Public Health 2.

0: Social Innovation and the Rise of Open

Health

Jody Ranck, DrPH

Principal Investigator, Public Health Institute

August 2009

"We need to convert the social safety net into a social safety
network through the creation of smarter communities that are
information-rich, interconnected, and able to provide opportunities for
all citizens." -Rosabeth Moss Kanter & Stanley Litow

“Innovation is something everyone wants more of, but nobody is too

sure what it means exactly”-John Gapper
Some Social Media Factoids to Digest:1

-25% of Americans have watched a video in the last month, on

their phones

-there are over 100 million videos on YouTube and YouTube is the
2nd largest search engine on the web

-Facebook added 100 million new users in 9 months, if it were a

country it would be the 4th largest in the world

-the Dept. of Education found that online students out-performed

face-to-face teacher-student learners

-Wikipedia is more accurate than Encyclopedia Britannica

-1 of 8 couples who met in the US last year met online

-there are 1.5 million pieces of content on Facebook

-80% of the “tweets” on Twitter are from mobile devices

The list could go on. Something has shifted in how we communicate.

Public health professionals can no longer dismiss social media as the
playground of teens. Those who do may soon find themselves largely
irrelevant to the public(s) that constitutes public health. Networks and
communication tools are central to how societies organize themselves.
We’ve seen text messaging both overthrow despotic rulers as well as
incite ethnic violence. Mobiles are changing the way resource poor
communities access services, obtain market information and improve
their livelihoods. The challenge is this—publics around the globe are
1
See “Social Media Revolution”:
http://www.youtube.com/watch?v=sIFYPQjYhv8
ahead of public health in their ability to use these tools to innovate.
We’re playing catch up again. Innovation in the field of public health
too often has meant innovation in the life sciences and medical device
world. We need to rapidly develop our thinking around social
innovation and innovation systems that can move beyond the
traditional confines of biomedical and healthcare innovation. The
nature of the web in this point in time is evolving rapidly toward the
“network as platform” model where the more people use the platforms
and applications the better they become.2 This means that people
contributing content, data, and insights act as a form of sensor for
what is going on around us. Furthermore, there are more physical
sensors and mobile devices that enable us to “see” what was
previously invisible and make connections to health outcomes. Your
average smartphone now contains numerous sensors such as
microphones, cameras, motion sensors, GPS, etc. As Tim O’Reilly
observes, even Apple’s iPhoto ’09 has pretty good facial recognition
features. During the summer of 2009 we have witnessed a dramatic
increase in augmented reality applications that take additional layers
of data and add them to the physical space in front of our eyes via
mobile devices. The call for better open data polices and frameworks
is accelerating in government circles with efforts to track stimulus
spending and the creation of new jobs. This paper will provide some
initial thoughts as well as attempt to map an emerging landscape of
tools, technologies, and innovation insights as an initial step towards
developing frameworks for social innovation in public health. The
underlying rationale for this paper is first to provide a preliminary
overview of some of the technological changes that are happening and
make the connections to public health and why we need to become
more engaged with technology debates. Furthermore, how can we
drive the politics of technology deployment to make sure that the right
technologies get into the right hands, the data measure the right
things to drive better health outcomes, and generally to think more
strategically about social media, mobiles, sensors, visualization tools
within the context of intentional innovation policies for public health.

Introduction: This paper will explore the emerging landscape of

innovation in public health through the lens of social media, mobiles
and design and the possibilities that may evolve from the tools and
ethos of social media (or web 2.0 as these tools are often referred).
The emphasis is going to be on social innovation, or innovations that
have the effect of changing social practices. My objective is to shift
the emphasis in how we talk about innovation from a focus merely on
‘things’ or new technologies and to think about the complex networks
of people, technologies, and nature (eg. microbes) that come together
2
Tim O’Reilly (2009). Web Squared: Web 2.0 Five Years On.
Web2Summit.com
to form an “assemblage” of elements that produce new social
outcomes, namely preventing disease, ameliorating the negative
consequences of global climate change and addressing the social
inequalities and determinants of health. As Ilona Kickbusch (2008)
has recently noted, innovation in health and healthcare all too
frequently refers to the innovations in biotechnology and
pharmaceuticals that deliver medical value rather than social value.
Furthermore, she notes, we are undergoing a major shift in respect to
health and its role in society. Health is no longer, if it ever was, a
function of the delivery of medical care despite the almost obsessive
concern with medical care in “health reform” debates. The boundaries
of what constitutes health are broad and fluid and increasingly we
must think well beyond the health sector to account for the social
determinants of health and the range of factors that influence health
outcomes. Yet rarely do we do this in practice or in a manner that is
sustainable and actually brings sectors from outside of health in a
robust manner. The innovations that are occurring on mobile platforms
in low-resource contexts are making those who espouse luddite
perspectives on technology in public health increasingly irrelevant.
However, we must also be cautious to think critically about the
considerable amount of hubris that Silicon Valley-influenced techno-
libertarianism often mobilizes in the political economy of hype and
hope to create new markets.

The underlying rationale for the way of thinking about innovation

proposed here will attempt to provide a way of thinking about health
and tools to more readily enable us to see and make the connections
that can encompass this rather complex and challenging thing called
health. The purpose of social innovation in this context is about
developing the next generation of public health tools, practices and
politics that can respond to the ever-growing demands that the
public(s) demands of public health professionals, calls for the
democratization of knowledge, expertise and more participatory
practices of public health. There is a need to create more innovative
approaches to health that enable new voices and knowledges to be at
the table, and to catalyze development of approaches that can address
the complexity and global nature of public health challenges. We must
now recognize that ‘global health’ doesn’t mean public health
elsewhere. While much of the paper will provide examples of
technology or social networking platforms being used today, I want the
reader to think beyond the technology. Think of the examples in
socio-technological terms. Too often, in my experience, when we
mention new technologies, particularly social media, in a public health
setting the first questions are focused on technologies used by teens
and therefore considered irrelevant to public health or the view that
technologies are artifacts that the poor lack. An additional concern
that health professionals have at the mere thought of democratizing
knowledge and expertise is the perceived threat of inaccurate health
information. While this is certainly a problem I have strong
reservations as to whether it is nearly the problem that health and
medical professionals make it out to be. Yes, we can certainly find
quackery and an abundance of conspiracy theories on the internet.
But this does not discount the enormous positive contribution that
publics make to the development of knowledge and expertise in
health. Deshpande and Jadad (2009) argue that it is time for the
health professions to move on from the skepticism they exhibit towards
online health information and engage with the incredible number of
expert patient/citizen science communities that are growing daily and
co-creating important health knowledge. A growing number of citizen
science projects worldwide can attest to this (Corburn 2005). I will
argue here that social media, mobiles, design, open innovation, cloud
computing and new forms of technological citizenship (Barry 2001) will
enable a very different form of public health in the future if we engage
with the public in a more open manner.

Across the governmental sector we’re finding that the magnitude of

problems (particularly post-September/October 2008) is growing, the
diversity of stakeholders is broadening and geographical scope and
scale of issues is becoming more challenging (eg. climate change).
With the increased focus on governance and transparency coming from
the public and NGOs and fueled by the web 2.0 revolution, we will need
to adopt a different approach to knowledge creation, innovation and
the politics of health. The private sector has recognized that innovation
is often best achieved when the boundaries of the firm become more
porous through the adoption of open innovation methods (see
Nambisan and Sawhney 2007). Non-profits have grown in number and
so has the fragmentation of the non-profit sector (Moss Kanter and
Litow 2009). This has resulted in a growing call for mergers and
strategic partnerships. But will this solve the challenges we face? Not
unless we manage to drive social innovations that radically change
organizational forms and platforms to take advantage of our growing
knowledge of networks.

This is why we will be looking at the role of social media in public

health. It is my opinion that we are still fighting network problems
with analog institutions despite having many networking tools at
our disposal. Yes, many public health professionals use social media
tools in their professional and private lives, but have we thought
through how we can innovate in terms of organizational forms,
innovation platforms and our understandings of networks and health in
a robust enough of manner to confront the tasks at hand? It is
commonly heard that public health, as a field, averages roughly 8-10
years behind the innovation curve of other sectors. I have frequently
heard young innovators mention that public health is where innovation
goes to die. This doesn’t have to be the case. Things are beginning to
change if we look at the early stages of the mobile health revolution
taking place in Africa, for example. But how can we create the
institutions and innovation networks where we will be in a position to
drive innovations in social media and networking? Going forward, this
will be one of the imperatives of public health. If we are going to stake
a claim in the arena to work with not only the public at large, but the
most marginalized we will have to become masters of creating the
innovation systems that integrate the voices of end-users into the early
R&D of new technologies and policies. New innovation systems for
global health are growing in importance and we are just now beginning
this discussion within the domestic US public health space. Hopefully
this paper will contribute to the debate.
Social Media: What do we mean by web 2.0?

For many in the public health field the terms “web 2.0” and “social
media” were rather alien species until 2008-09 when Twitter became a
mainstream news item due to celebrity adoption of the tool. After the
Mumbai terrorist attacks the growth of Twitter took off due to the
attention it received on CNN for its role in late breaking news from
people on the scene. However, web 2.0 and social media have been
around since the early 2000s, if not earlier. What we’re really talking
about here is an eco-system of communications tools that evolved
online from the first generation of the internet that we all experienced
from the late-1980s through the 1990s. This was an internet of mostly
one-way communications tools where information was pushed out to
an audience in the traditional publishing mode. Tim O’Reilly coined
the term “web 2.0” around 2005 when, in the wake of the dotcom bust,
new “platforms” arose that enabled users of the sites to share and
create content, and find like-minded people. Most of these platforms
also offered free services and were very inexpensive companies to
create. In fact, many of the web 2.0 business models posed challenges
for venture capitalists who were often not as necessary to the
launching of companies as they had been in the 1990s dotcom boom.
Figure 1 below was the overview in 2005 of the platforms and tools
that made up the web 2.0 eco-system at the time.

Figure 1: O’Reilly Web 2.0 Meme Map

O’Reilly described the emerging web 2.0 as constituting an
“architecture of participation”. For the reader interested in learning
more about the history of the emergence of web 2.0 one can consult
the original O’Reilly piece (2005). For now, one should recognize that
what we’re talking about is a more “social” web that enables one to
tap into the collective intelligence of online communities, share
content, create mashups or remix content (eg. Google Maps mashups).
Social media are about the sociality that the web platforms enable.
Below is a list of common tools that are included in this social media
eco-system:

Social Bookmarks: Rather than bookmarking a website on your own

computer you can “tag” a site and share those tags with a social
network. Some examples: Delicious.com, Ma.gnolia, Diigo,
StumbleUpon

Crowdsourced Content: Rather than obtaining content through a

traditional newspaper, print journalism mode one can “grab” content
from a variety of sources, comment, rate and share. Some examples:
Digg, Yahoo Buzz, Mixx, Reddit, Newsvine
Blogs: self-publishing of content using a wide number of platforms
from Wordpress to Blogger and then some. In contrast to traditional
media sites the ethos of blogging is about sharing content and creating
a conversation. You can search blogs through sites such as Technorati,
Google Blog Search, etc.

RSS or Really Simple Syndication: This is a format used to update

readers on new content published on blogs, news sites, etc. in a
standardized format that can be seen as “feeds” that are aggregated in
an RSS Reader/Aggregator such as Google Reader. This enables one to
follow a large number of feeds in one site rather than having to track
down every website that one monitors on a regular basis.

Micro-Blogging/Micro-Media: Twitter is the most well known but

these enable the user to publish short entries of information. Other
examples include FriendFeed, Tumblr. Twitter has its own eco-system
of tools that can run on the API and enable the user to do surveys,
fundraise, post documents, music, video, etc.

Social Networks: These are platforms that enable like-minded

individuals to congregate and create profiles, share content, update
information, etc. These include Facebook, LinkedIn, MySpace, Beebo,
Ning, etc.

