International Network for the Availability of Scientific Publications
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Health Information Forum:

Working together to improve access to reliable information for healthcare workers in developing and transitional countries

REPORT OF HIF EXHIBITION AND HIF OPEN FORUM 2002, held at the British Medical Association, BMA House, Tavistock Square, London, UK, on Tuesday 19 March 2002.

HEALTH INFORMATION EXHIBITION 2002

Thanks to the following exhibitors:

• Healthlink Worldwide
• Institute for Development Studies, ID21 Health
• International Health Exchange
• TALC/e-TALC
• Update Software/Cochrane Collaboration
• Wellcome Trust, Tropical Medicine Resource

HIF OPEN FORUM 2002

CHAIR: Kamran Abassi (Papers Editor, BMJ)

PRESENTATION 1: 3 BILLION BOOKS: The affordable 'book machine' and its potential impact on access to information for healthcare in developing countries' Michael Smolens, Chairman & CEO, 3BillionBooks, New York, USA <www.3BillionBooks.com> <[email protected]>

As 3BillionBooks (3BB) deploys its network of book machines globally, there will be an ever increasing number of countries, then cities, then perhaps even villages, that will have the ability to create books on site from digital files which are current as of the date of delivery. This network will be able to deliver books on all subjects, in all languages at the same cost and speed.

To the extent the participants of Health Information Forum and their associates, along with publishers and aggregators of relevant health and medical content, can obtain access to, or create customized content in any language, this content can be delivered in library quality book form to any machine in our global network.

The price of this book will be determined by the owner of the content, with the cost of making the book paid to the local operator of the machine, and a small access fee paid to 3BB for the use of its network. Hence, if the owner of the content wants to give the book away for free to the ultimate user, the only cost would be the actual production cost of the book plus the 3BB access fee.

Depending on the alternative method of distribution, the total cost of getting the book to the closest distribution in each location will be a minimum of 40% - 50% less than existing methods, with nearly immediate access - versus the traditional methods of post, courier, ocean freight, etc., which take from weeks to months, plus the sometimes impossible task of getting through local customs and bureaucracy.

EXECUTIVE SUMMARY OF 3BILLIONBOOKS

3BillionBooks, Inc. is a private company which will become the first worldwide distributor of books printed on demand at point of sale from digital files. The company will deploy a unique, patented, low cost fully automatic machine that will print and bind as many as 20 library quality paper bound titles per hour from digital files of various trim sizes and lengths, each with its own four colour cover. The 3BB machine is in effect an 'ATM' machine for physical books delivered digitally anywhere in the world.

This system will supplement and eventually supplant the present unwieldy mode of book distribution, essentially unchanged since Gutenberg, in which books are printed centrally, stored in publishers' warehouses and reshipped to retailers where they await buyers until unsold copies are returned to publishers' and destroyed. Revolutionary new technologies have arisen in the past decade that replace this supply chain by permitting the digitization, storage in electronic form and instantaneous transmission at negligible cost per unit of virtually any book ever written in any language to our unique one-book-at-a-time machines wherever electricity exists.

Our plan is to test the machines and develop related technologies in the first twelve months and in the second year deploy 15 - 20 machines in pilot locations throughout the world in cooperation with the World Bank publishing program and the publishing programs of other non-profit multilateral publishing operations. This pilot program will be undertaken on a non-profit basis with foundation funding. Commercial applications will be pursued in subsequent years and profits will derive from per copy transmission fees charged to consumers of commercial content.

3BB will also create the proprietary software to access and distribute digital content wherever it resides but will not itself create content. In effect this software will serve as a vast directory from which users at their own computers will select, browse and transmit to a nearby book machine titles chosen from a multitude of digital files at innumerable locations. Our proprietary software will permit the transmission not only of encrypted content but appropriate licenses and other specifications.

Though our aim is to operate worldwide, we will focus our initial efforts in developing markets which are severely underserved and burdened by excessive inventory and delivery costs, yet the need for books in these markets is great and growing. We will also encourage and train local partners (publishers and distributors) to create local language content for worldwide distribution through our network. We will assemble a catalog of 30,000 - 50,000 titles on development and scholarly subjects from the lists of multilateral publishers, perhaps an equal number of titles from the University of Virginia Digital Library and 10,000 - 20,000 titles in local languages. Until connectivity and bandwidth are widely available these files will be stored in servers on site.

Most of these development and UVA titles are already in some sort of digital form and need only be reformatted for our print-on-demand (POD) machines; the local language titles will be scanned into either tiff or pdf formats by local partners. We hope to assemble this catalog in cooperation with the UVA library or a comparable institution.

