Supercourse, collaboration and Cuba

Autores: Dr. Ronald E. LaPorte* y Dra. Nancy Yodú Ferral**

 

* Director, Disease Monitoring and Telecommunications. WHO Collaborating Centre. Professor of Epidemiology
Graduate School of Public Health. University of Pittsburgh. Pittsburgh, PA 15261. USA

** Especialista de Farmacología. Profesora Auxiliar. Facultad de Ciencias Médicas "10 de Octubre". Ciudad de La Habana, Cuba

Dr. Ronald E. LaPorte

Dra. Nancy Yodú Ferral

Introduction.

Greetings:

What we will describe to you is what we call the Supercourse (www.pitt.edu/~super1). This is a radical new approach to national and global education, with out doing traditional distance education.

It is important to describe who we are:

Ronald E. LaPorte, Ph.D.

Hi, everyone calls me Ron, and hope that you do also. I was born on May 29, 1949 in Buffalo, New York. Buffalo is about 50 km away from Niagara Falls. It is known most for its snow, last year in 2 days my home town received 9 meters of snow, the greatest snowfall ever.
My background is very strange unusual. I am originally trained as an experimental psychologist, with a Ph.D. from the University of Pittsburgh. Upon completing my degree I heard about Epidemiology, and scratched my head and said "Is that a Skin Disease". I became more and more interested upon realizing that of all areas of medicine, Epidemiology and Public Health has saved more lives than any other.
I took post-doctoral training in epidemiology at the University of Pittsburgh. I got involved with some controversial topics. We were one of the first groups to show that alcohol consumption protected against heart disease. Then we showed that one did not have to be a marathon runner to protect oneself against disease. The area that I spent the longest time was that of diabetes epidemiology. In the late 80s and early 90s we decided to map out the world, and collect registry data. I first became a director for disease monitoring and telecommunications at our WHO Collaborating Center, and then we created a WHO multinational project for Childhood diabetes which encompassed 155 centers in 70 countries. Dr. Oscar de Mateo Acosta from Cuba joined and we wrote several most interesting papers with him.
In developing the WHO Course we began to see the critical need for inexpensive communication, and building cross_country relations, and grew fascinated with the Internet.
I still live in Wexford, PA.

Nancy Yodu, M.D.

To follow my friend. I also say Hi! I was born on March 10th, 1952 in Havana City, Cuba. All of you know Havana, our warm and beautiful capital.
I finished Medical School at Havana University in 1975. Later I received an Specialization on Pharmacology and it was not till I started teaching it at different Faculties of our Medical Sciences Institute that I really began to learn more about it and to discover its life-saving potential derived from a correct and rational use.
"10 de Octubre" Medical Faculty, the place I have been working in since 1978, didn't have many resources to do expensive research, so I began to look for something useful and inexpensive to do. That's the reason I started studying the way doctors prescribe drugs, which I consider a critical stage in effective patient treatment. These drug utilization research, a branch of Pharmacoepidemiology, has served as a way to initiate some of my students in the field.
More recently I discovered the Supercourse. This project has opened a whole new source of knowledge for our students and professionals, but more than this, it has contributed enormously to make us concious of the Internet prevention potential, provided we all joined our efforts in the fight against disease. Yet, I believe the main lesson we have all received through the Supercourse is to understand that it is friendship and mutual cooperation -and nothing else- the powerful engines that move our world ahead to a sustained betterment. A tangible example you say? I invite you to consider the following paper!

Supercourse:

There has been considerable interest in the Supercourse with almost 5000 faculty from 114 countries. The interest in Cuba has been phenomenal. Table 1 shows the top 10 countries and the number of faculty who have joined the supercourse. The US has,not unexpectedly the largest number of faculty. Cuba has been exceptionally well represted with 103 faculty, putting it in 5th places of all the countries. The collaborators in the US and Cuba have become close friends, both dedicated to the improvement of health through teleprevention.

