Information and Communication Technologies (ICT) Options for Local and Global Communities in Health-Related Crisis Management

ABSTRACT

This paper discusses information and communication technology-driven options for local and global communities aimed at supporting rapid responses to public health emergencies. Our examples stem from local groups within the U.S. where various crises have spurred a dynamic response through technology-mediated devices. Other examples focus on local communities’ interaction with global philanthropic efforts that are geared towards using ICT for addressing training and education needs in health pandemics, such as HIV/AIDS. Recognizing the problem of effective communication and the integration with local crisis responder roles, we discuss options for the use of interoperable devices and protocols that parallel mobile technology’s advancement. We introduce the case of the Infectious Disease Institute treatment and learning Center in Uganda as an example of global and local community coordination for the treatment and prevention of one of the world’s largest pandemic.

Our analysis of local and global communities suggests focusing on the management of communication during public health crises to better understand the complexities and variations presented in these communities. Leveraging experiences from emergency response efforts, we seek to identify tools that enable effective communication among the different public health stakeholders on a routine basis as a way to prepare for time-sensitive emergencies. We argue that the planning and deployment of effective responses in several countries can be supported by the increased availability of mobile cellular and mobile broadband communication networks both in developed and developing nations.

INTRODUCTION

Governmental, nongovernmental and private sector organizations are increasingly aware that the solution to health crises, hazards, and pandemics depends on the collaboration and coordination of responders at the local and global community level. In most large scale crises, responders at the local level assume responsibility until global (and often more advanced) resources can intervene or replace them. Moreover, the need for effective and interoperable communication between responders during a crisis is essential and must be timely. While ongoing initiatives have enabled new opportunities towards the integration with information and communication technology (ICT) for crisis response, the management of communication and information sharing protocols remain a challenge (ICT4peace, 2010). For example, electronic health (E-Health) emergencies place emphasis on the delivery of information (i.e. medical informatics, public health and healthcare administration) through multiple information and communication technologies and standardized communication protocols (Eysenbach, 2001, WFP, 2010). Extending the use of technology-mediated devices further, we turn to bio-survellance which is the monitoring of ongoing health-related data and information for the early warning of threats and hazards, the early detection of events, and the rapid characterization of an event so that effective actions can be taken to mitigate adverse health effects (CDC, 2010; Kass-Hout and Zhang, 2010). Extending the use of ICT tools from routine health protocols and bio-surveillance to the temporary use of advanced ICT during crisis response (Crisiscommons, 2010) is the focus of this research. Being able to determine under what conditions ICT access can be made usable and useful (Gurstein, 2003) is a consideration for health-related crisis management. Overcoming a few ICT related barriers such as access and training (Salvador and Sherry, 2004) for routine activities that involve communication and coordination can increase individual preparedness for the appropriate use of static, mobile and nomadic information and communication devices as they are deployed for a given responder role.

In addition to ICT tools and incident protocols is the availability of telecommunication resources in a given area. For example, Urtubey (2004) discusses the importance of digital convergence for health and social development. Urtubey et al. (2004) also refer to extended health service providers (i.e. philanthropic and grassroots organizations), as “remote health actors” stressing their important role and involvement from preparation to the coordination of activities. Technological convergence has the potential for social inclusion of these providers by enabling the use of affordable ICT connectivity services. “Civil society and grassroots organizations are coming up with innovative use of accessible and affordable technologies, particularly mobile telephony, that address their local development challenges in unforeseen ways (Gaid, 2009).” Community Informatics (CI) is the study and the practice of enabling communities with Information and Communications Technologies (ICTs). “CI seeks to work with communities towards the effective use of ICTs to improve their processes, achieve their objectives, overcome the "digital divides" that exist both within and between communities, and empower communities and citizens in the range of areas of ICT application including for health, cultural production, civic management, e-governance among others Enable communities with effective ICT usage is also a means to bridge the ‘digital divide’.” (Gurstein, 2004).