Video and Photo Sharing: Social media tools also include video
platforms such as YouTube and Vimeo, photo-sharing sites such as
Flickr, document sharing such as Scribd, presentation sharing such as
SlideShare.

Twitter: Twitter has become one of the most popular social media
sites over the past year and is a service that enables users to generate
messages of up to 140 characters. The simplicity in design and use
betrays the power of the medium for building communities of like-
minded individuals who share links to content, generate discussions,
fundraising campaigns and collectively aggregate content through the
use of hashtags (using “#” in front of a keyword allows users to readily
search for the “tweet” (posting)). While there is a certain amount of
hype about the effects of twitter in various discourses there is no
denying that the social impact of the tool has been considerable when
we examine everything from the Mumbai terrorism attacks to the Iran
election protests to everyday development of online conversations
around social entrepreneurship, global health, healthcare reform and
technology development. I will attach an appendix of some of the most
important health professionals on Twitter.

Brian Solis has created the following social media map in Figure 2.
The reader should note that the map is somewhat dated and there are
additional entries under most headings and some of the companies on
this map have ceased to exist.

Figure 2: Social Media Map (Brian Solis)

In my appendix I provide links to some social media primers for those

uninitiated into the world of social media.

The Mobile Web. An important thing to keep in mind is that the web
is becoming increasingly mobile. With the release of the iPhone 3G in
July 2008 we witnessed a step-change in innovation and the number of
people accessing the web from a smart phone. In August 2009 the
European Information Technology Observatory (EITO) estimated that
the number of people worldwide using mobile phones rose from 3.9
billion in 2008 to 4.4 billion in 2009, an increase of 12% resulting in
nearly 2/3 of the global population now possessing a phone.3 Not all of
these phones are smartphones capable of accessing the worldwide
web, however one must conclude that overall access to mobiles
worldwide greatly exceeds the 2/3 of the population due to the fact
that the mobile is not always constructed as a “personal” device and is

3
http://www.egovmonitor.com/node/26957
frequently shared across households or communities in lower income
settings. The CDC noted in late 2008 that nearly 20% of all US
households no longer had landlines, a trend that was increasing due to
the recession. Some recent Pew Internet data is useful as well. When
one looks at traditional internet access points via broadband
approximately 46% of African-Americans have broadband at home
(Figure 3).

Figure 3: Pew Study on Broadband and Mobile Access

However, once one looks beyond broadband to mobile devices the

picture begins to change. Access for African-Americans begins to
change dramatically (See Figure 4). African-Americans are 70% more
likely to access the web via a mobile device than White Americans.
Yet, we still find many skeptics in the public health community
questioning the relevance of social media and mobile technologies for
lower-income communities and minority populations. If one looks at
the applications available in the iPhone AppStore, out of the 65,000 or
so applications most, arguably, are not applications designed to
produce public health outcomes. One of our innovation challenges
going forward will be to find ways to engage citizens on mobile
platforms in ways that speak to their lived realities and own
constructions of technology use. A great deal of the content that will
be presented in this report will be artifacts, ideas, trends and concepts
that we can work with in our “innovation sandbox” to achieve these
goals. While the mobile is not the only platform or technology
available, it is growing in importance worldwide. The next generation
of public health practitioners will need to find ways to develop
innovation systems and platforms to get out in front of the curve rather
than following, and many years behind as is often the case.

Figure 4: Wireless Access in the US

Despite the challenges of small screens, limited bandwidth of mobile

carriers, interoperability issues, security and privacy challenges, the
mobile web is rapidly approaching (perhaps it is already here, we just
haven’t noticed). So as we go forward thinking about social media and
health it will be very important to keep these insights about mobile
usage in our heads and remember that the web is increasingly mobile,
so much so that within the next several years it will just be referred to
as the web, not the mobile web.
 Social Media and How We Can Think about Public Health 2.0
Strategies

Now that we’ve been introduced to a range of tools and insights on

where the web is going and a cursory view of some of the effects of the
web on organizational life it would be useful to think about some of the
functions of web 2.0 tools in the social sector so that we can create the
building blocks for innovation strategies. Gaurav Mishra provides one
of the most basic frameworks to describe how social media are
currently being used in the non-profit sector. His “The 4Cs of Social
Media” looks like this:

Content: Social media tools enable anyone to create content and

distribute or publish this content via a range of social media tools such
as blogs, wikis, YouTube, etc. Social media tools also enable readers
and users of content to tag and share resources, create mashups via
data visualization tools or Google Maps. Co-creation is becoming
increasingly important in social services and health as we move the
compass from more bureaucratic, top-down approaches to more
bottom-up, user-generated content scenarios in health. While one may
not replace the other we will have to think about how to effectively
manage a medically and socio-politically pluralistic universe of ideas
and knowledge. There are also content aggregators such as
alltop.com.

Some examples of platforms for creating/curating content would

include the following:

Social Documentary (http://www.socialdocumentary.net) This site

aggregates content (photography, documentaries) from individuals on
critical issues of the day. The goal is to use photography to motivate
action on a particular issue. The site also serves as an image bank for
students and professionals concerned with social issues.

Witness (http://www.witness.org/): Witness uses video to fight human

rights abuses worldwide. Video content is used in conjunction with
litigation, research and organizing for change using conventional
human rights tools and methods.
Collaboration: social networks, blogs, Twitter, etc. enable users to
find like-minded individuals and aggregate voices in a more nimble
way than traditional media sources. Anything from conversations
around emerging issues to co-created knowledge to rapid responses to
breaking events, legislation, etc. are facilitated by social media
platforms. One can begin as a conversation, if curated or fertilized by
"community gardeners" , can evolve into co-created knowledge, new
partnerships or new products. Moving ideas from conversations to
aggregate actions, on legislative issues for example, requires both
online and offline integration.

Some examples:
City of Toronto’s Transit Camp (http://transitcamp.wik.is/): When the
Toronto Transit Commission needed to develop a new transportation
policy they created the Transit Camp site and activities to engage the
citizenry. Rather than generate a policy prescription that is then
communicated to the public after the fact, their approach solicited
feedback on the community’s own framings of transportation issues
first and their ideas for solutions. Policy-makers could then build on
the “crowdsourced” proposals and suggestions.
All Hazards Consortium (http://www.ahcusa.org/) : Disaster
Preparedness involves many different sectors involved with evacuation
planning, infrastructure protection, food security and cybersecurity
(Nambisan 2009). This diverse eco-system not only has different
players but each may have a different framing of the problem and
ideas for how to best address the problem. The All Hazards
Consortium created this portal to bring together the different parties to
settle on a common framework for addressing the problem and then
bringing all of the stakeholders to the same table. Through the forum
they learned how different agencies constructed “special needs” and
shelter requirements differently. The Consortium was able to sponsor
working groups to generate discussion and consensus across agencies
The All Hazards Consortium example has become a very successful
case study in how to create a collaborative platform. The sponsor of
the platform had the responsibility of creating a collaborative
environment where all parties could voice their perspectives. In other
words, the role of government became less a matter of leading the
direction of change and more about developing and maintaining an
infrastructure for social knowledge creation.
Community: sustained collaboration is the basis of many professional
communities. From building a community around a conference so that
collective action and community can evolve post-conference to
maintaining effective collaborations among geographically dispersed
individuals, social media tools can be effective if the role of community
gardener is developed and the community is fertilized with good
content and effective (time-saving, ideational, etc.) tools and
relationships.

An example would be the political blog Daily Kos

(http://www.dailykos.com) that creates communities of progressives to
exchange ideas and commentary and occasionally organizing political
action.

The number of health communities online is proliferating. Referred to

as Health 2.0 sites, they are having an impact on the doctor-patient
relationship. In fact, what we’re seeing here is a form of online
biological citizenship with examples such as the Genetic Alliance
(http://www.geneticalliance.org) and PatientslikeMe.com demonstrate
(Rose 2006). When individuals with similar biological (health, medical,
environmental) experiences come together and work to refashion that
experience, share data, make claims for access to resources and
clinical trials, for example, we are seeing this emergent form of
biocitizenship in motion. Rose discusses the new relationships that
patients frequently have with their bodies and disease within these
communities as a form of “somatic ethics” that is being reworked in
relationship, or at odds, with traditional bioethics. Within the health
blogosphere we increasingly hear about “Information Rx” and “Patients
2.0” as phenomena associated with social media and health
communities. Precisely how these communities will change the
practice of medicine at the moment is unclear, but they will have an
effect. The site PatientsLikeMe.com has become one of the most
successful Health 2.0 sites via communities of sufferers of ALS who
now share data and outcomes from treatment regimens. Physicians
can now see patterns earlier than what would normally have been
available in post-marketing surveillance data. One of the challenges in
this area is to sort the hype of those hoping for the next big business
opportunity in healthcare through Health 2.0 and truly innovative
changes in social practices. While there is no denying that the Health
2.0 universe is having some impact on how we think about health and
healthcare there is certainly a great deal of hype and growing
skepticism about some of the claims of its marketers. This may
change when rigorous evaluations of health outcomes, policy
outcomes and cyber-ethnographic data help us understand more
clearly the impact of these online health communities.

In the diabetes realm there is actually a lot of interesting movement.

From the diabetes blog, Diabetes Mine (http://www.diabetesmine.com)
to Manny Hernandez’s work with the Diabetes Hands Foundation’s
social network of diabetics, Tu Diabetes (http://www.tudiabetes.com),
these have become important nodes in the diabetes space for driving
innovation with new devices as well as peer-to-peer creation of social
knowledge of diabetics.
When Amy Tenderich, the blogger from perhaps the most important
diabetes blog, Diabetes Mine (http://www.diabetesmine.com) wrote an
open letter to Steve Jobs lamenting the gap in design quality between
medical devices and the iPod.4 Eventually a San Francisco-based
design firm, Adaptive Path, came forward with a re-design of the insulin
pump.5 This experience eventually resulted in the creation of a yearly
design competition for diabetes devices. Each of these examples
illustrates how online communities can have very significant impacts
on innovation in health and public health. We just need to begin
developing intentional strategies to manage innovation in this new
mediasphere.

Collective Intelligence: Extracting meaning and reliable content

from a variety of sources is another role that social media can play in a
world that we often characterize as one of information overload. Social
tagging, filters, reputation systems, open innovation platforms,
crowdsourcing and social ranking are features found in a variety of
social media platforms and tools. New artificial intelligence tools are
available to help us sort through networks and find the right expertise
when we need it. Difficult problems can often be solved by asking the
right question to the right social network, or finding ways to frame
problems into modular components that can be worked on in small
fragments of time. In many ways we are moving towards a world
where solution finders are as important as problem solvers.

Social Media Platforms and Collaboration: Nambisan (2009)

4
http://www.diabetesmine.com/2007/04/an_open_letter_.html
5
http://www.diabetesmine.com/designcontest/about
created a taxonomy of collaborative platforms such as those listed
above and provides a useful analysis of how we can think about social
media and cooperation in public health. There are three basic
platforms that organizations are currently deploying: exploration
platforms, experimentation platforms, and execution platforms.
“Exploration platforms” are used to define what the problem is; they
use experimentation platforms to test possible solutions to the
problem; and they use execution platforms to disseminate the
solutions. This typology is useful in helping us think beyond the “build
a platform and they will come” notion that often results in platforms
that fail to build communities and achieve any type of measurable
outcomes. Each type of platform requires different skills and
resources and represents a different type of question or problem that
one is solving for. One of the key points I’ll be making in this report is
that public health can be thought of as a collaborative platform.
In order to move our thinking in this direction we’ll need to think
through the ramifications of different platforms for different tasks.