Table 1. Supercourse Members by Country

Country No.
United States 2216
Canada 557
United Kingdom 127
Japan 125
Cuba 103
Brazil 99
Australia 73
Peru 73
Germany 60
Argentina 59
S. Africa 59
India 54

Cuba was the first country to set up a mirrored server. In addition, Cuba is developing their own Cuban Supercourse in close collaboration with the researchers in Pittsburgh.

Arriba

Development.

Al Gore was first to coin the term Information Superhighway. What Vice President Gore said about the information policy of the early 1990s holds true for the Public Health information systems to now, "(the information policy) resembles the worst aspects of our old agricultural policy which left grain rotting in thousands of storage files while people were starving." Clearly prevention information lays fallow, which, if developed into lectures and interconnected with data could have an enormous effect on the health of our country, and of the world (2).

"Information superhighway: The electronic transmission of data, information, ideas and pictures among computers via modems, fiberoptic cables, satellite communication, etc." "The communication network of computers is the Internet". (Last, Dictionary of Epidemiology) (3). For the first time in 1996, Dr. Last included these definitions related as a result of some of our work. Dr. Last subsequently indicated: "These unprecedented advances in communications technology are not only of immense educational and scientific value, they are the most important tool we have ever had to help us get along better with each other" (4).

Background: Remarkable improvements in life expectancy have occurred in the Cuba, the US and across the world this century. In almost all developed and most developing countries there has been a 25-year increase in life expectancy. This increase is greater than that seen at any time in history. The increased longevity was almost exclusively due to public health. We in Public Health have many reasons to be proud of our accomplishments. It has been estimated that almost 24 of the 25 year increase was due to simple public health measures such as sanitation, immunization, changing life styles, improved nutrition, etc. (5). Most of public health is information sharing. The first two eras of public health this century were that of sanitation and immunization. We have argued that the 3rd age will be that of Information, which will begin in the 21st century (6).

We have coined the word "Telepreventive medicine". This discipline uses the tools of the Internet to bring and collect information from large numbers of people to prevent disease. It is different from telemedicine, which targets expensive telecommunications technologies to a small number of sick people to "cure" disease (7). Telepreventive medicine for will establish a network and to train it on the Internet. The members on the network teach each other.
The Internet evolved from the Department of Defense in the early 1960s. Several of the fathers of the Internet are participating in this effort, these include Vint Cerf who was a principal architect during the formative stages of the net, Anthony Villasenor was head of the NASA Scientific Internet, and provided the Internet skills for the early development of the Global Health Network, and John Patrick, VP of IBM. In the 1990s, the Internet revolution exploded. Since 1990, almost all of epidemiology and in fact all of science in the US came onto the Internet with e-mail. In 1990, few scientists had access to e-mail. In 1993, there were only 200 home pages on the Internet. Now there are over a billion home pages.
It is important to reflect upon the current state of training in epidemiology/global health. In the US, the students in the Schools of Public Health receive excellent training, but it is very expensive and reaches few. In Medical Schools, Dental Schools, Nursing schools, often epidemiologic training is thought to be very boring. Many programs are now migrating to the Internet such as from Johns Hopkins, and North Carolina. The table below compares traditional programs with the Supercourse. The major point is that the web lectures being developed are radically different that the existing "Talking Head" type of Epidemiology/global health training as practiced by traditional schools. The medium for talking head is high bandwidth voice-video, the medium for the Supercourse is PowerPoint. Moreover, at $30,000 per year it is impossible to train many students from Zambia where the per capita income is $1,000. The target group is quite different also, we target the "tabula rosa" student, those young medical, dental, veterinary, nursing and pharmacy students through their classroom teachers rather than public health students. As this is a system designed to "educate the teacher of epidemiology/global health" we have the potential of reaching 50,000 students each year. The traditional programs have little quality control, or peer review. Based upon the direct comparison between the Global Health Network approach, and the traditional approach, our approach is far superior to the traditional approach in cost-effectiveness. This is not to say there are not still unanswered questions about our Supercourse, but we believe, and can show that it is vastly superior in reaching students across the world. We have surveyed the distance learning programs. Few outside the US can partake in the training because of cost. Our system circumvents this problem by leaving the teaching in the hands of the instructors world wide, but helping those teachers to have better lectures. It is likely that less than 500 students per year outside of North America are taking course work in epidemiology using the Traditional System. Already across the world at least 50,000 students are to be exposed to the Supercourse this year. What often is not realized is that now world wide over 98% of the students are taught in the classroom, in 10 years it may drop to 97%. There is little capacity in the talking head model to rapidly develop courses say on terrorism, or an earthquake in Kobe. We need thus to globally improve classroom teaching if we want to improve global training in public health and epidemiology.