The cost of acquiring exclusive rights to the book machine and eventually the company that owns the patents, the cost of creating the software for the worldwide network for further deployment of machines throughout the world and for the distribution of commercial content, and all other overhead will be borne by 3BB and its investors.

Our aim is to place 500 machines at local distribution points on a franchise basis by years three, four and five and to enter the United States by negotiating with foreign language publishers to distribute their titles through our network and our machines to foreign language markets in the United States where readers of Spanish, Russian, Hindi, Mandarin and so on are hardly served by existing retailers. By this time United States publishers should have sorted out the ownership of digital rights and their other problems and be ready to face the challenge of the paradigm shift that awaits their industry. We will then have begun to link our software to millions of digital titles worldwide and to thousands of book machines serving literally billions of readers.

We estimate that among the chief beneficiaries of this technology will be readers of scholarly, technical and other serious books who are now poorly served, if served at all, by the over concentrated American retail market with its emphasis on current best sellers. Inter library loans and exchanges will also be more efficiently and cheaply served by electronic distribution to POD machines, residing in libraries, which can produce a physical book and compensate the copyright holder at far lower cost than the present method, which in addition to its high cost fails to compensate the copyright holder at all. These new technologies will also permit the distribution, in book form, of rare, scholarly and research material now held in special collections.

FOUNDERS: Jason Epstein is the only member of the book publishing industry to have received all three awards for lifetime achievement: The National Book Award, The Curtis Benjamin Award of the Association of American Publishers and National Book Critics' Circle Award. His innovations include the so-called quality paperback revolution, launched by Anchor Books, the series of paperbound editions for serious readers that he conceived in the 1950's and which, along with Vintage Books which he later developed, is still the dominant brand in the field. He was a co-founder of the New York Review of Books, which remains after nearly forty years, the world's leading intellectual journal in English. He also founded the Library of America which has restored to print in convenient, permanent editions the works of leading American writers. In the mid-eighties he founded the Readers Catalog, the precursor to on-line retailing. For many years he was editorial director and vice president of Random House.

Michael L. Smolens has founded and operated, or been actively involved with, labor intensive manufacturing facilities, primarily textiles and apparel, in Haiti, Mexico, Hungary, Romania, Turkey, Pakistan, India, Egypt, Jordan, Russia and Azerbaijan - creating in excess of 20,000 jobs and directly supporting over 100,000 people.

PRESENTATION 2: Challenges of information support and resource centre development in the Newly Independent States. Stewart Britten, HealthProm, UK <[email protected]>

In June 2000 the Republic Medical Library in Tashkent, capital of Uzbekistan, and HealthProm set up a Learning Resource Centre. No doubt the possibilities and problems vary in some respects from one country to another, but I would like to ask you to think about problems and successes we have encountered.

I'm going to say very little about the Centre in Tashkent. HealthProm seeks to raise funding for our partnership projects from companies operating locally from their community relations programmes, with some success. In this instance a British-Uzbek telecommunications joint venture, Buzton, provided a computer with internet access. The British Embassy presented a photocopier. Jointly we appointed a part-time IT Co-ordinator, a medical student, and the American International Health Alliance provided training for him and a share of their block subscription to online databases and journals. Insofar as this project has succeeded it has been on account of the Library Director and staff, the donors and HealthProm's representative in Uzbekistan.

The snags came quite quickly. After we had spent much of our scarce funds on IT training, our first IT Co-ordinator left the country almost overnight. After an interval the Director of the Library appointed another medical student, who has learned fast on the job but lacks training. Together we were able to organise the training she asked for, but it has not yet taken place, for reasons which we don't know. The Centre is responding to about 80 queries a month from specialists in maternal and child health, but it seems probably only by searching the internet, not databases. The panel of British National Health Service consultants who had offered to respond to problematic queries has scarcely been consulted. The library charges for queries from those seeking information for their theses, and this helps towards making it self financing.

This is the reality I want to start from. There have been difficulties and some continue, but it's real. From here on out I want to talk about the parts played by fantasy and reality in creating anything that works.

We need daydreams or fantasies. Nothing would be created without a fantasy in the first place. That is the starting point. We all know what must follow: joint planning, discussion with all stakeholders leading to gradual shaping of a project, schedules of activities, timetable, budget, evaluation, etc. We know that to do this we need not only "seed people", but shapers and those who are good at seeing a piece of work through. Funders want to make sure we are grounded in reality, insisting that grant applications include thorough planning and assessment of risk of failure. I welcome the planning exercise they require us to do, and I like to do a stakeholder analysis too.