Three Types of Collaboration Platforms (Nambisan 2009)

Exploration Experimentation Execution

Objective -Define Core -Develop -Build and
Problems Solution disseminate solution
Prototypes templates
-Connect with
Problem -Test prototypes -Help adopters adapt
Solvers in near-real- to system-wide
world contexts changes
Role of -Build a diverse -Integrate ideas -Facilitate the
Lead coalition of from diverse collaboarative
Organizatio stakeholders stakeholders development and
n diffusion of solution
-Give stake- -Offer neutral templates
holders environments
numerous and for deep testing -Provide resources
varied forums of solutions that adopters can use
to air their to manage the “ripple
concerns effects” that follow
implementation
-Identify
potential
problem
solvers
Desired -Shared -Assessments of -Solution Templates
Outcomes definition of possible
 the problem solutions -Implementation
standards
-List of -Solution
potential Recommendatio -Rapid adoption of the
solutions ns social innovation

Nambisan concludes his analysis with some core capabilities that

organizations will need to master to drive social innovation in the
cooperation arena. The first is to develop a network perspective
that entails becoming more strategic in how organizations work with
diverse partners. This often requires a shift from playing a lead role in
controlling activities in the collaboration to the role of championing of a
cause. Appreciating the different roles and business models of diverse
stakeholders is central. Plug and Play Capabilities are another
aspect where organizations will need to become more flexible or
modular. What this means is that organizations need to become more
agile in how they deploy their expertise within the configuration of
these networks. InnoCentive, the open innovation platform, for
example, has the ability to conduct contests to solve problems across a
wide range of domains but also needs to understand the intellectual
property policies of firms within specific segments in order to work with
their clients. Organizations also need to also develop a portfolio of
success metrics that will work across the spectrum of partners.
Nambisan thinks that developing these core capabilities will enable
organizations to work across the government, business, non-profit
divides that will be necessary to bridge given the complexity of
problems we now face.
 Open Health: Towards a New Paradigm for Public Health
Innovation

Social media, in my mind, is less about the technology (the media) and
a far more interesting story about the social practices that they can
inspire. Several years into the era of rapid growth of blogs and wikis
we witnessed a dramatic increase in activities frequently described as
“crowdsourcing” or new forms of cooperation emerged from the ability
of like-minded individuals to find one another and collectively produce
content, exchange ideas and work to solve problems. Howard
Rheingold in is 2003 book “Smart Mobs” captured the ethos of the
emerging assemblage of norms, technologies, and movements when
after the 1999 anti-WTO protests in Seattle, the overthrow of President
Estrada in the Philippines and the texting behaviors of Japanese teens
all pointed to the growth of new forms of cooperation that were being
enabled by pervasive computing, mobiles and what many refer to as
“new commons” in the knowledge society (Hess and Ostrom 2006).

The commons is becoming an increasingly powerful tool in the

knowledge society as a space between public and private where
resources can be shared. The phenomenal success of open source
software is a prime example (Weber 2004). In health we see examples
of new commons when a community shifts from viewing obesity as a
problem of an individual who has a quasi-moral responsibility to
regulate her behavior to fit a norm around body types to a framing
where a community must rethink the walkability of a city, the politics
of funding physical education in a school, food deserts in low-income
neighborhoods, crime that prevents people from exercising and school
lunch menus for healthier food. Open data policies from city
governments create new data commons, in effect. These data
commons then become a resource for building new services and
platforms for the public. The health commons around obesity would
also include the voices of those whose bodies are targeted by health
interventions and their expertise and body politics views to derive a
novel approach to obesity.6 One of the most important experiments in
commons building at the moment is the Science Commons created by
John Wilbanks (http://www.sciencecommons.org). The mission of the
Science Commons is:

“Science Commons designs strategies and tools for faster, more

6
The framing of obesity might also include the neglected ‘disease(s)’
called mental health and trauma given a growing body of research that
points to the role of childhood sexual violence as a causal factor in
obesity for a significant number of women.
 efficient web-enabled scientific research. We identify
unnecessary barriers to research, craft policy guidelines and
legal agreements to lower those barriers, and develop
technology to make research, data and materials easier to find
and use.
Our goal is to speed the translation of data into discovery —
unlocking the value of research so more people can benefit from
the work scientists are doing”

The Science Commons currently sponsors several distinct projects:

• The Health Commons

(http://sciencecommons.org/projects/healthcommons/): a
biomedical orientation and focused on therapeutic cures and
consists of databases of tools used in drug discovery

• The Neurocommons (http://sciencecommons.org/projects/data/):

an open source knowledge management project for biologicals

• The Green Exchange

(http://sciencecommons.org/projects/greenxchange/): an open
patent exchange for creating an innovation eco-system for green
technologies

There are insights here for how public health organizations can create
pooled resources that include data, knowledge assets, tools and
templates that can be adapted to specific contexts and problems.
Later in this report where we will examine mapping tools, data
visualizations and social networking platforms that hopefully will
illustrate the range of possibilities. The commons is also a space, either
physical or virtual or both, where users and contributors to the
commons can tinker and share tools. In other words, the commons can
become an innovation commons. Eric Von Hippel (2006) has coined
the term “user-led innovation” to describe how end-users of projects
often tinker with and modify products to suit their individual needs.
Companies that have developed relationships with end-users are then
in an ideal position to take advantage of these modifications and build
new lines of products and services from what they learn from end
users. Central to the concept of user-led innovation is the notion of the
“toolkit”. When you go to a hardware store to buy paint they have a
toolkit that readily creates any desired color from a toolkit of color
palettes and computerized mixing machines. In healthcare we have
not been that innovative in developing toolkits today despite many
options for doing so (Demonaco and Von Hippel 2007). For example,
with diabetes we trust people to prick their fingers and check their
glucose levels, then self-manage by injecting themselves with a
potentially very deadly drug, insulin. On the other hand, with
congestive heart failure or high blood pressure where there are simple
tools available for patients to measure their health status (scales for
weight with congestive heart failure and home monitoring kits for
HBP), yet management of congestive heart failure and high blood
pressure typically entails intensive, expensive clinical management.
Self-management regimes with adequate toolkits have proven to be
effective and cost-efficient. The barrier to adoption turns out to be the
way in which toolkits alter professional relationships and may shift
power relations in clinical encounters and roles. We might want to
think about how we can create new innovation commons and develop
toolkit and social networks of stakeholders with incentives in alignment
to surmount these barriers, but in ways that move beyond personal
healthcare and into the civic engagement arena of public health.
We can also use the commons to reframe problems as a community
issue rather than one of individual responsibility as has become the
case in recent years as the health sector becomes more consumer
focused and emphasizes consumer responsibility. This often leaves out
the structural issues and the issue of structural violence. Framing
issues in terms of responsibility or the commons is a political act.

The UK Design Council’s RED Project provides the most useful insights
into how to rethink health and healthcare from an “open” perspective
through its “Open Health” Project
(http://www.designcouncil.info/mt/RED/health/). Here, service design
meets smart mobs in an approach to diabetes management that
emphasizes designing for “desired health outcomes” rather than
creating a program on the basis of existing healthcare infrastructures
that are increasingly problematic for addressing chronic disease
management. ActivMobs and interventions that were co-created with
diabetics lie at the heart of the intervention. It is here that we see the
potential for social media to be deployed in a strategic manner to
change health outcomes and the institutions and policies that we will
use to drive the future of public health innovation. The fundamental
insight of the project was to build around desired incomes rather than
working from within a dysfunctional system poorly designed for chronic
disease conditions. As we experience the latest round of failed medical
care reform this could hold potential for how public health
professionals will need to think about social innovation that moves
beyond merely enhancing access to a poorly equipped system. There
are insights and tools for building bottom-up systems, particularly if we
look at the social innovations taking place in developing country
contexts such as India.7
7
See Aravind and Narayana Hrudayalaya Hospitals for example.
We will now look at some of the building blocks for creating an open
health framework for innovation. This will require a brief tutorial to
social media and the manner in which these tools are being deployed.
We’ll begin with a discussion on social networks and organizations.

Networks and Network Organizations in the Open Health

Model:
There is growing recognition that we are increasingly living in a
networked world. One of the drivers of an emergent open health
paradigm is the way that organizational forms are changing due to the
collaborative tools, proliferation of data and data analytical tools have
the ability to facilitate more networked or virtual organizational forms.
We saw this with the manner in which WHO facilitated a network of
collaborating research centers with the SARS outbreak.8 Later we’ll
see how cloud computing and Software As A Service (SaaS) are
creating opportunities as well.

If we think about the nature of most health issues we see that they are
outcomes of networks. There are networks of different service
providers, health outcomes are the result of different networks of
microbes, genetics, environmental factors, social structures, medical
and other forms of knowledge, transportation policies, the built
environment, etc.9 Health itself is a network phenomenon. Yet, we are
using analog structures to deal with network problems. Our
institutions have done little to evolve to match the nature of the
challenges. New technologies and social practices also mean new
organizational cultures are emerging. The 2003 SARS outbreak
provided some insights on how we will increasingly have to work.
When WHO created a network of collaborating institutions to identify
the unknown virus this work was accomplished in short order via
virtual collaboration. Too often we’re trapped within the iron cage of
bureaucratic hierarchies and organizational charts that can become a
significant barrier to innovation. Many of the practitioners of open
innovation have observed that innovations can come from anywhere in
the firm if we open our minds to who can innovate and why and
actually pay attention to informal networks as well as create
intentional innovation systems to bring knowledge in from the edges.
Here is an organizational hierarchy on paper vs. the social network of
the organization in practice to illustrate my point:
8
See James Surowiecki (2003). The High Cost of Illness. New Yorker,
May 12, 2003.
9
Actor-Network Theory developed by Bruno Latour should become part
of the public health curriculum and goes a long way in helping us to
understand the complex ecologies of health issues more broadly.
 Figure XX: An organizational chart vs. actual organizational
networks

To illustrate how networks and open innovation can work together we

can look at some of the examples provided by the open innovation
platform InnoCentive. InnoCentive is a platform where companies can
post difficult problems that need to be solved and individuals
registered on the site can earn small rewards or recognition for solving
a challenge. The company was formed by the pharmaceutical
company Eli Lilly to find a way to solve for difficult scientific problems
that they were unable to solve internally after many years and millions
of dollars. Frequently these seeminingly intractable problems were
solved in a matter of weeks by individuals from half way around the
globe coming from a very different disicipline. For example, a lawyer
who was good at chemistry solved a major industrial problem in his
spare time. An x-ray crystallographer from Moscow solved a
challenging physical chemistry problem that Eli Lilly could not solve in
3 years. Overall, roughly 30% of the challenges have been solved.
The Rockefeller Foundation is now using the platform for difficult global
health and development challenges. Paying attention to actually
existing networks and building intentionally open systems may help us
to open up organizations and create more dynamic and resilient
institutions if we develop a new set of managerial skills to accompany
the emerging open health landscape.

I recently attended a workshop at the University of California, Berkeley

on H1N1 as part of a social science study on networks of expertise in
public health. Throughout the 1 ½ day workshop we consistently
heard some of the leading influenza epidemiologists speak about the
need to practice “sound science” while in the same breath speak about
how they had to make decisions in a rapidly changing, politically
complex world through “gut feelings”. These “gut feelings” are a form
of tacit knowledge that is grown through the less formalized networks
that the organizational hierarchies depicted in the first illustration
above may overlook. We now have tools to help facilitate the sharing
of tacit knowledge and more effective forms of cooperation if we learn
to deploy social media tools with the right organizational fit. Part of
creating more resilient architectures of organizations and information
will be to understand the nature of networks within organizations and
network organizations.

To help us understand the emerging network cultures we may want to

explore the literature on heterarchies, or the use of complex
networks, to address organizational problems (Stephenson 2009). Take
someone with a chronic disease like diabetes. They have a physician
who they see for their illness but on occasion they end up in the
hospital and then a physical therapy unit, a nutritionist, etc. Therefore
a network of providers covers the spectrum of needs. But
collaboration across the spectrum is rare and fragmented delivery of
care is the norm. A heterarchy is a system where at least three
separate hierarchies collaborate to accomplish a collective good that is
more complex than the sum of the parts. Each part attempts to
optimize its own success criteria but they must all cooperate. This
essentially describes much of public health or most organizational
cultures today, but unfortunately, as Stephenson notes, heterarchies
are managed rather poorly and we see the Enron’s, FEMA with
Hurricane Katrina as examples of poorly managed heterarchies.
Competition between peers is the norm. However, we can find
examples such as the City of Philadelphia that mapped all of the
parties working on urban renewal in the city. This network analysis
enabled them to identify important nodes in the network who were
doing exemplary work and then became assets that helped inspire one
of the more dramatic civic engagement for urban renewal programs.
In essence, they created a virtual organization through fostering
trust across the most important nodes. The tools and platforms we’ll
be assembling here will hopefully inspire thinking as to how we can
weave the social technologies with software to enable new
organizational forms such as heterarchies to accelerate.