This paper is aligned with the stated Community Informatics objectives by placing emphasis on local and global communities for specific health-related emergencies. As the health-crisis severity increases, we discuss aligning ICT tools and techniques to enable effective use for a given situation (Gurstein, 2004), while balancing the interaction among local and global players. Spanning from management information systems (MIS) desktop access to mobile ICT tools of smartphones and PDAs, we propose a mix of tools essential for large scale low-richness early warnings and exchanges, as well as dynamic and nomadic ICT tools for planning and preparation. We highlight the advanced technologies that have been deployed for health related crises and show examples of the integration with a region’s existing technologies. We stipulate that communities can increase access to MIS applications and web-enabled services such as e-Health, by identifying the information needs associated with a specific emergency, and then training local respondents on mastering usage of the appropriate devices to maximize the interface with advanced technologies.

Crisis Management, local and global communities, and their interactions

Crisis management is defined as a way to prepare and control an emergency or to prepare to reach and mitigate the outbreak of a life-binding problem. Crises management seeks to respond to both emergencies - “dangerous events that can normally be managed at the local level” (Canton, 2006) - and disasters, defined as “dangerous event that causes significant human and economic loss and demands a crisis response beyond the scope of any single agency or service” (FEMA, 1996). Crisis management has at least three public health drivers: 1) extreme poverty, 2) chronic-illness (obesity, HIV/AIDS), and 3) crises initiated by disasters (for example, the Tsunami, Katrina, the Haiti earthquake and other natural emergencies). An incident evolves into a crisis when a time factor impacts the lives of citizens and influences the responders (or specialists) who are called upon. The Bureau for Crisis Prevention and Recovery at the United Nations Development Programme (UNDP) notes that while most national governments and relief organizations have made progress in mitigating the impacts of disasters through improved preparedness and early warning, we still view disasters as exceptional natural events that interrupt normal development and that can be managed through humanitarian actions. We need to continue multilateral efforts to prepare for and face emergencies with a multimodal response, both local and global.

Shifting the perspective to the local level, we highlight the complexities of a community. The definition of a community and its scope may be dramatically affected by the boundaries through which the community is defined (Norton et al, 2002). Geographic boundaries are found at the local, state, federal and global levels, whereas mission-oriented, religious, cultural, and illness-related boundaries also exist within each of these groups (see Figure 1).  Norton et al. (2002) state that “it is important to focus not only on geographical or geopolitical boundaries, but also on the nature of ties or connections that exist within communities, including network connections among individuals and inter-organizational relationships”.  In a few words, the focus needs to extend from the physical to the virtual community - a group of people who interact through interdependent tasks strengthened by communication technology and guided by a common purpose crossing organizational boundaries (Lipnack and Stamps, 2000) - where a number of additional opportunities (but also challenges) reside. For instance, the use of social media such as Facebook and Twitter during the 2010 Haiti Earthquake enabled interactions between Haiti and other countries but protocols for communication were implemented as the response effort evolved. Being able to leverage virtual groups enabled the coordination of external resources which in turn enabled other local resources. Preparedness and pre-established protocols may in fact extend the chance of more timely reactions (independent from physical infrastructure or co-presence) as witnessed thereafter with the Hawaii tsunami warnings for evacuation in February 2010 (LATimes, 2010). For example, ICT can play a critical role in supporting public health and the management of medical emergencies by bridging the gap between local and global communities through the establishment of a connection and communication link which may join the ad hoc virtual community, which has been temporarily brought together with the objective of preparing for a medical emergency. The limited infrastructure in Haiti when the earthquake took place demonstrates the critical need to bridge the connectivity gap and also highlights strides that can be made.

A crisis that has geographical implications, such as in Hurricane Katrina in the U.S., introduces the importance of local public health community infrastructure. Moreover, Hooke and Rogers (2005) discuss health risks associated with crisis and remind us how important the role of crisis management and public health is within a community. Turoff et al. (2004), refer to organizational emergencies where implications can have a macro-social effect causing harm to people outside of the organizational jurisdiction or boundary, initiating a concern from local, state and federal agencies. Examples of such emergencies include: the BP Oil Spill, Bhopal, Three Mile Island, the Tylenol poisoning event, and the Exxon Valdez. Recognizing that the landscape of the public health sector community has multiple boundaries, ranging from local grassroots organizations to global public health agencies and providers, the management of communication is needed in more than one organizational level (Figure 1). Crisis management relies on communication patterns that must be clearly mapped, enabled and coordinated across the multiple boundaries. These include the use of ICT. Information systems, and especially ICT, which can for example, support inter-agency coordination and multimodal preparation and response.

