We have published over 60 papers in leading medical journals including the Lancet, British Medical Journal, Nature Medicine among others. We are putting mirrored servers into over 70 centers with the goal of having mirrored servers in every medical, veterinary and nursing school in the next 3 years and in the curriculum of all schools. Initial pilot studies reveal that 2500 individuals will see each lecture each year, which is 50 times that of our classroom teaching. We have just beta tested lectures in 2 centers in Japan and one in South Africa.

"The Internet is THE Information Superhighway" John Patrick, VP, IBM

John Patrick’s words echoed in our ears as we started to construct a global distance learning program for health. We wanted to improve health and higher education by using systems technologies that have proven to be effective based upon principles from the Internet culture, cognitive psychology, and quality control in manufacturing. We also wanted to make it available to as many people as possible. As a result we have constructed a "supercourse" having now 65 lectures.

Traditional models of distance learning have tended to be satellite based, where the students have to go to a central place to acquire knowledge and are very expensive, well beyond the means of developing countries. These courses try to mimic the classroom setting, but at a distance. They have been called "talking head teaching" as there is a talking head (a teacher) at one place, and other talking heads (students) at other places. The systems are becoming better and better at mimicking the classroom. However, the "Sage on stage" approach will never be the same as the classroom setting. We question the need to mimic the classroom as the Internet offers unique powers, and we potentially can produce better learning through the Internet than through the classroom/distance learning setting.

We have been constructing at "freeware" course on the Internet for medical Schools, nursing schools, veterinary schools, dental schools, etc. world wide. We provide the lectures to the teachers in the schools. The lectures are on epidemiology, global health and the Internet. The lectures are targeted towards students just beginning their health career. There are several unique features of the course: 

1. Shareware: In the culture of the Internet much of the software is shared. Various terms are employed such as shareware, freeware or the "open source model of software". Higher education lectures, in contrast are rarely shared. We have the simple proposal that global faculty members world wide should share their lectures, by placing them in a "library of lectures" with appropriate quality assurance.
2. Lectures for the classroom teachers: The target group is the global higher education faculty across the world. For the experienced faculty member, this would be of major benefit, for example, those teaching chronic diseases, would know much about say cancer, but not diabetes. New teachers will have an enormous benefit. A lecture from one of the world’s diabetes experts, Peter Bennett could be used. In health there is to our knowledge there is no repository. These classroom teachers would field questions of the students, and would markedly improve their courses. For developing countries there is very limited access to the current literature. These lectures would form a means to improve knowledge of the teachers as well, and foster collaboration.
3. Statistical Quality control: We have developed a quality assurance program. Before the lectures on put onto the web, we present these for comments to the global faculty. Based upon our first 30 lectures we have been very successful as between 5 and 74 sets of comments have been provided, about 60% were from people from academia. This is not peer review in the traditional sense as the reviews are not designed to provide a judgement of inclusion or exclusion. In stead the goal is to provide comments and feedback to the author for the improvement of the lecture. We have been very pleased with the response in that over 98% of the responses were constructive. The approach of monitoring lectures is that of Statistical Quality Control (SQC). This has proven to be very helpful in industry, but it has rarely been used in education, let alone on the Internet. This will be accomplished by having all students taking the lectures to complete a rating form. As many as 20,000 or more could take the course each year. The ratings will be monitoring using SQC to identify "dips" in ratings. Once we see this, the lectures will be reviewed, and the authors asked to update the lectures.
4. Hypertext Comic Book: We recently published in one of the most prestigious journals, Nature Medicine, the concept of hypertext comic books.

The major difficulty of the epidemiologic and medical literature is that it is easily forgotten. A recent letter in the Lancet showed that journal articles that are read typically cannot be recalled 2 months later. Because of our background in cognitive psychology, we were struck that often when people visit their homes where they were brought up, and looked at comic books from 20-30 years ago, upon seeing the cover, they know exactly what happened to Superman. We remember Lois Lane falling from the window, and being swooped up by Superman, we recall Superman in a fallen position being exposed to the green rays of Kryptonite, and we recall Superman as a baby landing in the corn fields of Nebraska. Great Ceaser's Ghost…Why is it that we can remember so Comic Book information from 30 years as well but we cannot remember reports from the Lancet from 2 months ago? The answer lies in cognitive theory. The first component is that of iconic learning as espoused by Pavio in the early 1970s. Iconic learning in its simplest form is….a picture tells a thousand words. As one walks into a classroom, one can remember the 40 faces much better than the 40 names. The second component is that of schematic formation. Bartlett 3 in 1932 developed a theory that has held to this day. When we learn there is too much information, it is impossible to memorize it all. Human information processing has to be selective. As we read a representation, or schema is formed which is like a backbone. We hang "flesh" onto the backbone. Anything that does not fit is discarded. Thus when we read a comic book we go from frame to frame, building a very powerful visual schemata which we can remember very well for weeks, years and even decades. The information rich text journal article does not permit this.