Networks and Health Policy Innovation. An observation: we

shape our networks and our networks shape us, as one follower of
Marshal McLuhan once observed. As Albert Lazlo-Barabasi states in
another manner:

"The diversity of networks in business and the economy is mind-

boggling. There are policy networks, ownership networks,
 collaboration networks, organizational networks, network
marketing--you name it. It would be impossible to integrate these
diverse interactions into a single all-encompassing web. Yet no
matter what organizational level we look at, the same robust and
universal laws that govern nature's webs seem to greet us."

Lazlo-Barabasi’s work has important implications for how we will need

to think about public health innovation and organizations in the future.
We’ve always had social networks but now the platforms and tools to
both analyze and mobile networks for social change are revolutionizing
the nature of politics, communications and collaboration. This means
that the nature of organizations is going to change in important ways
going forward. We’re in an experimental period at the moment where
organizations are playing with new organizational forms, democratizing
decision-making and looking for ways to innovate in more
decentralized ways. Even many funders such as the Case Foundation,
Cal Endowment and Rockefeller Foundation are exploring ways to take
advantage of network effects to do philanthropy differently. This
period of changing organizational forms and norms does not mean an
epochal shift—older forms and norms will persist so we are likely to see
many different hybrid models emerge. Therefore a certain amount of
critical thought will be needed to know when to deploy social media
and social networking tools and when to use traditional media and
approaches or to deploy hybrid concepts and strategies.

Social media are social in the sense that they enable “many-to-many”
communications and connections and they can be both real-time and
asynchronous. Scearce et al. highlight the nature of this networked
reality where people can:

1) self-organize without centralized planning and infrastructure

(remember the progressive reaction against the Swift Boat
campaign in 2004 where bloggers created databases overnight
that launched a campaign against Sinclair Broadcasting that
destroyed $100 million in market capitalization in several
weeks10)
2) spread ideas and form groups more quickly
3) overcome barriers to collaboration to find others who share
specific passions and to take on larger projects that would have
been previously unthinkable
4) access knowledge, leadership and expertise in places that were
once beyond their reach
5) share information quickly and with little effort, making more
resources available and enabling people to easily build on the

10
See Yochai Benkler (2007)
 work of others
6) come together and disassemble as needed to achieve goals (a
Hollywood studio model of working)

Now to take these insights to health policy and public health we need
to think where health policy innovation might move in the context that
we’ve been describing so far. Warner and Gould (in Kickbusch 2008)
write that health policy innovation only happens when high-level
intentions are linked up with and make a change to ‘practice’---what I
refer to as social innovation. Historically, policy changes have been
thought about in mostly vertical terms, however, the future will lie in
thinking about the horizontal connections across sectors and policies
and from the bottom-up. We’re very accustomed to the calls for
intersectoral collaboration and horizontal approaches, we just don’t see
the calls put into practice in a successful manner that often, if at all.
Part of this is our lack of understanding of how to think about
governance of network organizations and how to build network
organizations that are more than traditional partnerships. Warner and
Gould are attempting to identify the key challenges to working in this
manner and how we might move forward in thinking about network
governance. While rarely spoken about in public health, this will likely
be at the center of public health innovation in the future. The social
media technologies and tools that receive the focus around innovation,
should be viewed as tools to be appropriated for creating the next
generation of networked public health organizations and strategies
rather than stand alone technological innovations in their own terms.
Social innovation is about connecting the social technologies to
software or hardware technologies to produce social outcomes.

Some of the key challenges for multi-sectoral policies include; 1)

addressing the fragmentation of service responsibilities across agency
boundaries, 2) competition-based systems of governance, 3)
differences in planning cycles/procedures/horizons/information
systems, 4) differences in funding mechanisms, 5) competing
ideologies and values, 6) professional self-interest, 7) conflicting views
about client/citizen/consumer interests and roles, 8) differences in
legitimacy between elected and appointed agencies. These challenges
are likely familiar to anyone in public health who has attempted to
create a major multi-sectoral initiative and many of the collaborative
platforms already mentioned were created to help build bridges or
consensus around divisions arising out of these types of challenges.
To build on the lessons from the platforms discussed so far, we can
explore some of the thinking that Warner and Gould (ibid: 131-145)
have developed for networked governance.

One of the first approaches is to create a “virtual neutral space”.

Imagine an organizational chart with interconnected boxes. The space
between boxes is the white space and indicates an absence of
organizational activity. These are both constraints and opportunities
where networks can create opportunities and redesign services. It is
interesting to note here the work that is taking place in the social
capital/social venture world with the development of xigi.net. Xigi.net
enables users to see the connections between different players in the
social venture capital world and the projects they’ve worked on. In
essence, one can visualize the networks of social venture capital and
more readily see gaps, areas of duplication (although this would take
more than just seeing connections). But the general gist of the tool is
useful here---we could use similar tools in public health in designing
networks to more readily see the gaps and duplicative services. We
can also begin thinking about how to reframe a problem in terms of the
commons, or a public good that is a space for sharing expertise,
funding, intellectual property, etc. and how to build the trust and
governance structures to maintain the commons while addressing
problems such as “free-riders”.
Xigi.net

Source: http://www.xigi.net/index.php?gallery=1&map_id=6 (Lucy

Bernholz map)
Warner and Gould use a version of Leavitt’s Diamond that replaces
‘goals’ with ‘culture’ and ‘participants’ with ‘governance’ to serve as a
mental model for how we can think about the impact of new
networking technologies. The introduction of new technologies forces
us to reconsider the changes in culture and governance as we design
new networks. The need to think how a culture of cooperation can be
developed will be essential. Frequently this requires a strategic
framework that can think through the short-term costs and benefits of
closed system thinking versus the long-term costs and benefits of more
open, cooperative systems approaches and the opportunities that may
open up through moving beyond siloed knowledge systems.

Leavitt Diamond

Our understanding of the social determinants of health grows broader

almost daily. What this means is the underlying rationale of
movements such as the Healthy Cities/Communities movement are
growing in importance. The built environment, social inclusion in the
context of increasingly digitalized lives, pandemic preparedness that
requires cooperation across political boundaries, the health effects of
climate change, the expansion of the territory of health into more
sectors and aspects of people’s lives (Kickbusch 2008) and an
extremely fragmented system of governance for global health demand
new approaches. Policy networks that cross geographic boundaries,
approaching health as a global public good or as a problem of the
commons will grow increasingly important. We’ll also need to become
conversant in the network theory and understand the typologies of
networks that are possible for a given configuration of organizations,
problems, funding, governance, type of problem, etc.

We see some early signs of what may be emerging in the public health
and social sectors with examples such as Habitat for Humanity Egypt’s
new network approach to housing that has enabled them to move from
a production rate of 200 houses per year to more than 1,000. 11
Scearce et al. also point to the work of Boston Green and the Healthy
Building Network (funded by the Barr Foundation) as another example
of a network mindset for their use of social network maps to bring
together public health and environmental advocates for policy
advocacy efforts around building standards. The concept of the
“platform” is growing in importance so I want to turn to one recent
example of how this has worked for the development of civic
applications in Washington, DC.

11
See Jane Wei-Skillern and Kerry Herman (2006). “Habitat for
Humanity-Egypt.” Harvard Business School Cases, October 3, 2006 (in
Scearce et al. 2009).
Citizen-Driven Innovation: Apps for Democracy and the City as
Platform for Innovation.
In 2008, Washington, DC’s Chief Technology Officer, Vivek Kundra,
launched a project “AppsforDemocracy” that remains one of the
leading citizen-driven innovation examples to date. Earlier in the year
Kundrek’s office adopted an open data policy that utilized RSS feeds
(RSS means “really simple syndication” and allows followers of a site to
be notified when the site is updated) to enable citizens to download all
sorts of local government data from trash collection to government
purchasing behaviors, in all, there were over 200 feeds. Once the data
were available the public was encouraged to identify problems that
were in need of a solution. Then developers could submit software
solutions for the problems. The first edition of Apps for Democracy
yielded 47 web, iPhone and Facebook apps in 30 days - a $2,300,000
value to the city at a cost of $50,000! 12 This represents a 4,000% ROI.
Compare this to the old way of doing municipal software applications:
several years of development to the tune of several million dollars and
less than stellar software produced. We are also learning that the more
people use data, the better the data become (Zittrain 2009).
Crowdsourcing solutions for citizens, businesses and government
employees produced better solutions in a matter of weeks and at a
fraction of the cost. In an era of dramatically reduced financial
resources the public health sector must search for new ways of
innovating within tighter constraints and we feel this is one potential
solution.

As illustrated in Beth Simone Noveck’s “Wiki Government”, social

media are changing the way both governments and non-profits work.
These platforms enable us to harness the power of open data and open
source software to catalyze “citizen-driven innovation” toward a
system that creates innovations around expressed needs and helps
create stronger institutions built on trust and responsiveness.
Government, or in our case, public health professionals and health
service providers, can work to become civic enablers in a 21st century
context where rights and citizenship increasingly mean becoming
technologically proficient citizens. As AppsForDemocracy
demonstates, the results, when government builds platforms that
enable civic participation and innovation, can be astounding. We can
contrast this experiment with the traditional view of government as a
“civic disabler” (Sirianni 2009:8). This is the view that too often
government puts up too many barriers, does not produce the right
incentives, or overinvests in technical and bureaucratic tools and
becomes part of the problem that it is attempting to solve. The civic
disabler role arose from the command and control methods of a
regulatory state that is also responsible for the design of bureaucratic
12
See http://www.Appsfordemocracy.org
structures with silos and narrow rules. These bureaucratic structures
have been a major challenge to thinking more systemically about
problems. Our challenge now is to create the incentives and platforms
that can catalyze more collaborative action across the silos. The
critique that Sirianni provides above is not a position spoken from the
right-wing of the American political spectrum either, for her critique
also addresses the tendency over the past several decades to try to
frame citizens as consumers through the use of market-based tools.
This view of the citizen as consumer runs the risk of undermining civic
engagement.

AppsforDemocracy.org is now in the second generation of activities

where successful programmers may now have opportunities to scale
up their businesses through access to venture capital and government
funding. Here we see the next generation of social innovation at work
—the public sector acting as enabler of innovation from below. These
innovations can then attract the seed capital from the public and
private sectors to scale up. This is a far more efficient manner of
producing new ehealth and mobile health applications that respond to
user needs. This is the world of “Government 2.0”, that is, a move
from government as “vending machine” to government as platform.13
The next generation of public health innovations will likely extend this
thinking to how public health can play the role of innovation platform
for engaged citizens. Our plans for the Public Health Innovation Center
at the Public Health Institute in Oakland, CA include plans to build on
this experience for the health sector and to create an
“AppsforHealth.org” platform in the very near future. The platform
we’re creating can also serve as a “listening post” for both
entrepreneurs and funders and help catalyze the market for health
applications and innovations. Our understanding of behavioral
economics, gaming and persuasive technologies can facilitate the
creation of “choice architectures” and systems of incentives/sanctions
that can help modify behaviors toward healthier outcomes (Sunstein
2008). Many of the existing platforms and providers of solutions for
civic life, city planning, social mobile applications can be readily
deployed for health-focused applications if the incentives are there. By
creating a platform for designated health applications we can create a
type of innovation commons where potential investors and government
will be able to find promising entrepreneurs in the health application
space and offer the opportunity to scale up viable solutions.

