EDITORIALS

bureaucrats, to develop national policies for public and environmental health which might bring the fractured and disparate approaches to these matters into a more harmonious arrangement and define where and how the Commonwealth might add value to them.

But over the last five, perhaps more, years, the adequacy of Medicare to provide universal access to needed care has declined. As well, the contribution of private dollars to meeting the costs of health care has increased to the point where now about one third of the $35 billion spent on health care each year come from private pockets, and the revenue raised through the Medicare levy approximates that raised through private health insurance. The copay- ments required b y the Pharmaceutical Benefits Scheme have risen to the point where they now exceed, in some cases, the acrossthecounter price of the same products in the United States. These erosions of the universality of Medicare were recog- nised and legitimated in a way that puzzled Medicare’s ‘true believers’ in the proposals put by Labor in the recent election to subsidise, dollar for dollar, the private spending of families on non- Medicare services.

The decline in adequacy of Medicare has been the experience also of the providers of health. The recently elected Labor government in New South Wales was in the weird position to make the reduc- tion of public hospital waiting lists-in many respects a federal issue-its own, with its commit- ment to reduce waiting lists for elective surgery by 50 per cent during its first year in office. The failure to retain and develop the original concept of Medicare has been seen by many to be a most unfor- tunate ideological failure of Labor governments in the past few years. The relatively recent loss from the federal bureaucracy of Mr Alan Bansemer-the Henry Kissinger of the Medicare agreements between the Commonwealth and the states and ter- ritories-may well explain some of this amnesia about the real purpose of Medicare. The strange symmetry of the Labor and Liberal policies with regard to health care financing at the recent federal election was further evidence of this drift of Medicare away from its ethical foundations and con- cern for universal access to all necessary care.

This evidence of loss of vision and traction in rela- tion to Medicare aside, there is a natural apprehen- sion among the public health community, because of the growth of public health in the past decade, about the change of government and its conse- quences for public health.

The Coalition’s history of criticism of Medicare and absurd belief in the superiority of unmanaged private health insurance and hospitals cannot read- ily be forgotten, but these concerns may prove to be misplaced. While the Coalition clearly has an agenda for reform of industrial relations and deficit reduction, its health policy (elaborated in more detail than any health policy by either party in the history of Australian federal politics) contains much to reassure the public health community that its concerns are shared, and there has been progress in Coalition thinking and values in recent years in rela- tion to the values that underpin Medicare, Medicare itself and the broader issues of public health.

Most of the Coalition’s public health proposals were contained in the Health t h r m g h t hfe docu- ment. The broad framework is unexceptionable: Acheson’s definition of public health (the art and science of the prevention of illness and the promo- tion of health through the organised efforts of soci- ety) is used, as indeed it is by the Public Health Association when we are in action and in commu- nicative (rather than mystical and elliptical) mode. There is a commitment to some specific projects, which, while rather too medical for some (folic acid for prepregnant mothersto-be; a national action plan for diabetes mellitus), at least demonstrates that the new minister, Dr Michael Wooldridge, is quite capable of thinking constructively and care- fully about health from a public health perspective. Immunisation (a major policy focus for PHA) , youth suicide (likewise), a ‘healthy seniors’ initiative, an additional $1 million for public health research through the National Health and Medical Research Council, are all canvassed. Perhaps most interesting of all is the promise to consider the establishment of an interministerial council to explore injury reduc- tion, along the lines of the Ontario Premier’s Council on Health.

Dr Wooldridge’s appointment to the health min- istry is welcome. Others whose names were men- tioned in relation to this portfolio have established records, which, whatever their current conversion- dispositions, would be seen by the public health community as serious risk factors.

The temptation to Dr Wooldridge will be to so immerse himself in the details of his new portfolio that he rapidly loses sight of the big picture. Health care financing policy has the capacity easily to over- whelm new ministers (and old) by its complexity, volume and spaghetti-like quality. By way of a pre- ventive manoeuvre, PHA stands ready to work with Dr Wooldridge on big-picture issues that would advance the health of the nation. Unlike some other special interest groups, who will be on his doorstep, blue-suited and smiling, flogging their spaghetti cut- lery, we can guarantee to help him keep, and develop, the vision he has begun to articulate in Health throughout life.

Stephen Leeder Presdent

Public Health Association of Australia

Not surfing, wading-testing the water in the Internet Most university academics in Australia have had access to electronic mail (e-mail) services on the Internet for nearly a decade, but many public health practitioners have only recently become aware of this important communication technology. Until recently, the only convenient way for someone work- ing for a health department to obtain access to e- mail was through a commercial private e-mail service (commonly called a commercial online ser- vice) such as MCIMail or Compuserve. By about 1990, MCIMail, Compuserve and other private com-

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mercial e-mail networks developed ‘gateway’ con- nections which allowed subscribers to send and receive Internet messages.