So we need our fantasies at the start, but fantasies which are prolonged (when we need to be engaging with realities) are harmful, coming between us and problem solving. HealthProm also works in Russia, which has a long tradition of illusion replacing reality. When Catherine the Great cruised down the Volga, she saw happy serfs waving to her from cut-out facades of picturesque villages, which her prime minister, Potemkin, had ordered to be constructed.

Factors which serve to sustain fantasy when the process of realisation should be progressing seem to me to be: Funders' wishes; Distance; and IT.

1. Funders' wishes, euphemisms or fantasies, such as 'seed funding', 'catalysing', 'cost-saving' and 'sustainability', are laudable, but to deliver them is problematic or sometimes downright impossible. Almost everyone wants to start something which will spread and grow without our continued input. Believing it is another matter. The ideal is to be a catalyst, for your substance not to be used up in the reaction.

An alternative is to make cost-savings, so releasing funds which would enable the work to continue. But who has actually made a cost-saving which has not been almost immediately used up before you could see it? For a Learning Resource Centre in a developing country with low per capita income to replace old hardware and software and to pay for online time itself may be illusion.

As for dissemination, we would probably all like to see our projects sweep across national boundaries. Some, of course, have. Mighty oaks do from little acorns grow - but for every one which grows to an oak, many perish. And tiny projects don't grow into large and successful ones, nor spread to other areas, without the prodigious energies of champions. The fertile ground in which seeds may germinate and grow are the minds of colleagues. 'Cascading' implies water flowing effortlessly downhill. This is almost pure fantasy. My experience of project work has been the opposite, almost a labour of Sisyphus.

2. Distance introduces the possibility of a gulf between fantasy and reality. There is a risk of failure whenever we don't discuss an issue with someone who will be involved in its repercussions. The reason we don't discuss an issue might be possibly because of lack of time or possibly because we know they would come up with problems which would seem to spoil it. I am, of course, talking largely of a risky psychological distance between those who write project proposals and grant applications and those who will be concerned with implementing them.

I once spent a weekend writing a grant application for a training project. There was a tight deadline and I didn't discuss it adequately with those who would be concerned with implementation. The managers were very forgiving. It wasn't until the training had been delivered and implementation of training started that we encountered the full difficulties. We were asking people who were already busy to do more work in the same time.

If I can fail to talk to people a few miles away, how much greater is the risk of lack of understanding the implications of a project for partners in another continent?

Distance learning is a particular favourite for the fantasist - and I speak as one who has worked for a long time to set up a distance learning partnership project. I was involved in a project which was meant to 'roll out' the training programme from the regional capital city to eight other towns or cities, across an enormous area. Soros had provided fibre optic cabling. To 'roll out' the training sounded so easy. I had a picture that the training would be injected into the fibre optic cables and somehow end up in the minds of the putative recipients, a bit like feeding battery hens.

It was the computer expert of the regional university who told me of what he called 'the problem of the last mile'. To nobody's great surprise the information can be zipped along the data highway to a remote region, but getting it from the computer terminal to the doctors who could use it might never happen if the crucial questions of building interest and enthusiasm of potentially active participants were not considered.

All Russians know this scene very well. You go to a day's training because you are expected to, like the Potemkin villagers told to wave to Catherine the Great, then you return home to reality, which has not been touched by what you have heard.

3. I'm not going to lay any blame for fantasy at the door of IT. The internet has given us the most powerful tool for every country in the world to improve its healthcare that there has ever been. But it also plays into our fantasies of omnipotence. A baby can cry for a feed and pretty soon the feed appears. It may feel omnipotent, but that baby later becomes a mature adult through adapting to realities, shortfalls when needs aren't met. If I can sit at my computer at home in the English countryside and send information to Central Asia and Siberia, I can feel pretty omnipotent - much more so than when you had to find the appropriate journal in the library, photocopy it and put it in the post. Without a liberal dose of humility, I fear that the omnipotence given us by IT is not good for partnerships or for us as individuals, any more than it is good for politicians to start to believe that their policies are realities.

And how does it feel in the developing world to receive this increasing flow of information from your omnipotent northern and western neighbours?

It has been my intention to be provoke discussion. But on one point I am not wanting to be provocative. Some believe that small is beautiful; others that big is better. I believe *small is real*.

A postscript. Thanks to an unforeseen factor, the Learning Resource Centre in Tashkent has become sustainable. The Soros Foundation there wanted to set up an Open Medical Club, and as a result of the Centre they saw the Library as the best place for this. So they have provided equipment and are putting in $16,000 a year. They will provide a DVD player if we provide DVDs for training in clinical practice.

