Two patients walk into a clinic in China with unusual symptoms…the next day the clinic sees 6 patients with these same strange symptoms.  A local newspaper picks up the story and starts to report on this strange illness.  Within a week, news blurbs in Toronto and Vietnam are reporting the same strange symptoms.  The world is unaware that a virus is poised to explode into a world-stopping pandemic.  It is in this critical period of early infection that the world has a chance to stop a major disaster in its tracks, but nobody even knows about it.  Nobody except for a few people in Canada with a computer scanning the web for just this instance.

A New Model of Information Sharing

The Global Public Health Intelligence Network (GPHIN) identified a novel virus 3 months before the World Health Organization (WHO) even announces it, and the world takes action to stop the spread of this new threat.  This is the story of the SARS outbreak in 2003.  Even though China was hesitant to announce a flu outbreak to the WHO, a group of surveillance officials had picked up the reports and alerted the world to a possible disaster.  SARS should have spread worldwide and caused havoc, shutting down travel and global commerce; but it was the pandemic that never was.

This is the perfect example of how to put the power of information into the hands of the people.  News reports from local sources tipped off a webcrawling computer that something was amiss.  There was no need for a massive organization with thousands of foot soldiers monitoring clinics around the world to alert us to this problem, in fact that system was shown to be far inadequate to attack the virus at an early chokepoint.

Fast forward to today where a novel flu virus jumped from Mexico to every continent in a two month span.  At the same time an unusual phenomenon arose in Iran where Twitter, a social media outlet became the dominant medium for the spread of information.  It only takes a small leap of the imagination to combine these two events, along with the lessons learned from early detection in the SARS epidemic to imagine a system where all the medical personnel around the world become a surveillance agency for the arrival of a new pandemic-potential outbreak.

Twitter has shown both its uses and weaknesses as a reporting platform since the unrest over the Iranian elections began.  It’s biggest strength is the inherent nature of social media, everyone who has access to the internet becomes a node of information, capable of contributing to a growing body of knowledge.  In a short amount of time a single event (the tragic murder of Neda for example) can storm into the consciousness of the public and the mainstream media (MSM).  Being able to contribute to this globally searchable body of knowledge only requires an internet connection or a phone capable of communicating with the Twitter platform.  Not only can anyone contribute to this type of social media, but the information is accessible by all of those who are a part of the network, the model of information sharing has shifted from a funnel to an interconnected web with all nodes equally able to share and uptake the contents of the network.

Surveillance 2.0

The medical community should take notice of this trend in information sharing.  The power of social media to synthesize and spread information presents us with an incredible opportunity to harness the world as our surveillance team.  By connecting physicians, epidemiologists, and surveillance communities we have a chance to produce an unprecedented world-wide organization to monitor the health of the world.  GPHIN has already produced the evidence that the web can alert the world to a nascent threat.  It is now our charge to take this evidence and build a program to harness the power of social media for public health concerns.  Observing the power of this new platform should impel us to create this type of network, it amounts to negligence to ignore the evidence for the life-saving power this new model of information sharing brings.

Web 2.0 and Medicine 2.0 have been touted lately as being the future of interaction between people.  I have followed Bora and Berci as they promote the usefulness of these new modes of communication and been intrigued by the power of social interaction on the internet.

It is now time to harness these same characteristics to build a surveillance network to supplement “Surveillance 2.0“, which can connect all of those involved in to globally monitor the signs of a new outbreak.

The SARS outbreak and the new swine flu outbreak can give us a model of how this information can work.  SARS was picked up early by GPHIN and that organization most likely saved the world from a massive slowdown in global production and travel by early surveillance of the web.  The swine flu on the other hand escaped early detection and spread throughout the globe a matter of weeks to months.  Looking closer at the swine flu outbreak we can identify the points where establishing a chokepoint on the disease could have possibly slowed or stopped global transmission.  On March 18 the Federal District of Mexico began reporting an unusual amount of “late-season” flu, but it was not until a month later, on April 21 that the CDC alerted the world to the outbreak.  One can imagine a situation where the physicians around Mexico log onto a network and begin reporting anomalies in flu cases, this information is accessible to everyone on the network and an investigation can begin to take place.  This wouldn’t have guaranteed the isolation of swine flu but it would have created a point where the world could decide whether to take action to stop the spread of the disease.