The recent debates (or some would argue, lack of debate) on health
care reform in the US illustrates the complexity of health issues and
political fragmentation. With deadlock in government producing
13
See http://blogs.law.harvard.edu/palfrey/2009/07/03/tim-oreilly-on-
the-history-and-future-of-government-20/
anemic policy responses to major health issues we will have to develop
additional strategies to create bottom-up approaches to health reform
in the future. We no longer, if ever, have A PUBLIC, but rather
multiple publics. Many health issues can no longer even effectively be
resolved through traditional partnerships but require much larger,
broader and more diverse networks, or what Robert Agranoff (see in
Siranni 2009: 16) calls “complex value creation networks”. This
demands new approaches to civic problem solving and the platforms
for collaboration, content co-creation and implementation as our
earlier discussion on platforms mentioned. These demands and
opportunities will likely change the way philanthropy and government
funding as well as public-private partnerships will work in the very near
future.

Public health needs to learn from this experience and create spaces
where targeted health innovations can be produced, or better, co-
produced. What if we were to begin building innovation platforms for
health, and more specifically public health, that would be capable to
developing tools to manage chronic diseases, map public health
problems locally and connect problem solvers to those in need of
solutions, or enhance the ability of marginalized communities to bring
attention to community development issues that bear on public health
outcomes? The ability to map and visualize connections between the
built environment, social determinants of health and health outcomes
is becoming much easier with the development of open APIs, Google
Maps, infographics and data visualization tools, and mobiles. Open
data programs are beginning to proliferate, and with the right software,
empower citizens to use data in their daily lives. And take a look at the
results. In the world of mash-ups Google Maps dominate with over
45% of all mash-ups on the open API of Google Maps as compared to
4% and 3% of all maps on MicroSoft Earth and Yahoo Maps that are
both closed systems. The healthcare space is full of market failures
where incentives do not exist to keep people healthy. We believe that
an open innovation portal that builds upon expressed needs of citizens
has the potential to address at least some of these market failures.

This is where we can begin to think of a different conceptual model for

public health. Or, how can public health become a platform that
enables citizens to produce better health outcomes in a co-created
manner with public health experts? Constantio Sakellarides et al. (in
Kickbusch ed. 2008) have called for new ways of organizing health
systems for the 21st century that is centered around the citizen-user.
Health is becoming far more knowledge-centered and literacy
dependent. Sakellarides translates this into a need for citizen-
centered health information systems. To date, most of our discussions
on health information technologies remains very clinician-focused.
While clinical systems are important, we need to broaden the vision for
health applications toward tools and toolkits that can keep citizens
healthier.

There is a gap when we think about the personal use of mobiles and
applications and creating citizen-driven, community computing
platforms for health, such as the ePHIR (electronic personal health
information record where data can be shared (Sakellarides et al 2008)).
We’re still living with the legacy of traditional public health approaches
based on command-and-control systems and need to rethink our
strategies to build upon the actual mobile practices of citizens. As we
move from a command-and-control system to a more integrated health
governance model the mobile will become increasingly important.
The cost of development of mobile applications is rather low but the
voice of public health has been noticeably absent. We would like to
change this and create a platform that can source some of the best
minds in programming with the needs of citizens concerned with public
health. Our platform can serve the larger citizenry as well as provide a
source of software solutions to cities and states around the US. We will
also have the potential to develop mobile health solutions for
developing country contexts as well as use the platform to adapt
successful innovations from the African context, for example, and
adapt these solutions to the US healthcare system.

Urban Informatics and Public Health: The Next Generation of

Healthy Cities. The emergent field of urban informatics14 is
beginning to grow due to the ability to collect vast amounts of data
about the behavioral patterns of people in cities. From cellphone and
geolocation data to sensors data are being collected and there is
growing interest in creating participatory urban informatics groups who
can address issues such as sustainable growth, transportation policies,
environmental health and community planning through the creation of
user-friendly tools, persuasive technologies (eg. dashboards that
enable people to see their consumption pattern such as with the Prius
fuel consumption dashboard), public art and the use of public spaces
to highlight community issues. To date most government use of urban
informatics remains top-down. The AppsforHealth platform will help
facilitate more community-based approaches to urban or community
informatics. For example, Digital Urban Living
(http://www.digitalurbanliving.dk), a Danish, university-based
organization uses interactive media façades to engage communities
with their own interpretations of climate change in public spaces. This
approach is useful in that it illustrates the difference between pushing
14
For some interesting research examples of university departments
engaged in this type of research see: University of Oulu, Finland
(http://www.urban-interactions.net/ubiprogram),
information out to a public versus using co-created interfaces that
engage communities around their (re)framings of issues. In the health
sector this is one of the critical barriers we face; how to engage
communities and individuals. Cocollage (http://www.cocollage.com)
uses public spaces to enable citizens to share ideas and photos in
order to create new types of relations in public spaces and address the
“bowling alone” problematique that Robert Putnam construed as a
major barrier to civic action. Much of the research in urban informatics
is about how we can make data readily available and usable so that
the tools can be built to make the city more efficient and user-friendly.
Sensors, public displays, mobiles and open source software can come
together, hopefully in a sustainable manner, to provide necessary
knowledge resources. The following are important examples in the
urban informatics space that could be useful to public health:

• Urban Atmospheres (http://www.urban-atmospheres.net/): an

Intel experiment to use bluetooth and mobile devices to capture
new data on urban spaces

• SENSEable City-MIT (http://senseable.mit.edu/): collecting real-

time data on the built environment so that we can rethink design
of cities and anticipate changes

• BioMapping.net: a community mapping project being deployed in

cities around the world to understand the emotional valence of
sectors within cities

The idea of public health or the city as a platform is already beginning

to emerge on a small scale in the social mediasphere. Below I’ll
provide several examples of experiments that are ongoing that are
signals of some of the changes we’re beginning to see.

MySociety.org (http://www.mysociety.org/): a UK-based platform that

hosts and develops a broad range of democracy platforms such as
fixmystreet.com, whatdotheyknow.com (for government transparency),
theyworkforyou.com (covers MPs), etc.
Villes 2.0 (http://www.villes2.fr/): A French collaboration between Fing
and Chronos to re-conceptualize the “city as an open innovation
platform” that catalyzes new partnerships for regional problems. The
project is attempting to re-imagine the city or city planning as a
platform that can be modified by the users of the city. This will be
accomplished through the identification of resources that can be
shared by organizations and citizens combined with social media tools
and platforms that are user-friendly.
US government experiments in Government-Citizen Cooperation: The
EPA has launched an experiment in co-creation with citizens to develop
Public Service Announcements. A video contest for the best PSA
around Water Quality was recently launched:

Health and Human Services launched a similar experiment through the

Flu.gov site for influenza prevention PSAs:
Meanwhile, the city government of San Francisco has begun using
Twitter for 311 services and Gavin Newsom has been quoted as saying
that these free services, such as Twitter, now save the government
over $100,000.

While each of these programs represents an example of experimental

research we can see the opportunities for creating tools based on the
research above that could play a role in developing “persuasive
technologies” that can lead to positive behavioral change towards
wellness and sustainable livelihoods. Cities that become adept at co-
creation and urban informatics may find that they become more
competitive cities in the future. In short, AppsforHealth.org can
become a platform for sparking innovation in the next generation of
community health efforts.

Sirianni (2009) argues that we are now living in an era where

collaborative governance is necessary. Increasingly we must move
from the notion of citizens as customers or passive recipients of
government policies and data to seeing citizens as “co-producers” of
knowledge and policies. Those who work in the public sector or work
to build necessary public goods such as public health must now think
in terms of “civic policy design” and how government and public health
agencies can think of themselves as platforms that enable co-
producers to engage and support our work. From thinking in terms of
community assets to supporting citizen scientists, we are witnessing an
important shift in how we work with the rise of social media or web 2.0
tools. Archon Fung and colleagues from Harvard University see these
new tools as shaping a new “collaborative transparency” that enable
interactive and customized tools that empower information users to
provide and pool much of the data (Fung et al. 2007:157). Prior to the
present upsurge in interest in social media we could see this at play in
the development of the Oregon Health Plan as well as through a
myriad of environmental health movements where scientists and
policy-makers have engaged much more closely with civic partners and
citizen scientists.

Residents of California, for example, have experienced the

shortcomings of traditional governance structures in recent years
through the budget stalemates that frequently paralyze state
government. As Sirianni (2009) notes, “legislatures are often simply
incapable of fine-tuned deliberation on the many aspects of the many
policies with which they must deal and for various technical and
political reasons are prone to pass vague laws, which require
administrative agencies to become policymakers through their exercise
of discretion.” Furthermore, public health officials are forced to work
within a chronic situation of funding crises. But re-orienting our
innovation strategies and health governance models we can find ways
to innovate and provide better services within tighter cost constraints.
Platforms such as AppsforDemocracy or AppsforHealth can then be
deployed strategically to drive innovation in periods of economic and
political stagnation. In fact, they may become absolutely vital in
coming years to ensure that citizens get the necessary services that
they have come to expect from government. AppsforHealth.org will
not only work as an innovation platform but we hope to design our
intervention in a way that can provide new lessons for how to rethink
governance, public health and cooperation in a network society.

We need to begin thinking about health literacy in a digital age and

how to create the tools for citizens to empower themselves, not by
calling them consumers but through the creation of platforms where
they can access data as well as use and share data in their day-to-day
activities and prevention strategies. Kickbusch et al (2008) point
toward a future where we can begin to see collaborative innovation
systems which build on the experience of the PHR in healthcare to
create the Public Health Information System or PHIS that enables local
networks of individuals, citizen organizations, patient groups in
collaboration with health organizations can collaborate for enhancing
citizen health literacy, improved prevention strategies and new forms
of collaboration that can produce better health outcomes from our
current medico-therapeutic system.
 Social Media Tools and Platforms: Mapping

When Google Maps opened the API up to developers to build maps on

top of the Google platform this unleashed a great deal of innovation in
the mapping domain and we began hearing about the rise of the
“geospatial web”. As more data become tagged with location-based
tags and the prevalence of sensors grows there are opportunities for
collecting data on environmental health and empowering more bottom-
up citizen science initiatives. While maps have a long history of being
used to marginalize communities (there is a great deal of cartographic
anxiety in much of the critical geography community) there are now
many opportunities to counter this past history and use maps to tell
stories, to make the invisible visible and promote more progressive
public health outcomes. This does not mean we need to drop our
reflexivity towards the past but more participatory approaches to
community planning are now available and the tools are becoming
more user-friendly. Furthermore, a number of the applications we’ll
be covering here are becoming mobile, that is , available on the iPhone

Opportunity Mapping: Mapping opportunity in the region requires

selecting variables that are indicative of high (and low) opportunity. In
this context, high opportunity indicators would be the availability of
sustainable employment, high performing schools, a safe environment,
access to high quality health care, adequate transportation, quality
child care, safe neighborhoods, and institutions that facilitate civic and
political engagement. These multiple indicators of opportunity are
assessed in a comprehensive manner at the same geographic scale,
thus enabling the production of a comprehensive “opportunity map”
for the region.
Open Street Maps and User-generated maps: Inspired by
Wikipedia Open Street Map15 was created as a tool to enable end-users
to edit and build maps. The maps are published under a Creative
Commons license and there is an Open Street Maps Foundation with
the mission of encouraging growth and distribution of Open Street
Maps globally. Part of the mission is to provide free services that would
otherwise entail use of more expensive GIS/mapping services and
expertise. Most maps have technical and legal restrictions on their
use. Open Street Maps has recently played an important role in re-
mapping Palestine after the 2009 Gaza War where BBC was using
dated and inaccurate maps. Within a week, Open Street Maps
produced better maps that could be used by human rights and
humanitarian organizations delivering aid to the Occupied Territories.
15
One can see a year’s worth of edits via a video here:
http://www.worldchanging.com/archives/009381.html
There have been other examples of humanitarian groups using the
maps to coordinate services and avoid unnecessary duplication of
relief services. In the last year over 140,000 miles of highways have
been added to the map of Africa via Open Street Map.16

In the US, organizations have used Open Street Map to tell compelling
stories about education policy reforms:

Other mapping services have focused on making various forms of

16
http://developmentseed.org/blog/2009/apr/22/thousands_of_miles_ad
ded_open_street_map
social data more visible, such as crime. At the present time there are
numerous crime mapping platforms available. These platforms also
raise a number of ethical and ethics of representation issues and need
to be examined critically. At a recent Netsquared Conference in June
2009, activists raised questions about the manner in which maps could
be used against communities of color. Proponents of the maps made
the case that with some of the tools such as SeeClickFix people could
track drug dealers in neighborhoods and report and document
anonymously. For many community activists with negative
experiences with local police forces this was a worrisome development.
The founders of SeeClickFix reported that there were examples of
community activists and residents using the tools to report police
violations as well. But clearly we will need to encourage a robust
debate on the ethics of bottom-up mapping and not just assume that
bottom-up absolves us of ethico-political debate and analysis.