My interlest in possible public health usage of the Internet began in 1991 when I coordinated the response tct two outbreaks of meningococcal disease in Western Australia. With the help of colleagues, I had developed a portfolio of protocols, draft press releases, and draft letters to school principals and local general practitioners etc. to deal with the out- break. When a suspected meningococcal outbreak was being imanaged in another state a few months later, the public health physician involved contacted me to get access to my protocol collection. What I was able to provide was a small library of model doc- uments for modification for the local situation. I offered to send them by e-mail since access to elec- tronic copy would save valuable time. No e-mail con- tact was available, so I faxed the material, but it alerted me to the potential value of making impor- tant publtc health protocols available on the Internet.

I tried to work out how to set up a system that would provide information of this type, using stan- dard e-mail services, but found the complexities of file server computers and Internet file transfer to be beyond me Fortunately, a new and much friendlier technological solution came into being at that time; it was a special Internet service called the World Wide Web.

The Web provides the ideal technology for any- one who wants to make complicated information available 011 demand. The Web is a part of the Internet and it is useful to distinguish their charac- teristics and capabilities. The Internet is a network of computt:r communication networks that use a common caimmunications protocol (TCP/IP) and a standard addressing system (p. 26) . I The services available on the Internet are e-mail, transfer of large files from one computer to another, and Telnet, a method for dialing up distant computers to interact with them. E-mail is a system for sending messages from one computer to another. The recipient finds the message by connecting to his or her electronic ‘mail box’ iin a large local computer known as an Internet server. The World Wide Web uses special protocols (SLIP/PPP, for rapid transfer of large files) and hypertext presentation to give Internet users easy access to stored files of all kmds, including text, graphics, photographs, video and sound. The Web provides a way of avoiding complicated techni- cal procedures for file transfer. The key develop ment that made the Web accessible to ordinary users was the release in 1993 of a friendly browser p r e gram, (Mosaic) and a significant and timely fall in the cost of SLIP/PPP connections (access to these protocols is essential for full Web usage). Since then the growth of the Web has been exponential.

However, before saying any more optimistic things about the World Wide Web, I want to get in a few caveats, First of all, the most useful feature of the Internet for many public health professionals is e-mail, not the Web, and I believe this will remain the case for the immediate future. Secondly, access to Internet e-mail is fast, cheap and simple, whereas Web usage (‘surfing the Web’) is presently timecon-

suming, expensive, and poten tially misleading because of the huge amounts of useless, inaccurate, and out-of-date information that it contains. You can use Internet e-mail with a very old second-hand per- sonal computer, a slow modem, and a cheap online service subscription-all of which could cost you less than $500 in the first year, whereas satisfactory Web usage requires a fast new computer, a very fast modem (perhaps $5000 in the first year for equip ment alone), plus full-service Internet connection time. Having aired some of my scepticism, I can now tell you how useful the Web is.

The Web is an extraordinary communications technology that offers a great deal to information driven professions like public health. Its main advan- tage is its ability to present large collections of text, graphics, photographs and video in a hierarchically organised fashion that is easy to interrogate with browser programs like Mosaic (introduced in 1993) and Netscape (the current market leader). A second major advantage is that it is easy to update informa- tion offered on the Web; this makes it particularly valuable to public health organisations that want to make available the latest information, such as in the area of infectious disease control. A third feature that the Web is that it includes on-screen formatting, which means that ‘it looks like a magazine instead of a typewritten document’ (p. 461).’

Organisations that develop their own Web sites (called a ‘home page’) can reach an increasing number of readers with no associated increase in publishing costs; it allows them to make frequent additions or corrections to documents at very low cost; and it gives them access to colour publishing (and video and sound if they need it) at minimal extra cost. Of course, all of these advantages apply only if their clients have Internet connections and actually use it to gain access to the home page.

Australian developments The Public Health Association took the lead over two years ago in arranging for access to the Internet, via the Pegasus system, on a trial basis, for interested public health practitioner members. While techne logcal developments have overtaken this experi- ment, it meant that a significant group of non- university-based PHA members gained experience in Internet use. The Royal Australasian College of Physicians (which includes the Faculty of Public Health Medicine) is embarking on a bold develop ment with a commercial communication company (Med-EServ) to provide secure e-mail and Internet access for its administration and its members. Most Australian health departments have already estab lished, or are in the process of setting up, e-mail net- works that have Internet access.

