Reaching out of Africa

To most people, a mosquito bite is a minor annoyance on an otherwise pleasant summer evening.

But in sub-Saharan Africa, the insect is more than a mere pest. It's a carrier of malaria, and its bite can be deadly.

Although malaria is preventable and treatable, doctors and researchers in remote areas are hampered in their efforts to combat the disease. In Ifakara, Tanzania, for example, where there are no telephones and the road out of town is impassable in the rainy season, medical personnel had a hard time learning about the latest diagnostic materials and preventive measures.

But now, thanks to the Multilateral Initiative on Malaria (MIM), researchers in Africa are being given access to a real-time, satellite-based research network that enables them to communicate with their colleagues worldwide via the Internet.

The National Library of Medicine (NLM), part of the U.S. Department of Health and Human Services, oversees and manages the network, which is currently operating in eight sites: two each in Ghana and Tanzania and four in Kenya, where the latest site, at Mbita Point, went online June 1. And there are more on the way, with a site in Uganda scheduled to be completed this month and another in Malawi set to be up and running later this year, said Mark Bennett, the main technical consultant for the malaria project.

The network consists of very small-aperture terminals (VSATs) that use a satellite dish up to 3 meters in diameter to send and receive signals, Bennett said.

"The research should go on in Africa because that's where the disease is and that's where the cases are," said Donald Lindbergh, director of NLM.

"The major obstacle for scientists in Africa has been the lack of ability to communicate with [one another] and the rest of the world and keep up-to-date with [research]. Our contribution has been to fix up the communication. Communication is a huge, huge benefit."

Malaria strikes hardest in villages like Ifakara and Amani in Tanzania because it is so difficult for the medical community to reach such isolated locations. Tanzania, on Africa's east coast, is more than twice the size of California.

"It was impossible five years ago to think about having e-mail there," said Martin Alilio, a program officer at MIM who has worked in Ifakara and Amani. "E-mail and Internet access were almost alien. Those types of areas couldn't be connected, and you had to travel 50 miles to get to the Internet." That can be a long journey when you must rely on expensive public transportation that operates on a weekly basis.

Bart Knols, senior scientist in the malaria vector program and station manager at Mbita Point, has already used the system to complete a transaction with the World Health Organization in Switzerland within an hour. Without the network, it would have taken at least three weeks.

"This was related to a technical service agreement with WHO that I was waiting for," he said in an interview conducted via e-mail. "I sent them an e-mail, but it bounced because of a change of e-mail address," but he was able to find the correct address on the WHO Web site within minutes.

"As it was, the guy in Geneva was actually signing the agreement when my e-mail came in," Knols said. "He decided to attach the agreement and return it straight away by e-mail. We signed the contract and faxed it back to him. All was over within an hour."

Knols said that without the network, it would have taken at least 10 days for postal mail to arrive in Nairobi and another week for someone to travel to bring the letter to Mbita Point. Then, because the letter was addressed to one of his students, whom the mailman in Nairobi did not know, "the letter could have ended up in the "unknown' mailbox, and things would have been delayed further.

"Now, we are looking at a quick release and transfer of the funds, and my student can continue," Knols said.

Large generators provide the power at Mbita Point because the nearest power grid is 50 kilometers away, and the "phone lines were, and still are, a nightmare."

The Mbita Point researchers are also using their VSAT to find funding opportunities on the Web. Those untapped funds are now an agenda item at weekly senior staff meetings.

"The first time we did this, we came up with three new possible sources of funding," Knols said. "My people are now writing letters of intent and proposals [for programs] that we wouldn't even [have known] about a couple of weeks ago."

They can also download journal articles as PDF files. A library of the files has been established and made accessible to all staff members.

Researchers thrive on information, and the need for fast, reliable communication is growing. "The whole idea of information movement is different," Alilio said. "Information is power, and you need information to survive in the world now."

But survival used to be much more difficult for the malaria researchers in Africa. Access to timely research information was severely limited. Amani only has one library that carries just four journals, and there is no guarantee that those will be up-to-date.

Now, MIM researchers can access any journal in the world that is online,and if something is not available in electronic form, they can send an e-mail message to a colleague in London, at NLM or anywhere else and have it sent,Alilio said.

Being connected to the Internet can also relieve the sense of social isolation that affects many researchers. With no telephone service and no transportation during the rainy season, scientists felt cut off from the world, with no idea whether their work was having an impact or whether they were duplicating an effort being done elsewhere.

"You feel like you're missing a lot, even if you're not," Alilio said. "You're sealed in there, and all you can do is hope the rain will stop....There's no phone and no mail. The difference now is that you don't depend on phone lines. Rain or shine, you can access information. The weather hasn't changed. What has changed over time is the information, the level of activity and the people's confidence is using it."

The system provides 768 kilobits/sec of outbound bandwidth that is shared by the sites, and each location has a minimum dedicated link to the backbone of 32 kilobits/sec. That may not seem like a lot, but it's enough to support 25 people per site using the Internet at any one time, Bennett said.

The VSATs and connectivity are supplied by Redwing Satellite Solutions Ltd. near London, which has access to three telecommunications satellites: Intelsats 705 and 801 and Eutelsat II-F2.

That access enables the company to provide services throughout Africa, Europe, Latin America, most of the Middle East and parts of North America.

It costs about $40,000 to establish each African site, and the monthly fee for the satellite link is about $2,000.

Alilio said it is difficult to determine how information technology will ultimately affect malaria mortality rates in Africa, but when doctors and other health care providers use MIM or similar systems, that's when researchers can "actually count the number of lives saved."

Knols said one particularly valuable aspect of the network is that it enables researchers within Africa to share information. "We collaborate closely with centers in Tanzania and Mali, but apart from some difficult chains we created via the old e-mail systems, we never got far," he said.

"The net result of this is...that each of the groups out here was communicating with their partners in Europe/USA, but were simply unaware of what was going on in their neighboring country. That will change."

Vital to making that change occur is building up a "critical mass" of experts in Africa who not only have access to the system, but also are comfortable and confident using it, Alilio said.

"In some places, computers are available and people do not use them. We have to get people confident with the technology," he said. "A researcher might have a perfect [diagnosis] for malaria, but if a doctor looking for a diagnostic tool doesn't have the information," the solution and the patient are lost.

"People with e-mail are now reliant on it, and the demand and need are there now," Alilio said. "There is still homework to be done...but as the system grows up and people do use it, you'll start seeing a major change—and it is going to be a major one."

Beyond sharing research, the system will also help promote malaria control strategies, such as the use of bed netting, Knols said. "The system will be good to train more people in setting up such programs. Likewise, there is a great shortage of qualified personnel in developing countries that can practice malaria control—even within the existing structures. The system may find its value in rapidly increasing that number."

Julia Royall, a special expert in the international program at NLM, said there are about 700 researchers using the African system, ranging from about 250 users at the largest site to about 30 at the smallest.

The MIM system pays for itself through partnerships, grants and alliances, but NLM "oversees and manages all the sites and the people.

"This system is making collegial communication possible," Royall said. "It's not just a way for people here to tell people in Africa what to do. They work together. The technology, just by being there, has really leveled the playing field."