORMATION
Security is a growing issue for ICTs, and tools are being developed to anonymize data that are sent through mobile devices—for example, to ensure the safety of human rights workers. Dr. Ranck noted that the potential for de-anonymizing large datasets could raise privacy concerns. Many participants and speakers felt that innovations in ICT are ahead of current policies regarding privacy.
One workshop participant expressed concern over the implications of citizen reporting, vigilantism, and “trial by publicity.” Speaker Erik
1 Short Message Service (SMS) is a text messaging data application for phone, Web, or mobile communication systems, using standardized communications protocols that allow the exchange of short text messages between fixed line or mobile phone devices.
Hersman of Ushahidi responded that the police are already using cameras to gather information on behavior, so that citizen reporting may actually level the playing field. He predicts that this will settle out in different ways depending upon the country. Mr. Hersman also said that although data can be poisoned by misinformation, the best way to counteract that is with more information. Despite concerns over data corruption, he said, it has been found that as more people use the data the better the data become.
CROWDSOURCING AND OPEN INNOVATION2
The emerging open health paradigm, in which access to information and decisions about health are available to all, includes open innovation and crowdsourcing. One example, InnoCentive, is a platform supported by Eli Lilly to find solutions to challenging scientific problems that had remained unsolved in the lab, and it relies on the success of this paradigm. Crowdsourcing and open innovation platforms can significantly reduce the time and expense needed to find a solution. Dr. Ranck also mentioned the work of Deborah Estrin at the University of California, Los Angeles, and Ida Sim at the University of California, San Francisco, to create an open mHealth structure that can allow many new applications that cross data silos.
Speakers shared a number of examples of open innovation, including
• Video: Events carried out throughout the Arab Spring were exposed on video. Such visibility can strengthen political will, as happened when a video reached and influenced the Libyan ambassador to the United Nations just before the UN Security Council vote on NATO’s potential involvement.
• Satellite phones: Although allowing for greater access during conflict, when land lines can be compromised, satellite phones can place users at risk if used outside. A mobile network established in Benghazi with funding raised by the son of the deputy prime minister made it much safer for citizens.
• Microblogging: In emergencies—for example, during the 2011 Japan earthquake—it is important to get information from many sources, and when traditional communication lines are down, platforms like Twitter can be very valuable. There were more than 1,000 tweets per minute when the quake struck.
2 Crowdsourcing is the outsourcing of task completion to an undefined group of people, such as the general public, in an attempt to leverage the problem-solving power of large groups. Open innovation is the process of reducing barriers to internal and external collaborations as well as the inclusion of increased or different partners in finding new solutions.
• Mapping: Several speakers discussed interesting ways in which mapping has been used. Mr. Hersman mentioned the mapping of sexual harassment in Egypt and India. Speaker John Pollock of Technology Review said that in Tunisia, accounts of human rights abuses in prisons were disseminated using a technique called “geobombing,” in which geo-tagged3 YouTube videos show up in Google Maps and Google Earth. In this particular case, nongovernmental organizations (NGOs) geo-tagged videos to the presidential palace.
• Traditional TV media: Networks such as Al Jazeera, Al Arabiya, CNN, and BBC also play a role, if not their usual one. Because deliberate misinformation is present in conflict situations, particularly in conflicts between freedom fighters and governments, verifiability becomes very important, and it is sometimes possible through collaboration between traditional and new media.
Mr. Hersman noted that the bigger the network, the more powerful it has the potential to be. However, open data do not necessarily empower the disenfranchised. In India, more affluent people of higher socioeconomic status used land records, released on an open data platform, to acquire more land from people of lower socioeconomic status. It will be important to consider possible downsides and unintended consequences and to think about ways to protect against them.
Public health prevention successes over the past century depended upon huge social change, and ICTs can be used to accelerate change. Dr. Ranck noted that a person with a design mentality looks at how to develop technology in order to achieve a particular outcome, not how to solve a problem within the traditional infrastructure. A platform should be developed for public health that enables innovation but provides protection at the same time.
