I Reunión de Coordinación Regional de la BVS

The VHL and the democratization of the knowledge and information in health

Alberto Pellegrini Filho

It is for me a reason of great satisfaction to be again together with you after a year and a half since our last encounter in Costa Rica. The satisfaction is yet greater because we will have the opportunity to discuss our accomplishments in the implementation of our joint project, the Virtual Health Library (VHL). During this presentation I will discuss with you how I see the contribution of the VHL for the democratization of the knowledge and information in health. I will also present the proposal of a project that attempts to take advantage of this potential of the VHL.

I believe that it is worthwhile in the first place to conceptualize what we understand by democratization of the knowledge and the information. In a stricter and quite widespread conception, the democratization of the knowledge would be understood simply as the transfer or dissemination of the scientific knowledge to the lay public. This is not the concept that we will adopt in this talk, since we think that democratization is not simply expanding the access or the number of receptors of a given message, nor we consider the scientific knowledge as the only form of knowledge of nature and the society.

Democracy is not only a set of rules that permit the free and pacific living together among the individuals in a society, but also and mainly, the form of government that better than any other permits the full development of the human person. Unfortunately in our societies there are still many and different threats to the full exercise of democracy.

For Bobbio, in democracy all individuals are equally free, but this equality requires the full exercise of the social rights, particularly the essential ones, such as education, health and work, that are those which make possible the exercise of the rights of freedom. We know that in our Region there are increasing numbers of individuals and groups that do not enjoy these rights, which prevents them to participate fully in the democratic life.

But there are also other types of threats. For Lasch, one of the major problems that currently threaten the essence of democracy is the exclusion of the ordinary citizen of the public debate. More and more, all that count is the opinion of experts. It is not expected that ordinary people know about something, since the value of the knowledge based on experience is not recognized. The idea that the power of the elite derives from its superior knowledge and intelligence prevails. This idea installs the power of the meritocracy and sterilizes the public debate.

This is particularly troubling, since democracy is fueled by a vigorous exchange of ideas and opinions. For this exchange to occur it is necessary to recover and develop public spaces where the citizens meet as equals. The new communication technologies create new opportunities for the creation of these interactive spaces.

Levy considers that these technologies, particularly the Internet, open the possibility for the creation of what he calls the "knowledge space", where everybody can participate. The other person one can find in this space is not someone who is there because of his/her profession or social status, but because he/she is the carrier of a set of knowledge constructed throughout his/her experiences. In the "knowledge space" there is not separation of territories controlled authoritatively or bureaucratically as it still occurs in some institutions, even in some universities, which stifles creativity and innovation and ends up preventing the flourishing and dissemination of intelligence.

The creation of the "knowledge space" represents a new humanism, based on the principle that no one knows everything and anybody knows something. Levy suggests that this possibility of constructing a collective thinking permits the transformation of the singular idea of the Cartesian cogito "I think" for the plural cogitamus, or "we think."

All this has profound implications for the construction of a true democracy, since it permits the creation of what Levy calls a "virtual ágora", integrated in the community, that facilitates a collective effort for analysis of problems, decision-making, and evaluation of policies and interventions. Beyond the formal representative democracy, where the participation in political life usually is limited to an effect of mass that adds weight to a party or a person, this new democratic space permits a more qualitative participation where everybody can raise issues and formulate proposals for the resolution of common problems.

The role of the "virtual ágora" is not to make decisions in the name of the people, but to produce a mechanism of collective participation that contributes significantly for the strengthening of civil society or, in order to utilize a more recent concept, the strengthening of the social capital. According to Kawachi, the social capital is the group of elements of social organization such as civic participation, norms of reciprocity and trust in the other, which are elements that facilitate cooperation for mutual profit. Contrary to the physical or human capital that are private goods, the social capital is a public good, created by social relations. The reduction of the levels of social cohesion caused particularly by the growing gap between rich and poor has been leading to a downgrading of the social capital. This can be one of the ways by which the increase of income inequality affects the levels of morbidity and mortality.

Although what we understand by democratization of knowledge goes beyond the dissemination of the scientific knowledge, do not rule out this dimension. As we know, what characterizes the scientific knowledge is the systematic process of its production, the scientific research. Almeida Filho describes the several phases of this process, beginning by the observation, that is turned into data, subsequently processed to produce information, which finally emerges from this peculiar productive process as scientific knowledge. The transformation of information into knowledge is made through processes of synthesis and articulation in some conceptual framework, which makes it possible to liberate the information from the immediate objects to which it was referred and to locate it in a more general context, that allows us to understand other contexts and new situations.

