Maged Kamel Boulos is Editor-in-Chief of the International Journal of Health Geographics, which aims to bring to light the latest research in geospatial information systems and science, and its applications in health and healthcare. With an interdisciplinary view of the field, the journal covers findings as diverse as spatial data infrastructure, real-time geographic information systems (GIS)-enabled surveillance services, spatial epidemiology, and cyberspace mapping. Here Boulos explains how health informatics can help bring about positive health outcomes and what he thinks are the most exciting recent developments.
What is health informatics?
The knowledge, skills and tools which enable information to be collected, managed, used and shared to support the planning and delivery of healthcare, support the education of healthcare professionals and patients, and promote health. The biomedical health informatics field can be seen as a spectrum or continuum of applications and sub-disciplines, with micro-scale applications at the molecular/cellular levels (i.e. bioinformatics) at one end, and macro-scale applications dealing with whole populations at regional, country and even global levels (i.e. public health informatics) at the other end. In between these two ends, we have mainstream medical, clinical and health informatics. This deals with individual clinics, hospitals, care organisations, clinicians and patients, as well as specific clinical specialties and patient groups.
Data should flow seamlessly in this continuum of applications with outputs from one application feeding into the inputs of another. For example, aggregated individual patient and healthcare organisation data from a given geographical region forms the basis of public health informatics programmes and research in that region. Geographic information systems (GIS) help us analyse geo-coded clinical and care data in the context of location and their many other characteristics, to better understand health and disease ecology, better plan healthcare resources, and better target and optimise disease control and prevention, as well as develop health promotion programmes.
What is your specific area of research, and how did you come to this area?
My ‘playground’ lies both in public health informatics and in mainstream medical and health informatics. In public health informatics, my specific area is health geoinformatics (or geomatics). This area deals with geographic (or geospatial) information systems (GIS) in the context of health and healthcare. In mainstream medical and health informatics, I have multiple research interests, spanning social media and Ambient Assisted Living (AAL) to name just a few. The latter aims at developing tele-healthcare and mobile health (mHealth) solutions to support the independent living of older people. European populations are aging and nearly one third of European Union (EU) citizens will be over 60 by 2025.
My interest in health geoinformatics goes back to my PhD research more than 12 years ago. I pioneered a novel use of GIS to map virtual health information spaces (rather than the traditional use in mapping things on Earth). At the same time, I was working at City University London, UK, on M2DM, an EU-funded diabetes telematics project that can be seen as one of the precursors or early forms of today’s AAL applications.
What do you think are the most exciting recent developments in health geographics?
The most exciting recent developments are without doubt the results of the marriage between social media and geoinformatics. The ‘wikification of GIS by the masses’ is a phrase I coined in 2005, two years before Goodchild’s term ‘Volunteered Geographic Information’. Eight years later OpenStreetMap and Google Earth (GE) are now full-fledged, crowdsourced ‘Wikipedias of the Earth’, with millions of users contributing their own layers to Google Eearth, attaching photos, videos, notes and even three dimensional models to specific locations.
The ‘wikification of GIS by the masses’ also has many serious public and environmental health surveillance applications and an important role to play in disaster and crisis management. This is all about public empowerment, engagement and participation in health geography, and the so-called crowdmaps (or crowdsourced maps) we frequently come across these days are created and updated by large groups of citizens, for citizens. Also real-time mining of indirectly self-reported surveillance information harvested from geo-coded aggregates of Twitter and other social network feeds can offer useful data and insights about unfolding trends and emerging crowd behaviours at times of outbreaks and crises.
Is there a specific example which you think fully demonstrates the potential of using geospatial data to bring about positive health outcomes?
The best classic example remains that of John Snow. In 1854, a major cholera outbreak in London, UK, had already taken nearly 600 lives when Dr John Snow, using a hand-drawn map, showed that the source of the disease was a contaminated water pump. By plotting each known cholera case on a street map of London’s Soho district (where the outbreak took place), Snow could see that the cases occurred almost entirely among those who lived near the Broad Street water pump. This pump belonged to the Southwark and Vauxhall Water Company, which drew water polluted with London sewage from the lower Thames River. The Lambeth Water Company, which had relocated its water source to the upper Thames, escaped the contamination. Snow recommended that the handle of this pump be removed, and this simple action stopped the outbreak and proved his theory that cholera is transmitted through contaminated drinking water. People could also see on this map that cholera deaths were not confined to the area around a cemetery of plague victims and were thus convinced that the infection was not due to vapours coming from it as they first thought. By using a map to examine the geographical locations of cholera cases in relation to other features on the map (water pumps and cemeteries of plague victims), Snow was actually performing what is now known as spatial analysis, a common function of today’s GIS software.
What are the key health issues that you think health geographics can help to address?
Almost anything health and healthcare-related you can think about. The term ‘geographic information systems’ (GIS) was added to MEDLINE/PubMed MeSH (Medical Subject Headings) in 2003, and a quick PubMed search today using that term alone will give you an idea about how broad the scope of GIS is – from malaria, HIV, cancer, and diabetes, to environmental health, healthcare planning, facility accessibility and siting studies, you name it!
What are the key challenges in addressing these health issues?
Confidentiality and privacy constraints often preclude the release of disaggregate (geo-coded) clinical and other data about individuals, which limits the types and accuracy of the results of geographical health analyses. Conventional methods of anonymisation by removing address and postcode details make the data almost useless in fine-level (micro-scale) geographical analyses. Just imagine having to run the above-mentioned John Snow example without having full access to the exact addresses of all cholera cases in the Soho district. Without that data, it would be impossible to reach those conclusions and recommendations made by John Snow, which helped stop the disease and improve our understanding of its mode of transmission.
Access to individually geocoded (disaggregate) data often involves lengthy and cumbersome procedures through review boards and committees for approval (and sometimes is just not possible). This led me to develop a line of research to investigate solutions that can preserve individual health data confidentiality in micro-scale spatial analyses. We first proposed solutions using software agents (a computer program that acts on behalf of a user as an agent of sorts), and more recently developed a flexible, customisable and adaptive algorithm, which we called multidimensional point transform (MPT), as well as an associated framework, that can both be used for protecting individual data confidentiality and privacy in micro-scale analyses.
How important is open access and open data to researchers in health geographics?
Open Access has provided an unprecedented opportunity for research communities in low-income countries to access essential GIS research and results that would have otherwise remained locked behind closed subscription doors. GIS research is important for developing countries, e.g. in tackling malaria, dengue fever, HIV, environmental pollution, etc. Having access to research and results from this key area of knowledge is of prime importance in improving health, healthcare and living conditions in these countries.
In fact, the top 20 cities accessing our journal’s Facebook page as of May 2013 include several areas in low-income countries: Lagos, Nigeria; Bangkok, Krung Thep, Thailand; Yogyakarta, Indonesia; Curitiba, Parana, Brazil; and Mexico City, Distrito Federal, Mexico. Developing countries making it to our top accesses list include: Indonesia, Thailand, Egypt, Nigeria, Brazil, Pakistan, India, Mexico, Argentina, and Kenya.
Regarding ‘open data’, some of our articles feature data and software/algorithm supplements as additional files. However, geodata are generally ‘complex’ in that they often involve many layers and contributors, including national and government agencies, each with their own copyrights, licensing and attribution requirements. For example, in the UK, Ordnance Survey, the national mapping agency, only recently (in 2010) opened up a good portion of their data for free use. This was seen as an important enabling step towards building UK’s digital future.