Figure 1. Spanning geographic boundaries (adapted from Gomez & Turoff, 2006)

Figure 1 provides an example of community boundaries and the number of stakeholders that require coordination and interaction at both the local and global levels of a crisis or disaster. This level of interaction requires training and coordination of a large number of players especially when the boundaries span to a virtual ad hoc global collaborative setting. Determining the collaboration boundaries that exist on a regular basis between stakeholders in a local and global community enables an understanding of resource sharing needs during the planning stages to better coordinate responses in a crisis. Global collaboration may involve multiple large-scale players for occasional and targeted initiatives or for long-term worldwide crisis prevention plans. For example, stakeholders and organizations in the philanthropies group are increasingly moving beyond the time-limited ad hoc role to participate in long-term engagements beyond in-cash donations. They are transforming their relationships into an “integrative” dimension (Austin, 2000), whereby their collaboration embeds high levels of managerial support, multi-year resource commitments, and the inclusion of the donation programs and objectives in the strategic company framework. Spanning across geographic boundaries can be by ICT through the deployment of virtual teams and computer-mediated communications (CMC) tools across physical communities.

Examples of Local Communities

Local service-based organizations who serve the people in a community extend beyond public health and support many common initiatives. These organizations work with the community frequently in a hands-on capacity. An understanding of the local community landscapes and protocols for emergency response escalation can enable effective solutions to public health issues. The collaboration during a crisis initiates the formation of a crisis response team, defined as “a real and virtual community of specialists and experts that must have unrestricted access to one another and is able to act as a collective” (Gomez et al., 2006; Turoff et al., 2004; Hardeman, et al., 1998; Weick 1993, 1995).  Training and regular use of ICT can increase preparedness of these responders who may need to initiate a call for assistance from either inside or outside of the local community. Service-based responders, who find themselves responding to health-related emergencies (i.e. epidemic outbreak, bioterrorism), often form part of the crisis response team, yet research shows they are not accustomed to the use of technology-mediated communication devices.

Grassroots Organizations and Self-help Groups

Grassroots organizations in local communities are comprised of local people working together to find solutions in their communities (Idealist, 2006). These practitioners are trained for their organizational positions, but often lack information and communication technology (ICT) specific training due to limited financial resources as mentioned by the Institute of Medicine (2003). Moreover, these organizations often have a more limited infrastructure and a narrower range of organizational roles and reporting hierarchies. As a result, they may rely on larger external organizational structures for guidance (i.e. Centers for Disease Control, state and federal public health offices). Nonetheless, these local organizations who step forward in a crisis are invaluable in reaching community citizens and attending to their specialized needs. The specialized skills of these responders who form part of a community crisis response team are based on their organizational mission and community of interest. These practitioners do not always report to an office regularly or work with the other practitioners in their organization on a regular basis. However, they are accustomed to changing roles, responsibilities and filling-in for others as-needed providing the “on-call” status a crisis warrants.

Self-help groups are among the organizations in a local community available to aid citizens. These groups are comprised of volunteer practitioners with skills that are relevant to their respective organization. The premis of the self-help group is to generate a casual information exchange or assist with resources and provide a source of mutual aid. Self-help groups are driven by people’s needs to find others like themselves who have experienced a similar problem. These volunteers are motivated by passion and the cause which links them to the needs and organizations. Their informal structure and flexible nature encourage changing roles, and peer-to-peer relationships along a horizontal continuum (St. Clares, 2002). They are also an invaluable resource in a crisis that relates to the special needs of the group represented.