For the study of complex phenomena Science has recoursed to the isolation and reduction of these phenomena to their simplest elements. Through the isolation, it promotes the separation of the objects among themselves, of their environment, and of the observer while simultaneously isolating the disciplines and, according to Morin, isolating Science itself from the society. In addition, through reductionism, Science tries to identify in what is diverse and multiple what is elementary and quantifiable. However, in that process, as the same Morin warns to us, "it ends up recognizing as reality not the totalities, but the elements, not the qualities, but the measures and not the beings and entities, but the formalized enunciations"

It is necessary to recognize that the simplification of complex phenomena through reductionism and mathematical analytical models were turned into the more powerful instruments of modern Science, but have also generated the drawbacks of super-specialization, cloistering and fragmentation of knowledge.

For Wilson the great challenge that today all branches of Science face is to surpass this fragmentation of knowledge, that does not reflect the real world, and to promote the reconstruction of the constituent parts of complex systems. In fact, the search for solutions to the problems that concern us and that threaten sustainable development, such as violence, inequity, poverty, deterioration of the environment and so many others, requires the integration of knowledge produced by natural sciences with social sciences and even more so, with humanities.

For Morin it is necessary to introduce the humanistic culture into the scientific culture and the scientific culture into the humanistic culture, in order to establish a dialogue that modifies both. For him the culture is the meeting of what is separate, it is communication between what is scattered in hermetic compartments. "To be cult is not to remain encompassed in the specialization, nor to be limited by generic ideas unrelated to particular and concrete knowledge. Being cult is to be capable of placing information and knowledge in the context that gives them their sense; it is to be capable of placing them in the global reality of which they are part. It is to be capable of developing a knowledge that feeds the knowledge of the parts with the knowledge of the totality and the knowledge of the totality with the knowledge of the parts. It is to be capable of anticipating, to consider the possibilities, the risks, and the opportunities. The culture is in short what helps the spirit to provide a context, to generalize and to anticipate."

We are convinced that the "knowledge space" made viable by the new technologies of communication - upon permitting everybody to navigate by universes of problems and meanings, without territories and borders - permits an enormous advance in this regard. The great challenge is to create the conditions that allow these technologies to fulfill their potential. According to the report of a panel on interactive communication and health convened by the Department of Health and Human Services of the United States, the percentage of residences with personal computers in this country grew from 8% in 1984 to 45% in 1998. In 1998 more than 70 million adults in the USA were active users of the Internet. Less than a year after MEDLINE became free, the number of bibliographic research grew 10 times and 30% of the users belong to the general public.

In the preface of a report of the Club of Rome known as "The net"" it is estimated that the near 100 million current users of the Internet will grow to more than one billion at some time in the next decade. However, an obvious concern goes through the minds of all us: What about the unplugged?. Will it be that a new digital inequity that would aggravate all the other inequities is being created?. According to the same Club of Rome report, we are dealing with a new human communication medium capable to promote a change in our economic and social relations of comparable magnitude, or still higher, than the appearance of the printing in the century XV that, as we know, changed the culture, the science, the power, the economic structures and the very tissue of society. As it tends to occur with every change of this magnitude, we are seeing manifestations of confusion and uncertainty, as well as skepticism and resistances on the part of those that consider that they have something to lose.

As it happened with the printing, the telephone, or the automobile when they were invented, it is very difficult to foresee in this moment all the implications of the change that we are living. The rapid rate of these communication technologies advancements and the fast and significant reduction of the costs of services and products, allow us to foresee that they will have a broad dissemination, affecting everybody, directly or indirectly, as it occurred with the other aforementioned technological leaps.

However, although we believe that shortly we will see a broad and generalized access to these technologies, the concern over the inequity is very legitimate. Even in the United States an important gap is observed. More than 60% of the people with university degree in this country use the Internet, while this figure is less than 7% for those with elementary or lower education. Households with income higher than 75,000 dollars per year are 9 times more likely to have a computer and 20 times more likely to have access to Internet than those of lower income. White people have greater possibilities of access to Internet from their houses than the African Americans and the Hispanics have from any place, including the work. The inhabitants of the urban areas are two times more likely to have access to the Internet in comparison with the ones that live in the rural areas with the same income.

In Latin America the use of the Internet is growing faster than in any other part of the world. Between 1995 and 1997 there was a growth close to 800% in the use of the Internet in the Region, which corresponds to almost double that of the average growth at world level. However, 90% of the Latin American users of the Internet come from the upper or middle-upper social classes.

According to Eng, the causes responsible for the differences of access to the Internet are practically the same for less access to health care: cost, geographical barriers, illiteracy, disabilities, cultural barriers and other factors related to the ability of people to use services adequately and effectively. Eng classifies the barriers of access in three groups: those related to the infrastructure and "hardware", those related with the type of information and "software" and finally the characteristics of the non-users.

In order to overcome these barriers, he suggests a series of strategies that try to expand the access to the information and on-line communication in residences and public places. Among such strategies he emphasizes the development of programs that take into account the diversity of potential users, support for research on subjects related to the problem of the access, quality assurance of the information, training of users and of intermediaries (among them the non-governmental community organizations), and finally the integration of the concept of universal access to the information as part of the process of health planning.