Traditional Epi. Training Supercourse
Cost $10-20,000 per year $0.0
Approach Direct to student Educate the teacher
Faculty 1 school, all developed country 4700 faculty, 30% developing country
Format Talking Head Hypertext comic book
Medium Voice-Video PowerPoint
Sites 1 site 100 mirrored servers
Target Group Public Health Students Tabula Rosa students
Students/year 100 >50,000
Quality control No systematic Statistical Quality control

The Internet is the most powerful tool for global research, and teaching. It is a transparent, cost-effective medium. It is cheap, and becoming ubiquitous. In addition, the format of the system with hypertext links, and point and click can lead to very powerful new modes of cognitively based training. It is a very friendly medium and it breaks down the hierarchy between professor and student, students in Cuba, Asia and students in Latin America. On the Internet, people are equal. With the power of the Internet, for the first time we can use the best scientists of the world to share their best materials so that we can be better able to train our students.
Collaboration with leading experts in the Internet community has led us to a different model of international training.

Network Development: Supercourse I has grown beyond our wildest expectations. The core to Supercourse I is our faculty. We have a very powerful group of participants. There are 431 scientists from over 3500 different universities and 118 countries. It has taken over 15 years to build our network. Over 85% are from academia.

Lecture Manufacture: We never could have expected that now we would have 631 outstanding lectures which has taken us 4 years to accumulate. These lectures represent the "babies" of the faculty, in some cases they have been groomed for 15 years.

Yet, the faculty provide these for free to help others across the world. This must be put into context. To obtain a masters degree in epidemiology requires about 400 lectures. The interest in this worldwide is amazing. Over 20 lectures are contributed a month. The caliber of the lectures is extremely high. Most of the lectures come from full professors, who have shaped their lecture over 10-20 years. Our faculty has very able people. The head of the Centers for Disease Control, Jeff Koplan provided a wonderful lecture. Also, all the CDC lectures from their web site are on the Supercourse. John Last, the father of preventive medicine has a beautiful lecture and has been a major distributor of the Supercourse. Vint Cerf, the father of the Internet gives a great overview. John Patrick, VP at IBM provided a lecture. We have several outstanding lectures from Cuba as well. We have a commitment from 5 directors of the NIH, and the two heads of health at NASA as well. Excellent lectures are also available from developing countries.

Lecture Distribution: We have set up mirrored servers (these are copies of the Supercourse) in 36 different countries as seen on this map. Mirrored servers aid access as downloading times are markedly reduced. These include a server for Cubans Palestinians, Israelis, Iranians, South Africans, Chinese, etc. To our knowledge this is the first time that any web page in epidemiology or public health has been mirrored.
A large percentage of the world does not have access to the Internet. In distributing the CDs, we indicate that these are "gifts that are meant to be given". They have been widely dispersed across the Former Soviet Union. There are at least 50 centers in China using the Supercourse. The Ministry of Health in Peru will be distributing these to all health personnel.

The Ministry of Health of Pakistan plans to make this available for the medical schools. Access to the Supercourse is now available to every doctor and nurse in Cuba. It is difficult to estimate the numbers of people who will use the Supercourse, but it is likely in excess of 100,000. The combined number of students in epidemiology in Graduate Schools of Public Health in the United States is less than 5000. We thus are reaching more than 20 times the number of all the Schools of Public Health combined. We are also talking with WHO to have the CDs distributed throughout their Medical Library network, and the UN headquarters in Africa, who plan to distribute the Supercourse in 17 countries.