Examples of Global Communities

Global organizations also play a role in ensuring public health goals. Collaboration across government public health authorities have taken place with private sector health care providers, insurers, managed care companies, and nonprofit religious organizations to provide, directly or indirectly, various public health services (Gostin and Hodge, 2002). These organizations provide large contributions that are more global or recurrent in nature and are not as hands-on with the community on a daily basis.

Gerencser, Napolitano and Van Lee illustrate the concept of global organizations for public health and emergency preparedness by introducing the term “megacommunity.” A megacommunity is “a larger ongoing sphere of interest, where governments, corporations, NGOs, and others intersect over time. The participants remain interdependent because their common interest compels them to work together, even so they might not see or describe their mutual problem or situation in the same way.” (Gerencser et al., 2006, p.82). Examples of such megacommunities are found in the coalitions for the prevention of several emergencies. These include communities focused on fighting the spread of HIV/AIDS in India (initiated by the Global Business Coalition on HIV/AIDS, Booz Allen Hamilton and the Confederation of Indian Industry) and various others in environmental and development areas.

Philanthropic Organizations as Global Community Partners

Several foundations, public and private donors, and large corporations are increasingly involved in supporting social causes in transnational environments. Corporations are progressively focusing on promoting social growth through donations. (Conlin et al, 2004). In addition to monetary resources, private involvement also brings intellectual capital (in terms of knowledge and core competencies), in-kind donations (medicines), and can leverage specific business competencies such as logistics, distribution, and technology use. Private involvement in philanthropic initiatives is being driven by a raising awareness that the world is facing complexities that cannot be resolved by independent actors.

Examples of such business-led philanthropic efforts are found across industries. In the pharmaceutical sector, a large multinational conglomerate (“Big Pharma”) supported large infrastructure projects such as the building of a hospital in Uganda (the Infectious Disease Institute –IDI- in Kampala). In the IDI project, Big Pharma employees leveraged their specialist knowledge and business management experience to take leading roles in project management (playing project managers and content experts, as well as medical educatros roles), and provided resources to help with the strategic, tactical and operational aspects of the center construction. In addition, they provided consultation and other support, including free access to treatment medicines.

n other projects, Big Pharma employees offered technical service and knowledge to support medical treatments in areas of crisis and as well they have been deployed to help in reconstruction after emergencies. They have also contributed to health preparedness by enhancing science education and community health and services. Personnel rotated through numerous assignments, from responders to emergencies, to teachers and infrastructure building support. In Uganda, the Big Pharma ICT employees supported the development of new health information systems applications with new interfaces easier to use for the local health provider communities. The installation of satellite receivers also enabled moving the IDI into a distance learning center promoting affordable access to ICT’s, ensuring equal access for women and girls, and overcoming infrastructure limitations in rural or disadvantaged areas (USAID, 2006). Among the success factors of the IDI were the deployment of efficient communication tools and training deployment.

Both levels of community (global and local) intervention and coordination are needed to solve some of the complex emergencies the world faces today. Such coordination, planning, establishing communications patterns and responses are critical endeavors to guarantee successful response. For example, on January 31, 2006, a mine accident occurred in Saskatchewan, Canada which demonstrated how training and prevention at the local community level could protect the health of the miners while emergency rescue efforts were taking place (Cotter, 2006; Isaacs, 2006). One of the interesting results was the demonstrated preparedness and collaboration at the local level of all parties involved ranging from the individuals impacted in the incident, the union workers, and the emergency response teams. The training and availability of health-related supplies provided time for the emergency response effort to evolve. Ensuring the safety of the miners reduced the health-related threats while rescue efforts continued. Successful communication and coordination, including routine practice drills also contributed to the rescue efforts where communication patterns and contacts had been established prior to the emergency.

Issues in the Local-Global Community Continuum

The transition from local to global (visible in Figure 1), and the management of related interactions, poses a number of coordination difficulties. Typical examples of activities to be managed among the local-global stakeholders during a crisis include: direction and control definition or implementation, warning systems, emergency public information deployments, evacuation, provision of mass care, health and medical access and resource management. These activities, usually carried over at the local level, need to be coordinated through clear and effective communication channels when the size and scope of the emergency spans to the global community (disasters and pandemics). This coordination is essential for a meaningful and effective response. Speaking at an international HIV/AIDS conference in Washington DC (Kaiser Foundation, 2004), Dr. Ralph Shrader, CEO of Booz Allen Hamilton, remarked that in large scale problem-management he constantly witnesses a high need for leadership and collaboration. This is particularly true in the fight of a pandemic such as HIV/AIDS.