PRESENTATION 3: 'Developing: metadata'. John Lindsay, member of the British Computer Society and Information for Development Forum. <[email protected]> 

1. Chunks and clumps

The Commission on Intellectual Property held a 2-day meeting on 21-22 February to discuss how intellectual property rights could work better for developing countries and poor people. The meeting was organized into eight chunks:

• Introduction (with Clare Short)
• Agriculture/genetic resources
• Traditional knowledge and folklore
• Copyright in developing countries
• Technology, development and intellectual property rights
• Medicines and vaccines
• Research tools, gene patenting and public-private partnerships
• International institutions, rules and practices
• Capacity building.

This is a strange chunking and clumping. Topics were not equally dealt with in sessions.

Most disturbing is how little attention was paid to the role of new information and communication technologies. Instead much time was spent on classic arguments on pharma monopolies on patent rights and medicines.

Give the frequent reference to information and knowledge but no sessions on the systematisation of information or knowledge systems, we feel it necessary to make the following points to add to the material for the consideration of the commission.

We are going to presume, though the Minister did not specifically state it, that pro poor policies are not an add-on option, but an essential component of preparation to the Rio+10 world summit in September.

2. Professional societies

Professional societies in Britain derive their authority from Royal Charters which usually specify some obligation as a consequence of membership to promote the public good, to promote public understanding, and to promote knowledge.

The British Computer Society, the Society for Information Systems Practitioners has computing specifically mentioned as its domain. More may be found on www.bcs.org.

Chartered Institutions of Library and Information Professionals, or some such name, are present in most countries. These professionals could be close to the poor as they work in public libraries, schools, colleges, organisations, and have long traditions of being in support of access to information and freedom of expression. The world congress of IFLA, the International Federation of Library Association is taking place in Glasgow in August and provides a powerful opportunity for arguing pro poor sustainable development information policies.

The Information for Development Forum (IDF) was founded in 1983 to co-ordinate where possible the role of information in the process of development. More can be found on <www.jiscmail.ac.uk/lists/eldis>. The Forum contributed to the UK White Paper on Globalisation and Development.

3. Electronic governance interoperability framework

Since the White Paper, the UK Government Cabinet Office has established an office of the e-envoy which has produced a framework for electronic governance interoperability (eGIF) and a governance metadata framework. See www.govtalk.gov.uk for more. That framework specifically claims to have an international dimension, and to have a developing countries orientation.

The framework proposes identifiers, subjects and services with the Dublin Core as the key structure. For us, this raises issues of intellectual property and rights management which will have both opportunities and threats for poor people and developing countries.

4. Obligations, rights and goods.

The Globalisation and Development White Paper proposes the existence of international public goods. UNESCO has taken a similar position, claiming that items of cultural heritage, documents in the public domain, fulfil this category. The meeting however placed most of its emphasis on intellectual property rights as private rights to be defended.

It was frequently remarked that these rights are a right of monopoly. If the state is to allocate a monopoly right to a property then it incurs an obligation to regulate that monopoly. It is from the state that professional societies gain their rights, and therefore too the members incur obligations.

A right is a loss of freedom to those who are non right holders. They incur a duty to respect to that right. But are there differences in discovery, invention, creation, construction - in which rights might not be on the same basis? So, whether that duty is paid will depend on the respect held for the process of legitimacy? If we are working for sustainable development, does that mean that the rights holder should in turn incur duties?

Perhaps we might have three methods for approaching the task of deciding what could work better for the poor? We could start from abstract principles such as Nozick in Anarchy, utopia and the state, we could start from cases or evidence, for example the expropriation of common rights in enclosure or private rights expropriated in order to build railway systems, or we could just follow our noses? In any event if one set of facts, logics, arguments and ratio within a structure such as a logical framework produces a consistency of position then that we will support.

Rights and obligations however are not in themselves sufficient. These rights have to be capable of being exercised. I might well have a right of way. But if a carriageway is carrying 10 cars per minute at 50 mph and has no pavement, I have in practice lost my right.

It is unfortunate that we have at least nine common uses of the word information and no chance of gaining agreement on one, or even in knowing in which sense the word is being used by a particular speaker. Let us therefore create the concept of an object, which is a type of thing which will eventually be constructed within a computer on a network.

What then are intellectual property rights in Information Objects and how could these work better for poor people?

Let us consider these rights as goods. Goods may be depletable and excludable, or non-depletable and non- excludable. The former may best be socially organised by symmetric pricing through competition. The latter may better be organised by general taxation. The former may be private goods, the latter may be public goods. Both have externalities. Private good externalities may be negative. Public good externalities may be positive. How do market clearing mechanisms work for these?

Or we could state this other way round: there are private goods and public goods, these have externalities. How does the market clear these?