Progress Report

Historical Background: During the initial development of this effort, we were funded for three years by a grant from NASA, which ended.
Our program was quite successful as we have published or submitted for publication 105 articles. During the past 3 years alone, we have had 30 publications, 22 of which appeared in Nature Medicine, the British Medical Journal and the Lancet.
We were rated as in the top 6 telecommunication health projects out of over 30,000 other projects on the Internet as part of the Global Information Initiative (GII) awards.

In addition, in 1996 our Global Health Network home page won many awards, the most important being rated in the top 100 home pages by PC magazine: better than the NIH itself, and the leading home page in health. Recently the Lancet identified our home page as one of the 11 recommended health pages.

We have been fortunate to be collaborating with some of the global leaders in telecommunications, including Tony Villasenor, the former head of the Federal Networking Council of the United States. He also started and headed the NASA Scientific Internet. Vint Cerf, the father of the internet has been a strong supporter. He has provided a lecture, presented in Dr. LaPorte's class, and distributed CDs of the Supercourse to his friends.

To discuss where we are, and where we are going, we first wanted to provide a historical framework for this effort, and then describe the new technologies we have been established to demonstrate how this could lead into potentially exciting new applications for epidemiology and public health.

In 1985, our center became a WHO Collaborating Center and Dr. LaPorte became the Director for Disease Monitoring and Telecommunications and Dr. Dorman, the Director for Molecular Epidemiology. The diabetes project became a WHO Multinational Project for Childhood diabetes (8). We have published over 300 papers in the area of diabetes epidemiology. At this time there was a rapid growth in diabetes registries such that 155 centers from 70 different countries joined. This became one of the largest global studies ever completed.
Keeping track of the collection of data across the centers was quite difficult. Therefore we networked as many of the centers as possible, smoothing the operation of the of the project. This was one of the, if not the first WHO Projects with a telecommunications backbone.

One partner is John Patrick, VP at the Internet Division at IBM. In addition to these experts, Shunichi Akazawa WHO developed the home page for WHO in Geneva, and Carlos Gamboa, M.D. developed much of the networking work at the Pan American Health Organization joined. Francois Sauer, M.D. formerly from AT&T proved to be a major contributor. We were most fortunate to bring together some of the world's leading Internet and global health experts. These task force members of the Global Health Network will continue to collaborate with us. We currently receive no financial support from NASA,WHO, PAHO, or IBM.
We published the first papers on telecommunications and global health research in the American Journal of Epidemiology and Epidemiologic Monitor Monitor (9,10). We also established the first list server in epidemiology and public health. We were the first to publish in an upper tier journal (BMJ) on the Internet and global health (11). This was accepted and published as the lead article in two weeks (12). Our Internet articles have been in the prestigious Christmas edition of the BMJ for 3 consecutive years. One was a lead article (13), and the second was of such interest that the BMJ (14) had the editors of the Lancet, JAMA, Annals of Internal Medicine, BMJ, and others to comment upon it. Our article titled the Death of Biomedical Journals (15) in the BMJ stirred enormous interest and controversy. We were the first to publish an article in the BMJ, and concurrently put it onto the Internet. We were the first to publish a review paper (16) while simultaneously having updates on the Web. Tony Delamothe, web editor of the BMJ indicated that the Global Health Network was the reason that the BMJ moved onto the web. We also published some of the first papers using Statistical Quality Control in Epidemiology (17,18). Our Internet and statistical work therefore is viewed on the cutting edge of not only telepreventive medicine, but for all of health.
We were some of the first people to use e-mail and the web as a teaching medium in 1986. We have a 15-year history of International Epidemiology Teaching using telecommunication. This is the longest experience for probably any epidemiologist and some of the longest in science. Early on we decided to bring students from outside the US to be "cyberstudents". We sent readings to the students and faculty members by e-mail. The students in Pittsburgh were able to talk electronically with the students from overseas. This was the first web based class in epidemiology to our knowledge. We published in the British Medical Journal a call for the development of a Global Health Network University (19). We were the first argue for global Internet training in prevention (19).
We also started in several directions, which are proving now to be very important for expansion of our efforts beyond just teaching. In 1996 we published a series of review papers in the American Journal of Epidemiology(21). Instead of including tables of reviewed articles we put these onto a Web page, and just included a home page address in the article. The importance of this is that all review papers are 12-16 months old when published. Our approach markedly improve the "shelf life" of a scientific review paper (BMJ 16).
If we use a low estimate of 20,000 students a year seeing a lecture, then in 10 years 200,000 will have seen each lecture. Overall each lecture will take about $5000 to prepare. In ten years the cost to present each lecture to a student will be $500/200,000 or 2 cents. Contrast this with international talking head lectures where costs can run $100/student/lecture or $4,000 for an hour class of 40. Our approach in this case is 200,000 times less expensive.
We have published over 40 papers on the importance of monitoring in epidemiology and public health (eg. 22-24). Here we develop and use technologies to continuously monitor the quality in manufacturing which to our knowledge has not been used in Internet lectures. We will employ a philosophy and techniques of Deming who brought quality to the Japanese car industry.
We have the very simple concept that if we can provide excellent template lectures on prevention that can be used in PowerPoint world wide, we can improve the quality of teaching worldwide. We use PowerPoint, as it is the new language of science and presenting. PowerPoint slides are the atoms of information that can be re-arranged by teachers throughout the world.
The original Supercourse has been enormously successful for bringing science closer to the training, and for biomedical communication. The proposed second generation Supercourse is designed to markedly the transfer of epidemiologic knowledge at the time of crisis.