Maps are of growing importance in the sustainability or “green health”

field as well. Urban EcoMap (http://sf.urbanecomap.org/) is about
understanding where greenhouse gases come from in given
neighborhoods. Users can explore the interactive maps to obtain a
better understanding of their neighborhood’s impact on greenhouse
gas levels. The site also has tools for creating an action plan for
reducing carbon emissions through transportation, energy and waste
policies and one can set goals for the neighborhood as well.
We can also see how maps are being used to tell stories in policy
debates through the example of Barack Obama’s Organizing for
America’s Health Care Action Center’s use of a mashup that allows
people to merge location data with a narrative about their health care
struggles:

Open Data: Several years ago a movement started in the UK called

“Free Our Data” (http://www.freeourdata.org.uk) that pointed out that
many commercial entities such as Google and Amazon.com free up
data linked to applications or APIs for Google Maps, for example, yet
many government agencies funded by tax dollars keep data beyond
the public eye and in formats that are not readily usable by the
average citizen. In fact, there were commercial entities charging the
public for access to data paid for by tax revenues. Using the example
of Google Maps where the API was open and enabled a great deal of
innovation on the Google Maps platform, they launched a movement
for open data in the name of public sector and citizen-driven
innovation. Additional organizations such as “Mash the State”
(http://www.mashthestate.org.uk) joined the fight for open data and in
the US there is now a great deal of local and federal activity around
open data projects. The Obama Administration through the likes of
Vivek Kundra as the Chief Information Officer in the Administration
have created websites and tools for enhancing access to public data.
The drivers behind this movement include a growing demand for
transparency in the wake of the Bush Administration’s excessively
closed governance model which has been viewed as prone to
corruption, political manipulation and poor governance at best.
Several organizations in the US have been leading the charge in the
public sector, namely the Sunlight Foundation
(http://www.sunlightfoundation.org) and Maplight.org that have
developed numerous visualization tools to reveal connections between
politicians and lobbyists
(http://www.sunlightfoundation.com/projects/2009/healthcare_lobbyist_
complex/ and Open Congress (http://www.opencongress.org/)),
stimulus tracking tools (Stimulus 360
(http://github.com/sunlightlabs/publicmarkup/tree/master,
Recovery.org, Stimulus Watch
(http://www.usbudgetwatch.org/stimulus)), , public
markups/annotations of bills
(http://github.com/sunlightlabs/publicmarkup/tree/master), and the
number of widgets and transparency tools is growing almost daily. The
development of tools does not necessarily mean that we have
complete transparency in government and any visitor to the Sunlight
Foundation blog will find a robust discussion of poor quality data or
rhetoric not yet matching reality. Stamen Designs has created one of
the most interesting transparency tools to track stimulus funding in the
State of California
(http://www.recovery.ca.gov/HTML/RecoveryImpact/map.shtml):
Local governments such as the city governments of Washington, DC,
San Francisco and Vancouver, Canada have recently launched open
data policies. The effort in Vancouver has been characterized as an
effort to “make the city think like the web”17. That is, how can we
make the governance model of the city begin to look like the
characteristics we find in web 2.0, participatory and open. Some of the
principles here include using open source software for municipal
services. The web model they use is the Mozilla Foundation’s Firefox
browser, an open source browser that has flourished due to donations
of intellectual labor of users and programmers who have helped build
out the functionality. The rationale follows the observations that
Sirianni (2009) made earlier, the complexity of political life and publics
is becoming sufficiently diverse that typical command and control
models are becoming brittle. The way to build more resilient systems
is from bottom-up, co-created methodologies. Open data policies are
the enablers of this to happen. Next, cities will have to adopt open
standards so that data and software solutions are interoperable.
When these conditions are met we can begin to see the foundations for
new platforms that facilitate citizen participation and innovation. Some
existing examples of these platforms would include SeeClickFix.com.
SeeClickFix is a platform where citizens can “tag” problems on a map
and point out to local government officials when a problem needs to be
resolved. The application is now available on iPhones where your geo-
location data can be readily tracked. When problems can be “seen” or
visualized there is a greater likelihood that local movements will form
to work with government to resolve the problem. Furthermore,
17
http://www.slideshare.net/david_a_eaves/creating-a-city-that-thinks-
like-the-web-vancouver-remix-1741369
numerous studies have shown that the more data are used, the better
the data become (Zittrain 2008).

Transparency: The previous discussion on open data highlights the

growing political push for transparency in government, foundations,
corporations and NGOs across the spectrum. Fung et al. (2007) note,
however, that not all transparency policies are equally effective. We
need to think beyond transparency as a virtue in itself and think about
what constitutes a good transparency policy. If the data or activities
that are being “opened up” do not lead to positive social outcomes
then the particular transparency policy has obviously failed to achieve
the desired political outcomes. If there are no incentives for disclosers
to open up data then we may not see the necessary outcomes. In
public health there have been several transparency focused initiatives
that are worth following. In the UK there is a food hygiene rating
system for restaurants called “Score on the Doors”
(http://www.scoresonthedoors.org.uk/) and across the corporate
sustainability space we see numerous endeavors that assess products
and/or companies and their relative performance in sustainability,
health, human rights or social justice causes:
• DotheRightThing.com
• ProjectLabel.org
• GoodGuide.org
Good Guide is one of the most sophisticated in the moment and Daniel
Goleman’s treatment of the organization in his “Ecological Intelligence”
book is worth examining. Goleman is interested in how we can get the
right level of information to consumers at the right time so that
consumption behaviors change and produce social outcomes.
Industrial ecologists who work in the area of life cycle assessments
(LCA) such as Dara O’Rourke, the founder of GoodGuide.com, are
leading the charge in this arena through the creation of platforms that
are capable of collecting the most important data and then finding
ways to lower the costs of information access. Goleman quotes Nobel
economist George Stigler who pointed out that information has a price
and that is the “cost” of searching for it. When you’re looking at the
impact of a product on the environment, the social costs of global
supply chains or sorting through the health data on every component
of a consumer product these costs remain extremely high, unless you
have a Good Guide to do this work for you. GoodGuide.com currently
has information on over 70,000 products that comes from hundreds of
databases with over 80 million bits of information. Good Guide now has
an iPhone app that enables consumers to retrieve ratings of products
as well as make lists based on the filters-social, ecological and/or
health-that they prefer. They’re looking to the next generation of the
service that will rely more heavily on sensors (RFID) and automatically
alerts the shopper to the status of a product or an alternative route
that analyzes one’s credit card purchases. While platforms and
approaches may vary, the point is that new forms of transparency are
making their way into the marketplace so that citizen-consumers will
find it increasingly easy to consume through whatever normative filters
they chose.
Goleman interviews Archon Fung who points out that the first and
second generation transparency efforts were largely regulated
approaches, or top-down. Third generation, as seen in Good Guide, are
driven by vigilant, active consumers, or citizens as I would have it. This
need not be an adversarial, hostile relationship either. Progressive
companies can engage with these citizens and innovate through
engagement with feedback. I would add that many of the current clean
tech/green business innovations are precisely this form of innovation–
through an engagement with activist and critical discourses that were
once adversarial in nature but companies adopting a more
constructivist/open approach who actually embraced permeable
boundaries of the firm stand a better chance of innovating.

Goleman argues that while we see many examples of consumers

exhibiting purely price sensitive shopping patterns that this will begin
to change as these transparency platforms continue to grow and this
will have profound effects on industries dependent on industrial
chemicals. The chemical industry has a very different perspective on
toxicity than consumers, particularly consumers demanding more
access to data on the environment and their health, ie. biocitizens. And
it is getting easier to find other biocitizens sharing your values and to
amplify one’s voice. One of the key disruptors in development is
Earthster, a B2B, free, open-source, web-based program that enables
businesses to obtain a snapshot of their LCA-supply chains. This
enables businesses to benchmark themselves against industry
averages. Here information becomes power for purchasers who can
use this data as leverage with suppliers. The public sector can use this
data to combine efforts to exert more power in the marketplace. In
essence, you have a data commons for LCA that becomes the
market maker! There will be tremendous opportunities for companies
able to take advantage of this information and drive disruptive
innovation. And this brings us to the next signal of the future of social
media in public health with the use of data visualization tools and
infographics. These tools are growing in importance as tools for
sensemaking and influencing behavior as well as transparency politics.

Data Visualization Tools: Edward Tufte is know as the “King of Data

Visualization” and for his critique of PowerPoint as a tool for sharing
knowledge18. His critique focuses on the manner in which PowerPoint
works to reassure the presenter rather than enlighten an audience,
relies heavily on flawed hierarchies of simplistic bullet points that give
the impression of political neutrality. His work on visual literacies has
helped spawn a wave of interest in infographics and data visualization
tools. With the development of social media platforms many
visualization tools have become much simpler for the average person
not trained in graphic design or computer science to create
visualizations of data. Sites such as Swivel.com, Many Eyes
(http://manyeyes.alphaworks.ibm.com/) enable people to take data
sets and carry out a range of operations to make the data more
accessible, hopefully. There is also a site on Flickr.com
(http://www.flickr.com/groups/datavisualization/pool/) with a wide
range of data visualizations and infographics as well as the almost
daily contributions of Good Magazine graphic designers to the library of
infographics available on a vast number of social and political issues.
The social media blog Mashable frequently carries stories on new
visualization tools (see: http://mashable.com/2007/05/15/16-awesome-
data-visualization-tools/) . In public health we have no shortage of
data and yet there is hesitancy among many public health academics
and professionals to engage in public discourse with data visualization
or infographic formats that are being used by a growing number of
blogs, non-profits, etc. Privacy of health data is probably the most
often heard explanation as well as the fear of flawed analyses by those
untrained in public health. Given the quality of work in many other

http://www.edwardtufte.com/bboard/q-and-a-fetch-
18

msg?msg_id=0001yB&topic_id=1
areas it would be naïve to dismiss much of the work we’re seeing
developed and to find ways to engage and actually improve the data
that public health practitioners are using.
In fact, numerous NGOs have developed guides and tools for the
general public and activists to take advantage of visualization tools
and technologies in their advocacy campaigns. The Tactical
Technology Collective (http://www.tacticaltech.org) has developed
numerous guides:
• Maps for Advocacy
(http://www.tacticaltech.org/mapsforadvocacy): demonstrates
how to create maps and host them on a site for advocacy
campaigns
• Visualizing Information for Advocacy
(http://www.tacticaltech.org/infodesign): a guide to best practices
in information design and data visualization for advocacy
campaigns
Columbia University’s Spatial Information Design Lab
(http://www.spatialinformationdesignlab.org/) provides an excellent
example of how data, mobiles and information design are coming
together to offer new opportunities for innovation in public health.
Based in the Graduate School of Architecture, Planning and
Preservation, they are a think-action tank focusing on how to creatively
use the visual display of information on cities, namely social data and
geographic data, to help make sense of a growing amount of data that
are available about cities and events. They recognize that the WAY we
present data can be as important as the data themselves. Aesthetics
matter (imagine that in your biostatistics course in a school of public
health!). The list of projects currently under way include
(http://www.spatialinformationdesignlab.org/projects.php):
The most interesting public health application involves visualizing data
on air pollution and asthma in local neighborhoods.
Visualization tools, as mentioned earlier are increasingly being
mobilized for advocacy campaigns as well. In many ways this is
nothing new---politics have always been influenced by visual cultures
and tools but now we have many more tools available to convert
complex data sets into visualizations that tell stories across a wider
range of communication platforms. Users can now take data sets and
create a variety of visualizations on platforms such as:

• Swivel.com

• Many Eyes (http://manyeyes.alphaworks.ibm.com/manyeyes/)

• Many health 2.0 websites and mobile self-management platforms

for diabetics and a wide range of other diseases have data
visualization tools that enable users to chart their data and share
within networks19

• There are also repositories of infographics and data visualization

such as the one below from Flickr.com

http://www.flickr.com/groups/innovation-dataviz/

In the most recent Apps For Democracy round the site, Datamasher.org
at the time of this writing was one of the finalists. Data Masher allows
users to select different datasets and create mashups or visualizations
of the datasets. Others are using the combination of graphic design

19
See http://beta.glucosebuddy.com, GlucoSurfer.org, SugarStats.com
(accessible via Twitter)
and visualization to produce tools for informal sector workers to protect
their rights in city spaces.