When thee goods are intellectual property rights, they may be private or public rights and these rights will have externalities. How are these rights to be regulated?

We suggest that that consequence of incurring rights is that you incur obligations. These obligations will have to be defined in the electronic governance interoperability framework.

5. U::G::C

Most people can hear and speak. A large majority can read, write and count. But when information objects are created, they are virtualised, digitised, abstracted, and therefore become different social constructs from their predecessors.

In the Modernising Government agenda within which we presume this commission, and the office of the e-envoy sits, there is also an item of open government and government direct component.. These will have impacts on poor people and if part of an international harmonisation, then also on developing countries. If they are right, or the policies, programmes and projects which follow are to have good ends, then that which could work better must be supported.

The Framework 6 of the EU is going to put a large amount of money into research which will promote the information society as a component of sustainable development. This means that projects in that framework must support that which could work better for poor people.

So we have a simple model in which research is undertaken and knowledge produced. Let us call that U. There is then a framework for eGIF, let us call that G. There are communities in which people live and reproduce the daily conditions of their existence. Let us call that C. The :: notation is being used to indicate that some sort of information object has been constructed in order that processes with objectives and logics may flow. (This was developed in the course of the DfID project Strengthening the knowledge and information systems of the urban poor. See www.communityzero.com/kisup for the papers.)

The intellectual property rights in all these components have to be allocated. In most cases the processes will be explained in documents. The documents will have records which will be described in Dublin Core, this will allocate the metadata and that includes the intellectual property rights.

However there are special properties to what we might call information and knowledge. We need to know whether the knowledge and the actions which follow from it are true, right and good. This means we must be able to distinguish between knowledge here and now, and then and there. This is particularly the case in developing countries where that applicable to the west might not be. The promotion of health through clean water seems an obvious case. So information then becomes either stuff or shit. If it is not information, in other words it will not inform, then there is no point in paying for it, but I don't know til after whether it is. In addition, the absence of information, that something is not known, might be information. That there is not a patent is as much information as that there is.

The asymmetry of information is substantial enough that three Nobel prizes have been awarded to examining it. This has not resulted however in a taxonomy of use cases and it is the one size fits all approach of tradable intellectual property rights which seems the real difficulty for information professionals. Because this is both the subject and the object of our field we anticipate particular difficulties.

There is also the question of who owns the intellectual property rights of the individual subject? We now have data protection, and freedom of information, as concepts, and in some jurisdictions, as acts. If the result of gene research, someone can know that I have a propensity to a particular illness, even though I might not know it myself, is that a tradable good? If it impacts on my insurance, do I have any rights? If this scales from individuals to communities then how is this to be managed?

6. Simplify connect

Our interest in globalisation and development is particularly in the field of electronic commerce. It is this which offers the potential for reducing poverty by extending access to resources.

Because anything transmitted in electronic commerce is in some sense traded it will fall under the umbrella of trips.

We will need to build a three part model for describing this. There is the air of the clouds, Valhalla, the realm of ideas and models, concepts and theories; there is the world of the land, the gibichungs, the realm of exchanging real things with use values; and there is the world of the depth, the sea, the niebilungs (let us not include hell), the world of the technological infrastructure of mobile telephones, computers, networks, routers, dns tables, which will support all this. Any model in three parts will immediately attract opposition and divide into seven. But we have been here before.

Intellectual property rights will occur at each level with different parties and these will need to be built into a value network of actors and logics. Only some of these will be rights attracting duties. For example open source might be fee or free. Closed source might be also free or fee. But in gaining open source you gain something which you do not gain in closed source.

In our submission to the discussion on the white paper, we suggested the following ten points and elaborated them. This was published on www.jiscmailac.uk/lists/eldis

These seem still points needing to be dealt with.

• Intellectual property obligations
• Content and containers
• Development Information Plan
• Professional societies
• Education and training
• Methods, tools and models
• IDRC International /information development resource champions
• Connectivity
• Open source
• Governance good practice

The last might have added to it the particular practice of DfID in making projects, papers, places and people which it supports an international public good.

7. Relations and forces

One might argue that it is contradictions in the social relations of production which give rise to the opportunities for technological developments to take place. These technological developments in turn, the developments in the forces of production, in turn exercise pressure on the social relations, which either change, or destroy the technology. Thus it was with printing and the gun. And so it is now with the mobile telephone, the computer, the television set and what we are calling the internet.

Intellectual property rights seem to be one of the concepts of a social relation of production. These rights rose in particular situations. They were solutions to particular problems. They promise now to become a hydra which will strangle development. It is by engineering intellectual property obligations that a pro poor sustainable development solution can be found.