It is time to build this network, not just a group of computers crawling the web in every language and in every country, but a social network where members of the health community can deposit and analyze reports from around the world.  If there is enough of a disturbance in the equilibrium of the system then it could be possible to mobilize action and alert the world in a more timely manner of a public health threat.

Constructing A Social Network For Public Health

Twitter has many uses but global public health surveillance is not one of them.  It is an open social platform for unspecified use which is flooded daily by millions of “tweets” of every subject under the sun.  In order to filter out the noise and guarantee the sanctity of the information presented there needs to be a dedicated network for surveillance.  The construction of the network needs to have clearly defined parameters of use built upon the model twitter has presented.  Users can create “hashtags” to identify the area of the world they are in and the subject of the message they are sending so a global database can be filtered by multiple criterion.

An important aspect of building this network is getting a large portion of the global health community to participate and share information.  As the old (MSM, top down) is supplanted by the new (social media, bottom up) it is important to incorporate those who don’t participate in the newer modes of communication.  The power of the of scheme arises from the number of users and their willingness to participate in the system so it is important to get a large number of users.  For the purposes of pandemic surveillance epidemiologists, fluologists, virologists, public health monitors, and a range of other users need to be incorporated into the system.  A crucial aspect is to get the participation of the large surveillance bodies as well, the WHO needs to participate as they are the organization who can mobilize vast amounts of money and protective measures beyond what local health care workers can.  The ability to not only share with each other, but with the conventional power structures will bring together an incredibly powerful means to monitor and react quickly.

Surveillance 2.0 will not replace the surveillance that needs to be conducted in animals as most (if not all, I’m not sure) viral diseases arise out of animals and eventually end up in the human population.  But it can supplement this surveillance, as with swine flu we have seen that not all pools of infection are being monitored as thoroughly as everyone would like.  But in case we don’t pick up on a disease before it makes the jump from animal to human host, this type of system will give us the best chance at a quick response to stop the spread of the disease before it is out of control.

Larry Brilliant has spent a career trying to wipe diseases off of the planet and he was lucky enough to see the last case of smallpox, it is possible he will see the last case of polio.  The mantra he repeats for combating these infectious diseases fits perfectly with the goal of Surveillance 2.0: early detection, early response.  This is exactly what the goal is, to harness the power of the individual to create a massive detection network, a sensor that is acutely aware of disturbances from the norm.  Local physicians who know their territory can spot anomalies early on and begin the reporting process which can easily filter into collective knowledge for the world to assess and react to.

Surveillance 2.0 Beyond Pandemics

Although pandemic emergence has captured the headlines and minds of those in the global health community there is a multitude of uses for this type of system.  If a water source becomes contaminated or a community disaster occurs it would be possible to quickly inform those in the community to watch and prepare for those coming into their clinic.  Those on the scence of a disaster (earthquake, or yesterday’s Washington DC train accident) can quickly inform their commuinty health providers of the number of people involved and the type of injuries to expect.  A good example of this was the 2008 Sichuan earthquake in China, tweets flooded from locals and informed the world of the damage, all before the US geologic survey even reported the occurence of a seismologic event.  Local hospitals can start to prepare their clinics the minute a disaster occurs for the incoming patients.

Of course the first iteration of this type of network will have its flaws, there will be false starts and frustration concerning how exactly to filter results and what constitutes a false-positive use of the system.  This should not discourage us from attempting to begin the journey of building this worldwide community of health care surveillance.  Those in genomic research have run into this problem as massive amounts of data became available and false correlations began to surface.  But I doubt any would doubt the importance of opening up the raw information to the scientific community even though it may take time to figure out just how to best utilize it.

We have an amazing opportunity, and dare I say an obligation, to engage this emerging model of information sharing in its infancy and shape it into a useful tool.  It is not enough to simply watch as the medium grows, we must engage it and mold it into a succesful model for these purposes.  It is time the global medical community open their eyes to the capability of such a system and design it to suit our needs.

I am not a player in the science or medical community by any means but good ideas can come from anywhere and I hope that if you read and agree with the ideas presented here you can share with those around you and help to make this a reality.

“He who refuses to embrace a unique opportunity loses the prize as surely as if he had failed” — William James