Why then don't we continue to read comic books to obtain our knowledge? When we reached a certain age we stopped reading comic books. It is not because our mothers burned them, it was because there was not enough information in them. Books and journals are much more information dense than a comic book, so our comic books now reside bundled up in dusty attics.

However, the Internet permits us to use the power of the "iconic based" comic books while at the same time solving the problem of lack of information. This is through hypertext. Hypertext is one of the most important information tools that have been invented. With hypertext one can click on a word, picture, number, and immediately pull up additional information. Thus as above, if one were discussing the OR of 3 linking HLA-DQ molecules to childhood diabetes in a case control study, one could click onto OR and this would take you to the section in Epidemiology for the Uninitiated on OR. One could click on to diabetes and this would be in the Diabetes America, 2nd Edition web page and one could point and click on case control studies, and this would retrieve information from Epidemiology for the Uninitiated would come forth. The student determine the direction of learning, not the instructor. It is as John Patrick calls this, creative learning

5. Presentation Speed: A critical problem of internet based training is speed of access. We have developed a system to remove considerable information from the slides to speed access. We feel, however, that the solution to this is to provide mirrored servers in every center using the course. The amount of space required is small, but there is something about having the course on one’s own machine.
6. Books on the Web: There are very few textbooks on the Web. However, the British Medical Journal has at our request put up 2 of the major text books. We link the lectures directly to the books.
7. Multilingual lectures: The first lecture is translated into 8 languages. We will have all the supercourse in English, Spanish and Japanese.
8. Streaming Voice-Video Presentation: John Patrick VP at IBM has provided the latest state of the art technology for Internet presentation. He presented a lecture to our supercourse titled the future of the Internet. It is a powerful lecture, not only for the message but also for the technology. In the ideal world we would want to include voice and video as part of overviews and lectures. However, up until just a few months ago this was impossible as one would have to use very expensive satellite technology which is well beyond the reach of epidemiologists in the US and across the world. However, major technical developments in the past few months with a system called "Bamba" now permit voice and video streaming broadcasts through the Internet over a 28.8 modem. John presents his lecture using Bamba. This technology is not perfect, but this is just the beginning. Within 4 years we will be able to reach all across the world with voice video conferencing for almost no cost. It holds exciting possibilities, and we have access to the technology through John Patrick and IBM.

In addition to these we have currently underdevelopment: CNN type lectures where lectures are made as events such as Chicken Flu, Kobe earthquake, Cholera outbreak unfold We are also developing Internet evaluation procedures such as having students construct disease home pages, as well as protected access testing. Also, we are considering developing a global internet game of health, such as the spread of flu from China, or the effect of migration on diabetes. These are not being included in the proposal, but will be developed independently once the feasibility is determined.

The approach being taken is not distance learning for two reasons. The first is that despite our effort being global, there is a "death to distance" as the Economist has quoted. This means that if a student is in the next room, or in the next continent, it makes no difference. In addition, distance education means a separation between the teacher and the student. Here we have no separation in that the classroom teacher are doing the teaching, but they will have much better educational lectures than they ever had before.

Current Status: We have 65 lectures complete, and receive about 1 lecture per week. We have beta tested the lectures in two courses in Japan, and one in South Africa, the course worked very well, with considerable interest. In addition, for our best lectures in the classroom setting only 50 students per year have a chance to see them. Initial results indicate that 2500 individuals per year are accessing the lectures or about 50 times that of what we do in the classroom. In full operation there will be over 30,000 hits per year, which would mean we would have to teach 600 years to achieve as great a coverage as the supercourse.