“The idea is that if you are going to look at a problem like AIDS, you are going to need to bring the people at a national or federal level, the state or regional level, and the local level, government together.. But then you also need to involve all the other players and stakeholders.”

Booz Allen was engaged in a simulation project in India where it brought together governmental leaders, people from the healthcare industry, pharmaceuticals, and other stakeholders to estimate the possible scenarios of HIV/AIDS diffusion in the country. The key message of the two-day simulation exercise was, from Dr. Shrader’s point of view, the absolute necessity for multilateral collaboration.

“But not just collaboration at a superficial level, collaboration at a level which requires you to subordinate a lot of your own interests and ideas for the greater good.”

In the simulation conducted in India, which consisted of trying to identify multiple ‘war game’ scenarios of HIV spread over the years, it was clear that even less than a 1% growth level (which in India is still a significant amount of people) could bring the Indian health care system to an economic collapse. To be able to coordinate this level of emergencies, “Planning, Preparedness and Communication (PPC)” needs to be managed from the global to the local level.

Discussion on which entities should be in charge of this training and preparation at the municipal, regional, national and global level, however interesting and necessary, are beyond the scope of this discussion; rather we are focusing on how ICT can contribute to “preparedness” to be able to reach (and therefore implement the plans or the standard operating procedures defined to deal with emergencies) during the multiple stages of a crisis (pre-crisis, initial crisis impact, continued crisis impact, and post-crisis). Availability of training with and distribution of cellular mobile and nomadic devices (including the tablet computers later described) can support increasing the effectiveness along the crisis management chain because of their portability and their media-rich characteristics enabling connectivity to information resources and multimodal responses (video-messaging, large-scale text-based push alerts, data and voice communication).

How ICT can help: Effective communication through ICT tools

Xue (2004) mentions, that public health emergency response requires a low-degree of mediation and a high degree of collaboration. Moreover, protecting global public heath is important and should be orchestrated through worldwide coordination. Xue (2004) also notes that developing countries have “relatively fewer resources to deal with public health emergencies” and also less broadband infrastructure which in turn limits the use of ICT tools. Communication management and collaboration can be improved by varying the use of ICT tools based on the nature of the crisis and need for mobility. For example, a mobile cellular (narrowband) device can interface with a broadband service thereby leveraging broadband services. A recent example was presented during the 2010 Haiti Earthquake where a Person Finder application was developed that received SMS text-messages from mobile cellular (narrowband) devices and interfaced with broadband services that were coordinating Person Finder requests Google, 2010).

An understanding of ICT tools and capabilities including knowledge of communications and media-richness is fundamental to completing tasks such as those resulting from Person Finder. Understanding the technology-fit to specific emergency tasks, specifically to event response as characterized by different levels of “uncertainty” (Figure 2), is briefly presented to highlight the importance of aligning tasks and communication tools. Daft and Lengel’s (1986) media richness theory dates back to 1984 and is based on two forces: uncertainty and equivocality. Using rich media for rich information is predicted to resolve ambiguity and equivocality. Face-to-face (FtF) is considered a rich media. However, media of low richness is predicted to be most effective in resolving uncertainty. In our Person Finder example, uncertainty was the primary focus and only limited ICT resources were available. One of the few ICT resources that could be deployed was SMS text-messaging which is considered a low-richness medium. SMS played an important role in Haiti, which was a large scale disaster. With a collapsed infrastructure, SMS was available at the onset of the crisis for communication management until external relief organizations arrived with mobile broadband services.

Following this, and focusing on the preparedness phase of emergency management, SMS text-messaging for emergency preparedness alert notifications is continuously increasing. Early adopters of SMS for alert notifications include: the District of Columbia (2006) and the City of San Francisco (Hicks, 2003). We note that a low-degree of mediation in a high mobility crisis would lend itself to the low richness of SMS text-messaging.