Most speakers noted the need for and challenges of scaling up. Innovation is most likely to happen outside of large institutions, but these institutions are often important for supporting the scaling up of technologies created elsewhere. Speaker and planning committee member Vish Viswanath of the Harvard School of Public Health cited policy as a means of enabling scale-up. Scaling up can also occur through social media, which
3 Geo-tagging is the process of adding a geographical location to a piece of information (such as videos, tweets, or blogs). Geo-tags are not necessarily accurate because they reflect the location the user has chosen to add.
Mr. Pollock described as having the ability to transform small events into large-scale change. Speaking of Tunisia, Libya, and Egypt, he described how protestors, most of them young, were protesting part-time while they worked or studied. He also described how doctors, dentists, and shopkeepers in Libya joined together with students and became organized.
Speaker Mike Fealty, founder of Slugger Consults, referred to work that he is doing with partners at Queen’s University of Belfast on community asset transfer. The objective is to scale up ideas in spaces where people can converse and be part of the solution. In this way, if the audience is consulted and involved in the design from the beginning, problems that later arise are easier to manage.
Speaker Joseph McCannon of the Innovation Center at the Centers for Medicare and Medicaid Services spoke about the failure to bring innovations to scale and to bring about change. He suggested that the rewards in health care go to those who publish papers and post new information on the Internet rather than those who improve and scale up existing projects. One exception is Johns Hopkins University where successful improvements or the scaling up of a project is given equal weight with publications of original discovery in prestigious journals when determining academic advancement.
EVALUATION, DATA COLLECTION, AND PROGRAM DESIGN
Many speakers and participants felt that the lack of evaluation data is a large challenge. Evaluation methodologies that are applicable to the new technology and innovative programs are often necessary to convince governments, particularly those in low- and middle-income countries, to invest in the innovations and new policies under consideration. Speaker Harriet MacMillan of McMaster University said that interventions are too often scaled up too quickly without evidence, so that programs are often in existence even though there is no proof of their effectiveness. Speaker Judith Carta of the University of Kansas said she believes in starting with pilot studies, which make it possible to determine “at close range” whether the intervention is effecting small changes before moving to a larger study. Speaker Ben Sawyer of Games for Health concurred and also noted the importance of controlling for users’ interpretations of technologies.
The speed at which new technological applications are developed also calls for new evaluation methodologies more appropriate to the technology and its uses. Speaker William Riley of the National Institutes of Health said that the length of time required for traditional evaluations using randomized control trials (RCTs) would result in a situation in which the findings of an evaluation would not be available until long after the technology had become obsolete or modified. For example, research on the efficacy of
mobile technology that was begun in 2005 and completed in 2010 would have missed YouTube, the iPhone, Android, and the iPad, all of which happened between those years. Dr. Riley said there is a tension between researchers and computer engineers; researchers want the technology to stay unchanged while the research is ongoing, and engineers want to tinker with the technology through continuous iteration.
The field of technology and violence prevention has great potential, but it lacks a strong evidence base. Dr. Riley said he believes that randomized clinical trials will eventually be necessary, although he also said that community interventions can generally not be randomized. Standards for evaluations and metrics are needed as well as a virtual space where evaluations can be shared and methodologies refined. It is also critical that evaluation of the interventions takes place in specific cultural, social, economic, and political contexts. What works in one place may not necessarily work in another. Further information on evaluation methodologies and considerations can be found in Chapter 6.
On the positive side, new technologies may prove to be helpful for meeting the challenges in data collection and analysis. For example, instead of relying on patients to call in their information daily, wireless technology today can take the information from the patients’ devices to the server, making the data available in real-time and gathered continuously. Furthermore, using mobile technologies for recruiting and retaining individuals in trials will help streamline the process.
FINDING SIGNALS IN THE NOISE
A tremendous amount of data is now being collected through new technology. Datasets that are too large to be stored traditionally are called “big data.” These can be analyzed with cloud computing. Dr. Ranck noted that although such large datasets can make it difficult to find some important signals, today’s computing power can allow physicians to see certain signals that they ordinarily might have missed, such as predictors of domestic violence, because of increased statistical power.
