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HEALTH POLICY & ETHICS FORUM |
Andrew A. Sorensen is president of The University of Alabama, Tuscaloosa.
Correspondence: Requests for reprints should be sent to Andrew A. Sorensen, PhD, MPH, Box 870100, Tuscaloosa, AL 35487-0100 (e-mail: sorensen{at}pres.ua.edu).
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INTRODUCTION |
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Regrettably, the system that Winslow envisioned three quarters of a century ago still has not materialized. The disenfranchisement of the estimated 47 million Americans who have no health insurance, and thus have little or no access to medical care,42,3 underscores the desperate need for a better balance "between the clinical approach to disease, currently the dominant public health model for most risk factors, and research and intervention efforts that address generic social and behavioral determinants of disease, injury and disability."4(p6)
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THE IMPORTANCE OF THE INTERNET |
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The inequities abroad are even more striking: "Less than 2 percent of the world is actually on the Web, and if we subtract the United States and Canada, the number is less than 1 percent."10 Thus, billions of people around the world have been consigned to exclusion from this technology. However, at a recent industry conference Bill Gates "quarreled with some of the priorities of technology enthusiasts, ...saying that the Internet was useless to people who lacked basics of life."11
Admittedly, technologic literacy alone will not solve our problems. Andy Carvin reminds us that even if people have access to the Internet and can use information technology tools effectively, we need to address the issues of functional literacy ("Can I put my reading and writing skills to daily use?"), information literacy ("Can I discern the quality of content?"), and occupational literacy ("Do I know the basics of working in a business environment?"). In a warning that is highly consonant with Gates's view, Carvin contends: "If we ignore the importance of a better-educated, better-informed citizenry, all the Internet access in the world won't really add up to much."12 Another factor to be considered is that increased access must be accompanied by enhanced use. A recent study of patients in a large urban pediatric teaching hospital indicated that only two thirds of those who had access to the Internet and e-mail actually used them.13 The study of health-related Web sites revealed problems with inefficient search engines, inaccurate data, and conflicting information.9 This presents a challenge for us: to develop ways in which we can stimulate more effective use of the Internet.
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RICHNESS AND REACH |
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The draconian reduction of Medicare payments to managed care plans13 that caused more than 734 000 beneficiaries to be dropped by HMOs in 1999,14 with an additional 933 687 elderly and disabled people dropped effective January 1, 2001,15 takes a particularly dramatic toll on those who have very limited alternatives.16 But for those fortunate enough to remain insured and to have Internet access, several HMOs are creatively employing electronic technology to help their members understand the choices before them. Thus Kaiser Permanente "plans to spend $2 billion by 2003 on Internet services for its million members to put the consumer at the center of the system and empower her with information and access."17 Another tactic for empowering patients is the introduction of programs that "while a patient looks on, can let a doctor prepare a prescription to be printed, submitted by fax or, in the future, transmitted by wireless Internet links."18
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NEW OPPORTUNITIES, NEW CHALLENGES |
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The explosion of pedagogic offerings and the multiple media through which they are transmitted are often stunning in their originality, and the size of the audience is growing markedly. In the United States alone, more than 14 million people are currently enrolled in higher education programs. The e-learning market is predicted to hit $7 billion in 2003,19 and enrollment in postsecondary education is projected to rise to 16 million by 2006 (American Association of State Colleges and Universities, action alert sent to university presidents, August 10, 2000). According to Peter Drucker, these estimates are conservative. He predicts: "Online continuing education ...is a market ...potentially worth hundreds of billions of dollars."20
Thus it is not surprising that a whole host of companies—such as Kaplan, Inc, now a division of the Washington Post—are moving nimbly and aggressively into the marketplace. Kaplan recently announced the purchase of 30 commercial colleges.21 If those of us in traditional institutions sit on the sidelines and fail to expand our distance learning offerings, with considerable attention not only to the content but also to the mode of delivery, we will abandon this domain to expansive for-profit entities.22
Although it is alleged by some that distance learning programs are a "cash cow" for ostensibly nonprofit institutions,23 programs of high quality that include a comprehensive infrastructure available 24 hours per day, 7 days per week, to accommodate truly asynchronous learning are far more costly than traditional programs.24 Because enrollees in public health programs are highly unlikely to pay premium tuition rates, as we increase our investment in distance learning to improve our ability to compete in this market, we run the risk of engaging in what Robert Frank and Philip Cook call a "positional arms race."25
Lloyd Armstrong has noted that the tendency for competing institutions is "to spend just a bit more than the competition to gain an advantage." The entry of for-profit entities, with their deep pockets, into "this educational universe provides an even more negative outcome to this arms race."26 Thus, some elite institutions, such as Wellesley College, are considering the alternative of partnering with corporations in developing online courses,27 and some schools of public health are exploring such alliances.
Although we must diligently resist the temptation to go overboard, I am delighted that many schools of public health—among them Tulane, the University of Alabama at Birmingham, and Emory—are offering distance learning programs for practicing midcareer professionals with much of the contact on-line.28 We could benefit by emulating our business school counterparts in establishing a larger number of collaborative degree or credential programs with peer institutions in other countries29 or helping them launch their own globally oriented programs.30 The model employed in the MPH degree that Tulane offers with the University of Arkansas for Medical Sciences, or that developed by the National School of Public Health of South Africa,31 could certainly be replicated in many countries throughout the world.