Educate the teachers of Epidemiology/with a Web Lecture Library: Our goal is to provide the best PowerPoint lectures and slides that you and others can use for free to construct your own lectures. The author of the lectures does not teach the students directly from the Internet. One reason for this is that providing the latest information to the instructors leads to "educating the teachers" you will rapidly become knowledgeable. With this approach the developers of the lectures do not interact with the students. Instead the students interact with their classroom teacher and the Internet itself. The second reason is that when the course is successful lecture developers would have to answer potentially 20,000 messages a year from students. The lectures are like textbooks, where there is little interaction directly between the students and the author of the lecture, as with a student and the author of a text. Thus there will be considerable interaction between the students and the Epidemiology Instructor in their classrooms. The teachers of the world have a chance to pick and chose what slides and lectures they want to use improving the quality of their lecture, and their knowledge, while reducing preparation time. The lectures can be modified for K-12 grades, and these curriculum materials provided to the schools across the US and world.

Hypertext Comic Book format (25): (In Nature Medicine) We were the first to present the concept. The major difficulty of the epidemiologic and medical literature is that it is easily forgotten. A recent letter in the Lancet showed that journal articles that are read typically cannot be recalled 2 months later (26). Because of our background in cognitive psychology, we were struck that often when we went back home to visit parents in Buffalo, and looked at comic books from 20-30 years ago, upon seeing the cover, we know exactly what happened. We remember Lois Lane falling from the window, and being swooped up by Superman, we recall Superman in a fallen position being exposed to the green rays of Kryptonite, and we recall Superman as a baby landing in the corn fields of Nebraska.

Great Ceaser's Ghost…Why is it that we can remember so much Comic Book information from 30 years as well but we cannot remember reports from the American Journal of Epidemiology from 2 months ago? The answer lies in cognitive theory. The first component is that of iconic learning as espoused by Pavio (27) in the early 1970s. Iconic learning in its simplest form is….a picture tells a thousand words. As one walks into a classroom, one can remember the 40 faces much better than the 40 names. An icon we will never forget is the explosion of the plane into the WTC. The second component is that of schematic formation. Bartlett (28) in 1932 developed a theory that has held to this day. When we learn there is too much information, it is impossible to memorize it all. Human information processing has to be selective. As we read a representation, or schema is formed which is like a backbone. We hang "flesh" onto the backbone. Anything that does not fit is discarded. Thus when we read a comic book we go from frame to frame, building a very powerful visual schemata which we can remember very well for weeks, years and even decades. The information rich text journal article does not permit this. When we reached a certain age we stopped reading comic books. It was because there was not enough information in them. Books and journals are much more information dense than a comic book.
However, the Internet permits us to use the power of the "iconic based" comic books while at the same time solving the problem of lack of information. This is through hypertext. With hypertext one can click on a word, picture, number, and immediately pull up additional information.
The model of Hypertext Comic book should not appear to be foreign to us. This approach is exactly what is used with the icon driven Windows. All we are doing in the current research effort is creating a