Making Policy Public is an organization that brings together designer

and advocates and tries to make public policy issues more public
through:

While the effects of public policies can be widespread, the discussion and
understanding of these policies are usually not. This series aims to make
information on policy truly public: accessible, meaningful, and shared. We
aim to add vitality to crucial debates about our future. At the same time,
we want to create opportunities for designers to engage social issues
without sacrificing experimentation and for advocacy organizations to
reach their constituencies better through design.

A jury of prominent design and public policy experts selects advocates

and designers in a two-part submission process. The first call for
submissions is to advocates, organizations, and researchers with a public
policy issue, problem, or system that needs a visual explanation. The
second call is to graphic designers, visual artists, and other creative
workers. The jury chooses collaborative teams and announces them on
the Making Policy Public website. CUP provides the collaborators with a
working stipend, project management, and research assistance. CUP
publishes the resulting fold-out poster and gives 1000 copies to the
sponsoring organization for use in their advocacy and education work.”
The trend towards greater use of visual tools is being fueled by the
proliferation of data that are available for public use in recent years.
As open data programs proliferate and mature we will likely see even
greater political contestation over the meaning of data when these
very same data become used more frequently by a wider range of
citizens and organizations. A visual literacy around information
aesthetics will grow in importance as not all visualizations are created
equally. Blogs such as FlowingData.com and the infographics team
from Good Magazine, which has recently carved out an important niche
around the development of compelling infographics and data
visualizations on sustainability and social issues, have become
important sites for discussing and keeping abreast of the tools
available. Andrew Barry (2003) discusses the politics of data in the UK
over air pollution that may give us a sense of what the future holds.
When the government installed public dashboards in London and along
major freeways in the UK that gave readings of current pollutant levels
there were some unintended political ramifications. The particular
pollutants measured and levels of particular pollutants considered as
harmful became contested political data. Technologists often assume
that merely having the technology to measure alone will be a
progressive political act, however these cases illustrate that the
science or framing of science behind the numbers once the numbers
come into view can generate important political debates in society.
Barry points to examples such as this to emphasize the importance of
technological citizenship in the so-called ‘knowedge economy’. Citizen
scientists and experts do not necessarily passively accept the science
of the the experts at face value.

One of the forces behind the proliferation of data is the steady growth
of sensors. Mobile phones are being developed that have air sensors
and the ability for peer-to-peer monitoring (Motorola) and there are
some very interesting projects that have emerged in the past year to
take advantage of sensor data and visualization tools. Sensorpedia
(http://www.sensorpedia.org) is a new platform for sharing and
exploring sensor data from around the world. This type of platform is
going to be increasingly useful due to sensor data collection projects
such as Pachube (http://www.pachube.com) that is “a service that
enables you to connect, tag and share real time sensor data from
objects, devices, buildings and environments around the world. The
key aim is to facilitate interaction between remote environments, both
physical and virtual.” Individuals are able to connect their electricity
meters, iPhones, Second Life environments, architectural sensor data,
building management systems, wearable sensors, etc. and tag and/or
connect to other individuals and sensor environments to facilitate
interactions between real

and virtual environments. Conceptualized as the YouTube of portals for

sharing environmental sensor data, it allows users to embed this data
in blogs and websites and connect physical environments. The
platform was developed to make it easy to build new applications and
services off of the platform. In other words, it is a generative platform.
Some mobile sensor applications being developed at UCLA are also
useful for illustrating where this nexus of sensors, data, locative media
are going and could become very powerful in the public health arena.
The Center for Embedded Network Sensing (CENS,
http://research.cens.ucla.edu/) has a research initiative on urban
sensing (http://urban.cens.ucla.edu/) and participatory sensing. Here is
the description of participatory urban sensing:

urban sensing is about people like you—equipped with today’s

mobile + web technology—systematically observing, studying,
reflecting on, and sharing your unique world. through discovery
and connected participation, you can see the world anew. you
can tell your local story. you can make change.

This is an initiative that resembles many of the recent citizen science

programs that are using the mobile computing platform coupled with
sensors to empower local citizens to collect and share environmental
data and then tell stories that can influence public policy.
The Personal Environmental Impact Report is interesting from the
standpoint that it enables users to obtain a better understanding of the
local environment on their own bodies as well as obtain an
understanding of their impact on the environment. The sensors
currently record the following:

1. Smog Exposure (PM 2.5 particulate exposure)

2. Fast food exposure

3. Carbon impact

4. Sensitive Site Impact (PM2.5 particulate impact on sensitive

sites such as schools and hospitals)

The other important dimension is that it moves beyond the individual

and uses the social networking platform Facebook to share data and
create a community around the data collection. While many in the
health 2.0 world are interested in the ability of individuals to collect
data (for example, the Nike + iPod tools for collecting fitness data,
http://www.apple.com/ipod/nike/) or Kevin Kelly’s interest in the
“Quantified Self”
(http://www.kk.org/quantifiedself/2008/09/selftrackers.php), the CENS
projects have a stronger public health orientation via the social
networking aspects. Additional projects include:

• CycleSense (http://urban.cens.ucla.edu/projects/cyclesense/):
“What if bike commuters could work together as a community to
document hazards to biking and make positive changes to their
local routes? UCLA’s Center for Embedded Networked Sensing
(CENS) is collaborating with Los Angeles bikers to make this
vision a reality. We are designing an application that runs on
mobile phones that enables bike commuters to log their bike
route using GPS and provide geo-tagged annotations (images,
text notes) along with automatic sensor data (accelerometer /
sound) to infer the roughness and traffic density of the road.
Using this information, we plan to create an interface to enable
bike commuters to plan their route based on both safety and
interest vectors.”

• DietSense (http://urban.cens.ucla.edu/projects/dietsense/):
“DietSense is an online service that allows you to self-monitor
your food choices and further request comments from dietary
specialists. Mobile phones with CENS participatory sensing
platform will let you record photographs of your meal everyday,
either automatically or by sensible notifications (based on time of
the day or location). In addition to photos, you are encouraged to
annotate the photos with voice or text messages providing
information not captured by the images (e.g. diet soda as
opposed to regular soda). Data (daily photos, timestamp,
location via localization techniques or user-reported), and
annotations (text/voice) are stored in password-protected
accounts on web servers for self-review and specialist assisted
analysis. When you log on to your DietSense profile you will see
personalized presentation of your dietary habit. Dietary
specialists can provide further analysis if you configure your
profile to be shared.”

• Family Dynamics
(http://urban.cens.ucla.edu/projects/familydynamics/):
“Increasingly, every family member has a mobile phone. Doctors,
therapists, and life coaches are recognizing that these phones
can help families collect and learn from data about their habits,
environment, and interpersonal dynamics. Working with the
Semel Institute, we are developing technologies to document key
features of a family’s daily interactions (e.g., co-location, family
meals, and consistency). Phone-based tools can collect data
otherwise invisible to wellness professionals who most commonly
rely on family member self-reporting. For example, families and
 coaches can learn about behaviors such as consistency of
engagement at mealtimes using measures of proximity to one
another, as revealed by Bluetooth stumbling [Kotanen03]. Media
journals composed of images, video and audio from the phones
in combination with GPS and Bluetooth co-location data can
provide an evidence-based bridge between individuals, families,
and wellness professionals. We are also exploring similar
approaches to assess trends in the physical mobility and habits
of elders to enhance independent living. The first coaching tool
we are prototyping is Andwellness. It is a personal health self-
management application for the Android phones that supports
flexible geo-spatial, social and activity triggered reminders and
ecological momentary assessment.”

• Networked Naturalist
(http://urban.cens.ucla.edu/projects/naturalist/): “Engaging the
public in ecological research. We are creating a flexible
data collection campaigns for the modern, connected
citizen scientist. Citizen Science allows individual volunteers or
groups to observe, measure, and contribute to scientific
environmental studies. How have we made this experience even
better? Networked Naturalist is a collection of tools that
allows anybody to participate in the growing list of popular
citizen scientist projects, all designed to harness the power of
people who are not only concerned about their environments but
also want to do something about it. On-the-go, flexible data
collection schemes, tailored to your busy schedule, allow you to
use your cell phone text, email, and picture messages for data
collection, as well as sending us email or web forms from your
computer. You can see your data and how your data fits in
with other people’s data, and see how involved scientists
interpret those data — all in real-time.”
• Additional projects include the Walkability Project
(http://urban.cens.ucla.edu/projects/walkability/) , Surya (tracks
switch to clean cooking stoves in India,
http://urban.cens.ucla.edu/projects/surya/) and Remapping LA
(on the collective memory of neighborhoods in LA,
http://urban.cens.ucla.edu/projects/remappingla/

Locative media (http://en.wikipedia.org/wiki/Locative_media) is the

general term applied to the use of digital media to trigger social
interactions in particular places and can facilitate the reframing of
space and place. Ben Russell describes locative media as:
"Locative media is many things: A new site for old discussions
 about the relationship of consciousness to place and other
people. A framework within which to actively engage with,
critique, and shape a rapid set of technological developments. A
context within which to explore new and old models of
communication, community and exchange. A name for the
ambiguous shape of a rapidly deploying surveillance and control
infrastructure."20
The space of locative media is growing rather rapidly through mobile
gaming, spacial annotation through augmented reality applications
that the latest smartphones enable, geo-tagging and general geo-web
applications on mobiles and accessible via laptops and a growing
number of leading edge new media artistic examples that are being
curated in public spaces to make us think critically about public space.
BJ Fogg at Stanford University coined the term “persuasive
technology” or “captology” as the study “insights into how
computing products — from websites to mobile phone software — can
be designed to change what people believe and what they do.” This
work examines how computers and other technologies can be
designed to change people’s behaviors21:

Source: http://captology.stanford.edu/

The use of SMS or texting as reminders for medications or as nudges in

smoking cessation programs would be examples of persuasive
technologies. We see other examples in the Prius dashboard that

20
Russell, Ben (2004), "TCM Online Reader Introduction", Transcultural
Mapping Online Reader (Locative Media Lab), archived from the original
on 2006-07-20, retrieved 2005-11-13 (see in Wikipedia reference cited
above)
21
One can access videos on how this works in practice via
http://captology.tv
allows drivers to see the impact of their driving behavior on fuel
consumption. We can even find more public examples of persuasive
technologies in the sustainability field with examples such as the
carbon counter that was recently unveiled in New York City22. The
counter takes into account the major greenhouse gases and displays in
public the levels of gases in the atmosphere in real-time. The goal is to
get the public to think about their own contributions to global warming
and how they can change these behaviors. There are other examples
of public dashboards in public health where cities that have embarked
on obesity campaigns are using dashboards to track collective weight-
loss or BMI changes over time.