If we dedicate ourselves to providing access to the Internet and public health information for the have-nots as well as the haves, we will be able to reach our constituency with an efficiency and effectiveness that will marvelously enhance our labors in the public health vineyard.
As I know from many years of experience in the field of public health, we all too often feel like the mythical Sisyphus, "ceaselessly rolling a rock to the top of a mountain, whence the stone would fall back of its own weight."32(p119) Although our efforts, unlike those of Sisyphus, are neither futile nor hopeless, it is imperative that we cultivate in our students and fellow practitioners the skills that will make them more effective users of electronic media, and not neglect a marvelous opportunity to enhance the public's health.
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Acknowledgments |
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I am grateful to Dr Harris Pastides, dean of the University of South Carolina School of Public Health, and Dr Paul Whelton, vice president for health affairs at Tulane University, for their helpful comments on early drafts of this editorial.
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Footnotes |
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Accepted for publication February 23, 2001.
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References |
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2. Fronstin P. Economic Trends and the Uninsured. Washington, DC: Employee Benefit Research Institute; January 13, 2000.
3. McGinley L, Winslow R. Major HMOs to quit medicine markets. Wall Street Journal. June 30, 2000:A2.
4. Smedley BD, Syme SL. Promoting Health: Intervention Strategies From Social and Behavioral Research. Washington, DC: National Academy Press; 2000.
5. More adults seek health information. Tuscaloosa News. August 20, 2000:6D.
6. Fox S, Horrigan J, Lenhart A, et al. More Online, Doing More. Washington, DC: Pew Internet & American Life Project; February 2001.
7. Gladieux LE, Swail WS. Who will have access to the virtual university? AAHE Bulletin. October 1999:7–9.
8. McConnaughey JW, Lader W. Falling Through the Net II: New Data on the Digital Divide. Washington, DC: National Telecommunications and Information Administration; 1998.
9.
Berland GK, Elliott MN, Morales LS, et al. Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA. 2001; 285:2612–2621.
10. Colwell R. Information technology: Ariadne's thread through the research and education labyrinth. Educause Review. May/June 2000:15–18. Also available at: http://www.educause.edu/pub/er/erm00/erm003.html. Accessed May 23, 2001.
9. Arnold W. Cell phones for the world's poor. New York Times. January 19, 2001:C1–C2.
10. Carvin A. More than just access. Educause Review. November/December 2000:38–47. Also available at: http://www.educause.edu/pub/er/erm00/erm006.html. Accessed May 23, 2001.
11.
Mandl KD, Feit S, Pena BM, Kohane IS. Growth and determinants of access in patient e-mail and Internet use. Arch Pediatr Adolesc Med. 2000;154:508–511.
12. Evans P, Wurster T. Blown to Bits: How the New Economics of Information Transforms Strategy. Boston, Mass: Harvard Business School Press; 2000.
13. Jeffery NA. The elderly agonize as HMOs abandon Medicare. Wall Street Journal. October 16, 1998:B1, B4.
14. Pear R. HMO's to cancel coverage of 700 000 getting Medicare. New York Times. June 30, 2000:A21.
15. Thomas J. HMO's to drop many elderly and disabled people. New York Times. December 31, 2000:14.
16. Morrow DJ. Medicare panacea turns patient. New York Times. September 9, 1998:C1–C2.
17. Freudenheim M. Employers seek route to cutting health care costs. New York Times. April 9, 2000:1, 19.
18. Freudenheim M. Digital doctoring. New York Times. January 8, 2001:C1, C4.
19. Older students continue to fuel online education market. Eduprise/Need-to-Know [online newsletter]. October 11, 2000:3–4. Available at: http://www.eduprise.com/public/news.nsf/id/-Need-to-Know. Accessed May 23, 2001.
20. Drucker P. Putting more now into knowledge. Forbes. May 15, 2000:84–88.
21. Blumenstyk G. Expanding its reach in higher education, Kaplan buys chain of commercial colleges. Chronicle of Higher Education. July 7, 2000:A32.
22. Grimes A. A matter of degree. Wall Street Journal. July 17, 2000:B29.
23. Young JR. David Noble's battle to defend the "sacred space" of the classroom. Chronicle of Higher Education. March 31, 2000:A48.
24. Sorensen AA, Snider JC. Is increasing our reliance on technology enhancing education? J Continuing Higher Education.2001;49:11–18.
25. Frank RH, Cook PJ. The Winner-Take-All Society. New York, NY: Penguin Books; 1996.
26. Armstrong L. Distance learning: challenges and questions. Available at: http://www.usc.edu/admin/provost/dlremarks/dlremarks.html. Accessed May 23, 2001.
27. Weber TE. Allen is wooing elite colleges to teach online. Wall Street Journal. July 28, 2000:B1, B4.
28. Long-distance information: cyberspace scholars learn while earning. UAB School of Public Health Newsletter. 2000;6(Fall):6.
29. Leonhardt D. All the world's a campus. New York Times. September 30, 2000:C1, C8.
30. Overland MA. Indian business school seeks to give students a reason to stay home. Chronicle of Higher Education. November 3, 2000:A51–A52.
31. Dancing with the hippopotamus, and other cautionary tales. Findings [alumni magazine, University of Michigan School of Public Health]. Fall/Winter 2000:23–25.
32. Camus A. The Myth of Sisyphus and Other Essays. New York, NY: Alfred A. Knopf; 1961.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