Quality Assurance and Statistical Quality Control

Peer Review: Before discussing our work on peer review/quality assurance, it is important to point out that there is virtually NO quality control in web based instruction, or distance learning in epidemiology or any disaster material. We believe that ours is a significant improvement. Over the past 7 years a primary area of Investigation has been peer review. The Peer Review issue has been very contentious. Our experience began when we published a paper called the Death of Biomedical Journals in the British Medical Journal in 1996 (15). We soon discovered that questioning peer review is like questioning the Bible, Torah or Koran. Since then we have been on the cutting edge of the issues related to peer review and have published numerous articles in the British Medical Journal, the Lancet, and Nature Medicine. Moreover our work is the first ever in a major journal (the BMJ) to be put up for open review before a decision is to be made. It is important to examine the state of the art of peer review in epidemiology/global health. For journals we use an adversarial system of review that was developed shortly after Lincoln's assassination. It is a very costly, inefficient system, with very little information to indicate that it works. For lectures, to our knowledge there has been no attempt to develop a Web based system of peer review. Our approach is one of quality assurance, not peer review Peer review is designed to reject, quality assurance is designed to improve. Quality assurance has been a long and proven track record in manufacturing. Quality assurance is like reviewing drafts of our student's dissertations we do not grade and reject; rather we critique to improve quality. Peer review is more like a final grade in a course, Both are forms of quality control, however, as shown in the auto industry, quality assurance has become the standard.

Quality Control: All lectures undergo quality control procedures by the global faculty before they are used in the classroom setting. At the end of each lecture there is a review form which allows members of the global faculty to rate the lecture and submit comments to the author. The author then updates the lecture.
As students around the world take the course, they will also be able to rate the lectures. With the students' ratings, a continuous quality appraisal mechanism will be used based upon Deming principles. Annually each lecture will be reviewed, and the comments assessed to determine if the ratings have changed. This process is not a "peer review" system. The comments from the faculty are not utilized to accept or reject a lecture, but to help the author improve the lecture.

As of this date, 33 lectures have completed the quality control process. A total of 332 comments were received. We have recently received another 400 but have not had a chance to analyze them. The mean rating for all the comments was 4.06 (+ 0.83). The first few lectures received a large number of comments; Lecture 1 - 56 comments, Lecture 2 - 37 comments, Lecture 7 - 25 comments. All other lectures received from a minimum of 3 comments to a maximum of 19 comments, or an average of 5.6 comments per lecture. The average ratings for each individual lecture were quite high, ranging from 3.0 to 4.7 (Figure). The comments for each lecture were forwarded to the author of the lecture with a request to revise the lecture based on the suggestions comments provided by the other faculty members. Following the initial quality control check, the comments for an individual lecture are accumulated for a period of one year, after which they are forwarded to the author with a request to update the lecture based on new research findings and/or revise the lecture based on the comments received during the preceding year. Thus, the lectures undergo a continual quality control process. We have demonstrated that this works. During the next two years we will make this fully operational.

Statistical Quality Control: SQC has never been used in Epidemiology/global health training. In the Lancet (23) and Epidemiology/global health (20) we were the first to argue that a Deming "Total Quality Control" (24) approach to public health is needed, where there is continued monitoring, and continued improvement. The approach to analysis will be statistical quality control which is fully described at the end of the grant. We were one of the first groups to examine the use of Statistical Quality Control in epidemiology/global health.