Focusing on the management of communication and information exchange between responders, we highlight media synchronicity theory (MST), which details the extent to which a communication environment encourages individuals to work together on the same activity, with the same information, at the same time (Dennis and Valacich, 1998; McGrath, 1991). MST differs from media richness theory by placing emphasis on an outcome-centered approach to media selection. Whereas media richness theory has taken a task-centered perspective on task-media fit, MST proposes that every group communication process is composed of two primary processes, conveyance and convergence that are necessary to reach a group outcome (Dennis and Valacich, 1998). Communication effectiveness will be enhanced when processes are aligned with media that support the communication process (Dennis and Valacich, 1998).

In the case of health emergencies, the task consists of trying to resolve crisis situations with limited information but with high collaboration and synchronicity. As well there is a limited ability for technology mediation, especially when faced with geographic implications magnifying the need for a task-technology fit (Lim and Benbasat, 2000; Goodhue and Thompson, 1995; Tan and Benbasat, 1993; Vessey, 1991; Vessey and Galetta, 1991).  Having the right technology for a task is essential. The communication medium must be suitable for that objective. We posit that mobile communication tools may support the communication processes and needs of emergency situations, ceteris paribus (that is assuming that these tools are connected and accessible during emergencies) with care taken to understand the configuration of ICT resources (e.g narrowband.or broadband) available.

Mobile media options

Mobile devices – such as pagers, cellular phones, personal digital assistants, nomadic tablet computers (laptops with embedded touch screens and wireless connectivity cards) -- can play a pivotal role in emergency situations as they can serve three purposes: to be reachable anywhere and at anytime, to obtain information while in an outreach situation; and, to be ‘visible’ and traceable through a device enabled with GPS positioning capabilities. A mobile device maximizes flexibility, increases timeliness to reach community partners, and increases readiness for a crisis related health alert. Recognizing the ICT limitations of both mobile devices and telecommunication services (narrowband and broadband), we posit that protocols and standards for communicating (sending and receiving) can be created to ease interactions during emergencies. Most mobile devices have functionality that can be leveraged both with and without broadband service.

Although data transfer capabilities are increasing through wireless-wide area cellular third generation network channels, the deployment in remote areas lags behind. Moreover, the capabilities of many existing devices are still limited and require the need to shrink data (volume of information) and content of ‘what’ is communicated. In addition to connectivity options on the mobile device, it is important to identify codes and alter messages that may quickly trigger responses, for example through a specific set of pre-loaded icons or tools (as for example, the already famous ‘emoticons’ used in chat rooms). One advantage of low-mediation of mobile devices with access to a command and control process is to complement the infrastructure of developing nations. Health-initiatives in Latin America, Africa, and Asia are introducing alerts and reminders for preventative care and the communication of critical information (Srivastava, 2004).

There are a number of mobile devices, connectivity options, and communication needs that may be suitable to manage responses in an emergency situation. Each communication medium enables different levels of message richness (through multiple media such as voice, text, graphics and videos) that may in turn offer higher or lower richness capabilities (as presented in Figure 2). Some of these communication tools may not be easily managed in an emergency context due to electrical and connectivity requirements (the same being true for most communication tools). Therefore, while we can plan for their deployment, we always need to consider back-up options, such as the possibility to roam on satellite links should the cellular towers become unavailable. For example, Iridium low-orbit satellites (LEO) that offer world-wide coverage when no landline or wireless service is available, can provide a back-up solution for computer, cellular and pager communications through a variety of satellite-compatible devices (USAID, 2006). Other possibilities rely on solar rechargeable batteries and chips, such as those currently being tested or already available on satellite equipment.