An interesting example of the power of big data concerns Camden, New Jersey, medical billing records. A physician analyzed 8 years’ worth of medical billing records in Camden, which included shootings and homicides. His analysis of the records for 600,000 hospital visits over the 8-year period found that most of the treatment received was neither cost-effective nor medically effective. It also emerged that the majority of the costs could be attributed to a small number of patients. These findings resulted in a coalition of people concerned about how to target interventions to address the violence in Camden.
Dr. Ranck cited the need for better commons-based tools and resources and better use of the commons. Several existing platforms spaces, including InnoCentive and Science Commons, deal with biomedical issues, but it would also be useful to have data commons and innovation for social and behavioral sciences.
Addressing the Digital Divide
Panelist Michele Moloney-Kitts of Together for Girls pointed out that if sexual violence data were publicized the same way that data on infectious diseases are, the effect would galvanize action. She also noted that 9 out of 10 women feel safer with a mobile phone. However, the gap in mobile ownership between men and women is great. Women in the Middle East and Africa are 25 percent less likely than men to have a phone. In South Asia women are 37 percent less likely to own a mobile phone than men. Among the poorest classes, the gap is even greater. Ms. Moloney-Kitts said it is important that those who are disempowered have access to technology, and cited mWomen, a program supported by the U.S. government, the Cherie Blair Foundation, and GSMA, an association of mobile operators. One of mWomen’s primary objectives is to reduce the gender gap between male and female owners of mobile devices, particularly among men and women in lower socioeconomic brackets.
Panelist Kathleen McGowan of the U.S. Agency for International Development spoke about Afghanistan in order to illustrate the potential and risks that come with the proliferation of mobile technology. Mobile technology has transformed the country and its economy since 2001, and it continues to spread among the population. Eighty-five percent of Afghans live where there is mobile coverage. This mobile technology reaches where there is lack of infrastructure, ongoing insecurity, and high illiteracy rates. Women provide a great potential market for mobile phones, but cost can be prohibitive. Furthermore, control issues in a conservative society make it difficult for women to own phones. One operator in Afghanistan is trying to provide mobile devices to women through a package that the husband or father controls, which raises the issue of whether the reinforcement of traditional gender roles is harmful. One negative aspect of the spread of mobile technology in Afghanistan is that improvised explosive devices can be detonated by mobile phones.
Designers and implementers trying to prevent violence with technology must work to avoid doing harm, or, if that is not possible, at least to mitigate the harm. One audience member raised the issue of keeping child and female victims of domestic violence safe and helping them stay out of violent situations. Ms. Moloney-Kitts agreed and added that more public discussion about the issue, commensurate with its prevalence within society,
is required. She said she believes that the priorities include addressing child trafficking, pornography, and prostitution. Speaker and Forum member XinQi Dong of the Rush Institute for Healthy Aging works with the elderly, where the most vulnerable to abuse are cognitively or physically impaired, socially isolated, and have mental health problems, and he stressed the need to adapt technology so that these vulnerable people can access and use it.
Forum co-chair Jacquelyn Campbell of Johns Hopkins University School of Nursing brought up the challenge of making not only phones but also the ongoing cost of phone minutes affordable for poor women. Ms. Moloney-Kitts said it does not have to be one phone per person. Phones can be shared by communities, or individuals can rent their phones by the minute to others.
Health professionals also need to know how to develop a business plan and to negotiate with mobile operators for lowered costs. Dr. Ranck said there has been a lot of recent work in the mHealth field on negotiating deals with operators for uses that could be free or subsidized. At InSTEDD a guide for NGOs on setting up such deals with operators was being developed.
Key Messages Raised by Individual Speakers
• There is a need for an evidence base concerning the effectiveness of new technologies for violence prevention.
• The speed with which new technologies are evolving renders traditional evaluation methodologies infeasible. However, the new technologies may actually help with both the collection in real time of large sets of data and the analysis of those sets of data.
• Privacy issues have arisen because of the data collection capabilities and the computing power of the new information and communications technologies.
• Open-source platforms and crowdsourcing provide a means for the audience to become part of the solution to problems more quickly and less expensively than traditional “expert only” problem solving.
• The growing community of “citizen scientists” and their efforts may foreshadow future trajectories for open data systems.
• Scaling up can occur in several ways: through policies made by governments, through adoption of innovations by large institutions, and through social media raising the profile of an issue.