Quality control (QC) is defined as "a management function, whereby control of the quality of manufactured products and raw materials is exercised to prevent the manufacture of defective products" (1). In the current system our product is the overviews/lectures. We want to use state of the art QC derived from Industry to produce excellent lectures with few "defects". Statistical Quality Control is defined as all those methods that use statistical principles and techniques for the control of quality. This is widely used throughout manufacturing. In the context of distance education quality is defined as student ratings of the quality of lectures worldwide.

Mean and standard error for the Overall Rating Score (5 = excellent; 3 = average; 1 = poor) for Supercourse Lectures: Initial Quality Control Procedure

 

 

Four basic principles of quality control are to: (1) build quality control into the system from its inception; (2) set useful standards; (3) designate all personnel as quality inspectors; and (4) close the quality control loop. For web based training, the first principle is to build feedback loops to the authors and the presenters of the lectures. Here we do this with the student ratings of each lecture. The second "standards" means "some minimum level of quality or adherence to specification, below which the data are unacceptable. This implies that variation from a specified standard should be treated as an out of control condition. In addition, tracking lectures over time, once a lecture slip below its LCI (Lower Confidence Interval) it would be deemed as out of control. The third principle promotes detection of lack of quality at every stage of the teaching process. The continuous monitoring by the student's scores to detect lectures going out of control. Regarding the last issue, quality control can only function in a closed loop. Information about out of control lectures is fed back to the person who developed these lectures. In addition the comments by the students provide the feedback necessary to bring the lectures back into control. We have a leading SQC expert, Jane Harvill who has joined up, plus 30 statisticians on the Supercourse list to help.
Deming was able to instill quality control in Japanese Industry, which changed the face of all industry worldwide. Applying QC to epidemiology/global health translation and training could also change the face of epidemiology/global health. This approach will be very important for maintaining the best possible information and data concerning disasters. SQC will vastly improve upon the very poor information concerning data.
It is most important to compare what we are doing with the existing approaches to quality control in distance education. There is virtually no quality control. We think our approach, although not perfect is clearly better than any others.

Crossing the Digital Divide (29, published BMJ): Only 5% of the world's people have access to the Internet. We need to reach outside the US to share our science. For example, virtually all the CDC lectures could not be seen outside the US due to their lectures being too heavy. Any graphic that downloads slowly will not be looked at. Overviews/Lectures would not be possible if it takes 3-5 minutes for a picture to appear. We have developed three solutions. The first is to take the picture file (.GIF file), and reduce the amount of information using Adobe PhotoShop. A .gif slide has 1/200 less information than a PowerPoint slide. The gif files are cut and pasted into PowerPoint. The second is mirrored servers. A mirrored server is a copy of the overview/course located at another computer, but identical to our home page in Pittsburgh. It is updated every time the main overviews are updated in Pittsburgh. We have mirrored in 32 sites including Israel, Czech Republic, two in Germany, Norway, UK, the MOH in China, Hong Kong, Taipei, Japan, Australia, South Africa, Argentina, two in Brazil, Peru, Canada, the US and many others. Finally, we recently distributed over 4000 CDs. None of this has ever been done in medical information communication.

Multilingual Translation (30): (published BMJ) To advance the goals of translation and training in the US and worldwide. Overviews and lectures should be multilingual. In the US there needs to be at a minimum in English and Spanish. To develop Global Epidemiology, multilingual versions are needed.
Recently we discovered translator.go.com, and others like this which is a translator web page. One puts the name of your web page into this, and it instantaneously translates to up to 6 languages. It is not perfect, however, as a faculty member I could read only 15% of a web page that was in English. This will translate it into English, and I can understand 70%. We call this translation on demand and we plan to add this to the Supercourse. This will be especially important say there is a disaster in Los Angeles, and the information would have to be in Spanish and other languages.

Epidemiology Web Text books: These are only 2 epidemiology books available on the web. The BMJ put onto the Internet two of their well-known texts, Epidemiology for the Uninitiated, and Statistics at Square 1 for us.