Figure 2. Crisis Management Lifecycle (adapted from Gomez & Turoff (2006))

These tools provide different levels of mobility across communication and emergency responses. As noted in Figure 2, the need for mobility varies based on the phase of the crisis lifecycle. In the pre-crisis (i.e. planning stages), increased access to information and communication systems is imperative for accurate monitoring of alerts and in assessing resources and supplies. Once the severity of the crisis increases, increased mobility is needed. As the crisis evolves, practitioners begin to move across the community interfacing with resources that may be stationary in their respective roles. Post crises events and the return to normality reduce the need for mobility.

Leveraging ICT for advanced planning, communication and coordination is essential for local communities to implement crisis management. Collaboration with global communities adds value through extended access to resources and specialized knowledge. The nature of a crisis will determine ICT usage options. Disasters with infrastructure impacts and high field response will increase mobility and limit access to management information systems tools whereas a contagious disease outbreak would decrease the need for mobility and increase the need for MIS systems. Moreover, a disaster related crisis - such as hurricane Katrina or the South-Asian Tsunami have time implications with accelerated pressure to quickly respond to replace the impacted infrastructure resources. The stringent time implications place emphasis on the importance of preparation, planning, communication, and coordination.

Examples of ICT uses in Communities

Examples from US-focused Initiatives and Pilots

Recognizing where technology can improve communication with partners (Haddow and Bullock, 2003); community initiatives were introduced in the District of Columbia and the City of San Francisco. Many communities are turning to wireless communication to support both crisis response agencies and citizens based on the experience) of both the September 11 attack and hurricane Katrina (Haddow and Bullock, 2003. The lack of clear lines of communication are but one gap between partnering agencies, practitioners and local community citizens (Haddow and Bullock, 2003.

The 2005 hurricanes throughout Louisiana and Florida prompted, the District of Columbia (Washington) to dedicate two websites to the community and how they should respond in the event of a man-made or natural disaster. Viewing these catastrophes as lessons learned for the rest of the country, DC has initiated steps for its residents for preparedness in the event of an emergency evacuation (DC, 2006). The DC Office of Emergency Management and the Emergency Information Center were established to list services and information, area maps with evacuation routes and agency news affecting the community (DC, 2006). On the emergency information center site, community members can participate in “Alert DC” which is a three part notification system that has:  text alerts (citizens enroll online, identify their text capable device and access number), voice alerts (citizens are automatically enrolled, information is transmitted about impending or actual incidents which give proactive instructions to front-line responders for dissemination into the community), and an emergency alert system (for local media outlets and radio stations where emergency messages are broadcast). The varying roles of the public health community practitioner (see Figure 2) demonstrate how the use of mobile devices could vary in relation to what is currently being utilized in DC for their emergency preparedness efforts.

Dating back to January 2002, the City of San Francisco began initiatives through wireless communications towards improved public safety (Haddow and Bullock, 2003), such as becoming the first 9-1-1 center in California to receive wireless 9-1-1 calls placed from cell phones (Hicks, 2003). Google proposed free city-wide Internet Wi-Fi to the City of San Francisco to test local Internet services (Reuters, 2005). However, Levy (2006) also highlights needs for underserved communities to have access to affordable computers, appropriate training, and technical support.

Examples from Globally-focused initiatives on e-Health education

To reach a globally dispersed network of staff and partners, the United Nation Population Fund (UNFPA) established an ICT-supported distance learning program to provide health education in critical areas. Currently, the education process comprises six courses that cover reproductive health and population health issues. The courses run on-line for eight weeks where the learners (usually staff members and key member countries’ government or NGOs stakeholders) receive on-line personalized tutoring. E-mail is the main means of communication, but some courses provide access to video, audio or multimedia CD-ROMs (with these media physically shipped to the learners to overcome access limitations).

Another example with global reach is the global medical broadcasting and telemedicine network for health education. Medical Missions for Children (MMC - http://www.mmissions.org/index.html ) is a US-based charity that freely offers educational materials dealing with chronically ill children to healthcare professionals in underserved areas. The charity helps catastrophically ill children by means of their telemedicine outreach program (TOP). This extends the expertise of medical specialists (from about 100 countries worldwide) to underserved communities by electronically linking a physician with a patient in a remote location. The electronic link provides just-in-time medical knowledge and is supported by an extensive use of ICT tools. MMC also partners with the World Bank and the Global Development and Learning Network by supplying access to their medical network and libraries to the Bank’s client countries.