The international organizations of technical cooperation for development have an enormous potential to cooperate in the implementation of these and other strategies. In fact, the UNDP has recently launched a website known as Netaid to utilize the Internet’s potential to combat the poverty in developing countries. The site becomes a channel of communication between, on one hand, foundations, groups of volunteers, corporations and individuals interested in contributing to the combat of poverty in developing countries and, on the other hand, the inhabitants of these countries that need support to obtain opportunities for education, to find markets for their products, to establish contacts with medical health care providers and other needs. The initiative seeks to promote the empowerment of the poor through the information, based on the fact that the groups with good connections take tremendous advantages in relation to the poor without these connections, whose voices and concerns are not present in the global conversation. In order to promote the broad access of those groups to the Internet the UNDP is creating in its offices and of other agencies of United Nations, as well as at schools and churches, information centers where the local public can access to NetAid.

As PAHO is concerned, during our almost one hundred years of existence the management of the knowledge has been the principal orientation of our activities. In the past this management of the knowledge was practically synonymous of the transmission of the knowledge incorporated in our own staff members and more recently through the collection, analysis, and distribution of information and publications. The management of knowledge continues to be the pivotal axis of our activities. However, in order to be consistent with everything that we are stating, the management of knowledge today means basically the creation of environments and platforms that permit a broad range of interactions between various actors for the production and circulation of information and knowledge of different types. This should help break away from the traditional process of definition of agendas and policies in reduced circles of decision, contributing in the final analysis to an effective democratization of the knowledge and information.

The Virtual Health Library (VHL) that we are engaged to construct is exactly a platform of this type. During this week we will have the opportunity to know the progress that we are making to carry out the enormous potential that it represents.

In order to take advantage of this potential we are proposing a project with the suggestive name of DECIDES, which is the Spanish acronym for Democratizing the Knowledge and the Information for the Right to Health.

This project is based on the conviction that the conquest of the right to health depends to a great extent on the political action of the members of a given society. One of the basic requirements for this action to be effective in the transformation of structures and behavior is the empowerment of the citizens through access to information and knowledge of the determinants of health and their possible solutions.

DECIDES tries to take advantage of the cooperation mechanisms existing in the area of the MERCOSUR and has basically two components. The first refers to the generation and strengthening of virtual networks to multiply interactions and collaboration between researchers, health professionals, citizens, journalists, politicians, and other actors, facilitating the creation of groups of debate and discussion, virtual research groups, programs for exchange and training of researchers, etc.

DECIDES creates the conditions for the generation and proliferation of various networks, but will initially establish two of them. One, called Interactive Agenda of Research, represents a totally different way of supporting the formulation of R&D policies, the definition of priorities, and the planning and monitoring of research projects, through the creation on the Web of an interactive space of consultation between different actors. It will contribute to make R&D policies effectively public policies, submitted to public debate. The other network tries to promote and support the exchange of researchers in relevant areas for the public health of the Region, through the establishment of networks of cooperation among scientific institutions of MERCOSUR countries.

For the development of the second component, DECIDES will select 6 cities in MERCOSUR countries committed to implementing new approaches to promotion of health and health services management, based on solid scientific evidence, on broad social participation, and on the intensive use of new technologies. These cities will be articulated in networks, taking advantage of the mechanisms already existing in the Project Mercociudades. This second component includes organization of health information in an adequate format to reach different types of users, training of professionals and members of the community for the production and dissemination of this information, for the utilization of electronic databases, and for the mastering of modern technologies of communication and information. It includes also the creation of opportunities of access and training of the public in the use of the Internet at schools, sites of work and other community spaces.

The VHL will be the platform of support for all these activities of DECIDES and I invite you to join efforts to make this project deserve the name it has.

In the IV CRICS in Costa Rica Dr. Bezanson warned us that the experience of this century teaches us that the new technologies bring large promises, but also risks and that we cannot continue to believe in the inevitability of the human development and in the eradication of poverty and misery simply through the progress in science and technology. However, we also learn that this progress creates enormous opportunities if they are accompanied by a diversified and broad range of social innovations.

The challenge is, therefore, double: to develop, interpret, and adapt new knowledge and technologies and, at the same time, to create democratic mechanisms for consensus-building to make it possible that this capacity contributes in an equitable way to the improvement of the health of the peoples of the region.

Levy says that our culture helps us imagine the unimaginable, the science makes what is impossible to become possible, the technology converts what is possible into feasible, and it is the action that turns what is feasible into a fact. We have the imagination, the science and the technology to help us construct together this feasible utopia of a VHL that promotes equity. Daring adapt a phrase of Bernard Shaw, I would finalize saying that if we ultimately fail to reach what we want, it is preferable that it is because the smallness of the reality in contrast to the greatness of our dreams and not the contrary.

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