A number of public health organisations have established Web sites. These include the Common- wealth health department (http://www.health. gov.au) and the National Injury Surveillance Unit (http://www.nisu.flinders.edu.au/welcome.html) . The Communicable Disease Intelligence journal will soon be available on the Commonwealth health department Web site.

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How to get on to the Internet In theory, all you need is a PC or Mac computer, a modem, and a subscription to an Internet provider; in practice, things are a little more complicated. The experience of a United Kingdom doctor in having to abandon not one but four Internet providers because they were not functional is a reminder that the assurances of some enthusiasts about ease of access may be overoptimistic.*Vs You can find local Internet providers by looking up the phone book or by looking at the advertisements in the computer sections of major newspapers. Internet access will cost about $200 to $300 per year, but this figure could be much higher if you use the Web exten- sively.

What public health professionals can get out of the Internet E-mail I believe that e-mail, still the lifeblood of the Internet, will change your professional communica- tion for ever. E-mail offers a wide range of advan- tages to health professional^.^ Even if you do not have World Wide Web access, you can use e-mail to reach listservers, transfer files, and even to interro- gate other computers (pp. 239-72).’

Listservers and newsgn3ups Joining a list (an automatic mailing list dedicated to a particular subject) is a convenient way of partic- ipating in ongoing e-mail discussion of current issues in your areas of interest. Pallen provides a use- ful table of lists of medical and public health impor-

Newsgroups are online discussion forums that can be accessed conveniently via a Web browser program. A directory of medical newsgroups can be found at the Web address http://world-health.net/ newsgrou.html.

Electronic journals A number of journals of public health importance are now accessible via the Web and the full text of many (but not all) articles can be retrieved from the Web. These include the Journal of Epdeniology and Community Health, British Medical Journal, AIDS I n f m t w n Newsletter, Journal of the American Medical Associatwn, Communicable Disease Rtprt, and Mortal$ and Morbidib Weekly Reports. The addresses for these can be obtained quickly using the search function of Netscape or Mosaic.

To find out more about the different services available on the Internet, you can read a brief description by Millman, Lee and Kealy, or a series of articles by Pallen, or a comprehensive guide book such as that of Gilster.’~”’ Pallen’s excellent series of

articles on the Internet for medical practitioners can be obtained from the 3rittkh Medical Journal home page on the Web (http://www.bmj.com/bmj)

Setting up your own Web site In a recent article in Nmswe-ek, Steven Levy claimed that ‘If you didn’t start a Web site in 1995, your sta- tus may be endangered’.8 To support this, he quoted Kevin Kelly of Wired magazine saying that the Web was doubling in size every 53 days8 Even if you are not so worried about your ‘status’ as a hip commu- nications user, it is a timely reminder that many organisations should consider the advantages of establishing a Web site as soon as possible. To do this you need a server computer and an ability to use hypertext markup language (pp. 461-76) .z

Is the Internet elitist? Most definitely1 That is one of the reasons commer- cial enterprises are so interested in reaching Internet users, who are typically university educated, with good jobs and enough disposable income to buy expensive computer hardware and Internet access subscriptions. However, in the public health area, the potentially democratising effect of the Internet is being exploited successfully. The American Centers for Disease Control and Pre- vention (CDC) are leading an international move- ment to link public health professionals in the devel- oping world with cheap but adequate computers and free Internet e-mail access. This will provide unprecedented access to global information resources for many regions that in the past had few books and no journals. By joining the Internet, you can support this important move towards equitable distribution of public health information as well as advancing your own access to information and pro- fessional contact. Even if it is not yet time for you to start surfing the Web, it certainly is time to get your feet wet with Internet e-mail.

Charles Watson Faculty of Health and Behuvimral Scienus

Universib of Wollrgmg

References 1. 2.

3.

4. 5. 6. 7.

8.

Gilster P. ”he new Intenet navigatm. New York Wiley, 1995. David TJ. Accessing the Internet is far from easy. [letter] BMJ1995; 312: 55. Millman A, Lee N, Kealy K, The Internet. BMJ 1995; 311: 440-3. Pallen M. Electronic mail. BMJ1995; 811: 1487-90. Pallen M. Introducing the Internet. BMJ1995; 311: 1422-4. Pallen M. The world wide web. BMJ1995; 311: 1552-6. Pallen M. Logging in, fetching files, reading news. BMJ1995; 311: 162630. Levy S. Internet 95. Bullch’n w’th News& 26 Dec 1995: 112-15.

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