Linking Articles to the Supercourse: (in press, BMJ)
The marriage between research and teaching has been loving. Information from the laboratory is translated to the classroom. It increases wisdom for future generations. Conversely, student questions sharpen our research. Disappointingly translation of information from research to class meanders. One pathway has research re-written in books, and then lectures. This is characteristic of undergraduate training. A second route has faculty creating their own lectures from original articles as in graduate teaching. Both approaches have worked well. Now they are ill equipped to handle the speed and quantity of science. Research and teaching are growing distant.
It is often not recognized that epidemiologic research completed in 2002 may not be seen in classrooms for >5 years. A second problem of writing lectures from the original literature is the information explosion. A typical introductory course has 30 topics. It is impossible for faculty to keep up with 5 areas. Students do not receive state-of-the-art lectures. Journals on the web could use an Internet lecture-library speedway circle to "whisk" the latest science from research to the classroom. This model can bridge the "translation gap" between research and teaching.
The approach merely provides PowerPoint slides with each article on the web. A simple click downloads the slides. Instead of 1-4 years before science appears in the classroom, it would be 1-4 minutes.

Lectures and Journals into Developing Countries: Most developing countries have little access to scientific information because of cost. In 1997 (in the BMJ, 31) we were the first to propose the concept of a limited access server, this is a system whereby say the Lancet could be provided to Mali, Bolivia, or Cambodia for no cost on the Internet, whereas Japan, the US and UK would have to pay. The BMJ and WHO took up our call, and this year an agreement was signed by 6 publishers to provide their journals for free to developing countries.
Our program of development is well on its way, and consists of 5 components. It must be recognized that our overall program has only been going for 4 years, and funded for the last year and a half by NIH.

Terrorism (Lancet, 33) There is a unique, but sad timing to this grant. We recognize that it is not perfect, but in many ways it is a grant that is "just-in-time" as our society is threatened. Five days before the Attack on America, we published a paper in the Lancet where we argued the need for an Internet Civil Defense (33). The concept is simple, that we can link every public health person on the web, as well as to network people in communities world wide. Instead of having 10,000 eyes from the those in public health looking out for terrorism, there could be 6 million or more eyes, which would be 3 million brains. Thus the collective vision and collective intelligence of epidemiology and public health would be broadened immensely.

Muslim Collaboration: The days after the attack, the BMJ published a letter of ours authored by a Palestinian, and a Pittsburgher (LaPorte) where we are developing an Islamic Global Health Network (34). Our countries need an epidemiology educational program in place should this happen again.

Beta-testing the course: We have pilot tested the course in two Universities in Japan. Dr. Naoko Tajima used the Supercourse for all 87 in the 3rd year medical class at perhaps the best private medical school in Japan, Jikei University. This was recently published with a full description of her experience is clickable on the Web. There were 4 lectures translated into Japanese for the students. The results were extremely positive, only 1% of the students did not want to take a course like this anymore. Only 5% said they did not like the Supercourse lectures. These were typical medical students who had not interest in epidemiology/global health before entering the course. What was most surprising for the medical students was that 74% indicated a strong interest in taking more courses in epidemiology/global health. This must be a record for medical students! The interest in the course in Jikei was so high they have not constructed a special Internet computer Laboratory, and the course has been introduced into the curriculum, and is the first Internet public health course in Japan.
The initial tests thus provided to us that there is considerable interest in the course as evidenced by the number of people accessing the course, and by epidemiologists already beta testing the lectures to students in their own countries. Moreover, the pilot testing was very positive with all three teachers planning to use the course again, the development of computer laboratories specific to the course, and excellent ratings by students known to hate epidemiology. We think this is strong evidence that it is both acceptable, and that it works.

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Conclusions

We are about to see a change in education. Faculty world wide are willing and able to share their lectures for the betterment of our students, and of students in other countries. Collaboration between researchers in Cuba and the United States will yield important sharing of information between our two countries. Moreover, it will build a bridge of understanding, sharing, health and love amoung our scientists. The supercourse is the first generation of sharing, there will be many more. We thank the scientists in Cuba and the US for working together.

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Última actualización: 16 de Mayo del 2002
Copyright © 2001 Facultad de Ciencias Médicas "Cmdte. Manuel Fajardo"
cev2002@infomed.sld.cu
 
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