Drivers of Long-Term ICT Emergency Response Sustainability

The rationale for supporting and encouraging an ICT-driven long-term emergency response go beyond the preliminary list of examples presented earlier to include a response to the digital divide. ICT diffusion in developing economies is already making considerable inroads and offering opportunities not only for coordinated response but also for development. The Economist, in an article published in March 2005, referred to ICT, and particularly cellular and radio wireless access, as key drivers for economic development in traditionally disadvantaged countries (Economist, 2005). Urtubey (2004) also mentions opportunities for disadvantaged countries noting the endorsement by governments with the creation of the Institute for Connectivity in the America’s (ICA) with its focus on scalable initiatives in the Latin American and Caribbean Regions. Data from the United Nations Conference on Trade and Development (UNCTAD, 2006) shows that less developed regions such as Africa, Latin America and some countries in Asia have higher yearly mobile penetration growth rates than Europe, North America and Oceania. This indicates a great potential for service expansion in these countries. Although these developing economies cannot afford to deploy large-scale wired infrastructure (Srivastava, 2004), the deployment of wireless connectivity (which is cheaper than implementing traditional fixed-line infrastructure) enables accessing communication services and somewhat sophisticated applications and databases. For example, Africa, which has been substantially growing its information infrastructure over the last decade (AED, 1999; Plane, 2002), also ranks highest in terms of telecommunications services revenue as a percent of Gross Domestic Product (5 percent as displayed in Figure 3), followed by Oceania (4.5 percent) and Asia (3.8 percent).

Notes: Data from ITU World Telecommunications Indicators Database - ITU (2006)

Figure 3: Telecom Sector Contribution to Economic Growth

Nevertheless, if we look at mobile penetration in absolute terms, regional differences, while lower, are still very high with Europe leading with about 9 mobile phone subscribers out of 10 inhabitants, a penetration rate about eight times higher than Africa and four times higher than Asia in 2004 (ITU, 2006, pg. 5) (Cao, Yi et al. 2004). While the benefits of ICT in developing countries is promising, telecommunications infrastructures in most developing countries is insufficient (Gurstein, 2003). Wireless technologies may soon bring real opportunities for leapfrogging (Economist, 2005). The growth of the telecommunication sector will also be driven by upcoming revenue opportunities (even in less-developed / lower income countries). The impact of the telecommunications sector evolution on a country’s economic growth has been increasing over time, reaching a maximum of 12 percent growth during the dot.com bubble of 2001-02 (ITU, 2006). Such a sustained growth is fueling domestic development in several countries.  These observations suggest that leveraging (and investing) in an ICT emergency response (provided that access is followed by large scale training) is not only desirable but also sustainable in the long-term. Development of faster, solar-powered ICT tools is further encouraging optimism for a long term sustainable impact.

Conclusions

Information and communication technologies may support crisis response both at the local and global levels. A review of examples focusing on ICT-based crisis response implementation in health education initiatives in the US and globally, with a particular focus on Africa, show that there are multiple ways to leverage information technologies to support preparing for and solving local and global emergencies. Research based on media-richness and task-technology fit literatures suggests that the benefits of the deployment of different sets of mobile tools to support different players and phases of a crisis.

Low-cost access to ICT is essential and instrumental for local communities, especially those in developing countries or areas of extreme poverty. Beginning with cost-effective low-richness tools maximizing their full-potential for effective use, we believe that these ICT tools can compensate for the high deployment costs associated with large wired infrastructures. While the challenges are many, recent events have spurred a large interest and focus on planning for emergencies and coordinating multiple communication channels. For these tools to be effective, large scale training and local adaptation of ICT technology is necessary, as shown in the Infectious Disease Institute software adaptation and redesign of health information systems software that could meet local requirements. While some organizations have already initiated successful training initiatives, achieving proficiency that may lead to increased adoption by community responders still remains a challenge. However, overcoming this challenge will be the first step in preparing a serious and sustainable response.

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