Fogg lists several factors below that are important design factors in
developing persuasive technologies.
22
http://www.scientificamerican.com/blog/60-second-
science/post.cfm?id=carbon-counter-unveiled-in-new-york-2009-06-18
Ian Bogost (2007) has developed a critique of BJ Fogg’s framing of
persuasion as running the risk of becoming overly coercive and lacking
the reflexivity to examine the framing of problems and finding
alternatives. Bogost approaches games through the discipline of
rhetoric to force the participant to rethink underlying assumptions
about the world or a particular issue. His company
persuasivegames.com has produced a number of interesting
‘persuasive games’ that either directly or indirectly touch on important
public health issues.
One of the goals of persuasive games is to stimulate critical thinking
through the use of rhetoric. In the games above everything from
portion size and profits of food companies (Stone City-Cold Stone
Creamery) to the contingencies of the geographical spread of
pandemic flu (Killer Flu) are scrutinized. Rather than playing to a
script where the user or participant is directed toward a pre-
determined outcome, as in Fogg’s use of persuasive technologies,
persuasive games can be useful in generating different framings of
problems and critical thinking skills.

Augmented Reality: Another relatively new technology that is

growing in importance and becoming increasingly mobile as well as
utilized in mobile games is augmented reality applications.
Augmented reality applications ‘augment’ or merge virtual
environments with the actual physical environment. Typically this is
through a mobile device, for example, an iPhone. The user can use the
video camera in an iPhone 3GS and through an augmented reality
application obtain additional virtual information overlaid on the
physical environment that the viewer is watching at that precise
moment. For example, the Dutch-based company Layar enables the
viewer to obtain additional location-based data such as the location of
health centers, or one could imagine this with environmental data or
other risks in that geographic setting such as accident reports, toxics,
crime, etc.
Wikitude is another service that enables the user to obtain wiki-like
information about geographic spaces. The augmented reality field is a
new area with a great deal of hype about the services at the moment
due to the novelty. In actual practice there will be issues around the
buffer time to download information, the use of open platforms that
enable a rich eco-system of material to develop or be developed by
end-users as well. However, as one can see from the other examples
presented thus far, there are numerous ways to visualize health issues
and data that will change the way we think about how we drive policy
changes, engage with communities and these examples should give us
some insights into potential ways of constructing collaborative,
community platforms for health in the near future. The health
technology debates tend to be dominated by discussion of the
personal health record (PHR) or electronic medical record (EMR). My
point is that the opportunities are far more vast than what the current
health technology obsessions may reveal. We’ll now turn to the
emerging area of mHealth for a brief discussion of how texting/SMS are
being mobilized in many developing country markets and what we
might learn from these cases.

In the government 2.0 circles there is a growing discussion of the

potential for AR in large geospatial projects as a way to channel more
contextual information to users in situ. Furthermore, AR could provide
another potential application for citizen reporting when users have the
ability to upload video from particular contexts almost instantly. One
such government 2.0 application is the “Invisible City”.23 AR platforms
could be created that cross multiple government agencies into a
cohesive information infrastructure such that users would have access
to environmental, health services, crime, socio-demographic data
about a given neighborhood or location. As with all of the
applications, there are potential downsides as this same data could be
used to marginalize or redline a neighborhood as well. Our
‘information politics’ will have to co-evolve with the platforms and data
as well.

23
http://www.gov2expo.com/gov2expo2009/public/schedule/detail/103
60
mHealth: As the cellphone has rapidly become the primary
computing platform for the majority of the world, most of whom live in
developing countries we’ve seen a great deal of innovation in a rather
short period of time. From mBanking (eg. M-Pesa) and m-payments to
m-agriculture and mHealth ventures, there is a rapid rush to develop
new services on mobile platforms. The Rockefeller Foundation’s Health
System Transformation programmatic area is putting eHealth at the
center of health system transformation and mHealth is a major piece of
the eHealth eco-system. In early 2009 the UN Foundation, Vodafone
and Rockefeller Foundation launched the mHealth Alliance to help
catalyze the development of standards, business models and
regulatory frameworks for mHealth to take off

Most mobile health interventions at this moment consist of the use of

SMS/texting for reminders for drug adherence in complex protocols
such as DOTS therapy or with anti-retrovirals for HIV. The mobile
platform is also playing an important role in data collection for
community health workers in the field. The bulk of existing programs
are still in the pilot stage, however there is a great deal of growth in
the area without sufficient attention to sustainable business models at
the moment. This will likely slow the growth in the long run unless
addressed before too long. The best overviews of the mHealth global
landscape at the moment are the reports in the list of references from
Vital Wave Consulting (2009a, b).
There are many commercial mHealth initiatives in the US such as Be
Well Mobile that utilizes a simple color coded user-interface for asthma
sufferers (this is just one of their applications). The program
demonstrated excellent results in the pilot phase in San Mateo County
with low-income, high risk for hospitalization childhood asthma
sufferers. Users can input flow meter data and a green border on the
user interface indicates that the child’s asthma is currently under
control, yellow indicates the need to utilize an inhaler, red indicates
that the need for physician intervention. It is important to remember
that mHealth is not strictly about the mobile phone. There is a growing
array of Bluetooth and wireless devices that can connect to
smartphones, PDAs, etc. and will increasingly play a role in the space.

In general, we see mHealth applications being used in the health

sector for the following functional areas:

A good example of a low-cost mHealth approach that shows the

promise of becoming a disruptive innovation in global health is the
Frontline Medic SMS based on the work that Ken Banks, the founder of
kiwanja.net and Frontline SMS. Frontline Medic is rather simple in
terms of technology and the human dimensions of the approach are
developing rapidly. Below is a schematic diagram of a typical Frontline
Medic SMS instantiation. The savings in gasoline expenditures for
community health workers alone are substantial and can reportedly
cover much of the costs of the intervention in short order.
 Frontline Medic SMS
Some additional mobile interventions that are worth paying attention
to in public health would include TxtEagle and the Extraordinaries.
Thes are not mHealth interventions per se but involve the use of
crowdsourcing and mobiles---this makes them interesting examples for
our thinking on open health platforms.
TxtEagle (txteagle.com) takes advantage of the fact that companies
around the world have millions of minor tasks that could be completed
via simple text messages and opens up income generating
opportunities to Kenyans with mobiles to complete these tasks and
earn credits for the cellphone usage in the process. Keep in mind that
low-income Africans are spending a substantial portion of their incomes
on cellphone minutes because the mobile is often a gateway toward
higher incomes.
The Extraordinaries uses crowdsourcing via mobiles to find “micro-
volunteers” for small tasks that can be completed via text messages
during brief down periods that we may all have during a typical day.
From citizen journalism around environmental problems to
crowdsourcing location data for defibrillators around the world, the
Extraordinaries approach represents an interesting way to cultivate
greater civic engagement for public health issues.

Cloud Computing: Cloud computing has become a major focus of

attention in the technology and computing world over the past year or
so. But the technology has been here for quite a while. Cloud
computing by definition is “a style of computing in which dynamically
scalable and often virtualized resources are provided as a service over
the Internet. Users need not have knowledge of, expertise in, or control
over the technology infrastructure in the "cloud" that supports them.”24
If you have used gmail, hotmail, SalesForce or a wide variety of other
commercial software that you access virtually, through the internet you
have had an experience with cloud computing. Below is a schematic of
some of the players in the cloud computing space:

Often referred to as “Software as a Service” (SaaS), there are also

“Platforms as a Service” or “Infrastructure as a Service”. The
collaborative platforms mentioned earlier in this report such as the
Virtual Alabama platform used to integrate the stakeholders for DHS is
an example of how the cloud can be appropriated for more efficient
services as well as creating a better infrastructure for collaboration.
End users typically do not need a sophisticated knowledge of software
to utilize the services and the spread of cloud computing is growing in
the international development sector. Intel and Catholic Relief Services
have been using a SaaS platform rather successfully for agricultural
interventions in the Great Lakes Region of Central Africa. Some of the
challenges that cloud computing represents include the tendency of
chief information officers in organizations to be wedded to the 1990s
internet and block access to many cloud computing sites (as is the
case with many social media sites despite the fact that they are being
used increasingly for professional reasons). There are also issues
around privacy and security, particularly when we are dealing with
Personal Health Records when the data are in the cloud and not on an
organization’s server. Lascia (2009) points to the emergence of
multiple identities that we will have as cloud computing proliferates
where we will have professional identities for some services and
personal identities for others. There will also be hybrid services (think
about the multiple uses of Facebook).
24
see http://en.wikipedia.org/wiki/Cloud_computing
The features that cloud computing will offer to public health are lower
barriers to entry for building platforms given the rapid expansion of
data that we will have to find ways to manage in the future. The
possibilities for even greater collaborative platforms across sectors
given the multi-sectoral nature of public health are important as well.
The collaborative eco-systems that cloud computing affords will enable
more rapid dissemination of best practices and data, and opportunities
for “plug and play” platforms that can facilitate integration of a wide
range of services. We’ll now turn to one possible scenario for
collaborative platforms for public health that build on the PHR but
broaden the concept to become a community collaborative platform.

Citizen Health Information Systems: This report has covered a

wide range of technology tools and platforms currently available for
the public to obtain data, use data to see trends and tell stories about
the issues that matter most to them and to collaborate or foster
collective action to address the issues. Sakellarides et al (2008) have
suggested that in our current era of access to massive amounts of
health information and the general needs of the citizen in a knowledge
society that we are at the beginning of a transformation to mass
customization of health information. The growth of sensors, mobiles,
urban computing, etc. will mean that information systems that can
store, facilitate sense-making and customize data to our local/personal
needs will grow in importance. In the US the concept of the Personal
Health Record to store our personal medical records has become a
central focus of health IT in recent years. Services such as MicroSoft’s
Health Vault as well as Google Health have focused on this type of
platform alongside the collaborative effort to create Dossia.
Sakellarides et al would like us to think in much broader terms and
move beyond the simple notion of merely managing one’s health
information but to the creation of tools for health and digital
literacy and citizen’s empowerment. Moving beyond the personal
health record to community centered collaborative innovation systems
is the direction that their work is headed.

The idea of citizen health information systems recognizes the growing

importance of something that often goes unnoticed by public health
practitioners—the emergence of bottom-up health commons. The
technologies and platforms mentioned throughout this report are
largely being driven by citizens from outside of the public health
profession. More data on the environment, access to more biomedical
data, mobile data collection, geodata, etc. can be shared as we’ve
seen with health 2.0 sites such as PatientsLikeMe.com. The expanded
meaning of ‘health’ coming from below and the recognition from health
professionals that many of the factors influencing health outcomes are
issues often in the domain of other sectors such as economic
development and city planning, transportation, agricultural policies,
technology and innovation policies, etc. means that we must find
platforms that can bring these other drivers of health outcomes and
the data/expertise from these sectors together with health professions.
In global health we’re moving from vertically-driven health programs to
more diagonally focused health system transformation paradigms.
Actually existing health outcomes are the outcomes of the following
interactions:

What does this mean for how we think about innovation? It means
moving from a manufacturing perspective on innovation that
emphasizes the next great thing or piece of technology to social
innovations where platforms and technologies form part of an
assemblage of social practices, local histories, norms and values and
politics and how these can come together in the right form to construct
wellbeing and social outcomes. Often this means reconfiguring power
and expertise, new organizational forms, democratizing knowledge,
new ways of thinking about leadership. Open Health presumes
organizational forms that can move beyond command and control
systems based solely on professional expertise and that we can create
platforms based on new health commons (eg. shared data,
participatory budgeting, co-created knowledge, expert patients and
citizen scientists, risk commons/pools). Imagine a movement for
health reform that builds on a framing of health as an investment in
society, one focused on health and not exclusively medical care, an
ethics based on democratized knowledge and trust rather than
formalized and abstract bioethics, and outcomes based on broad
framings of health rather than absence or presence of disease, and one
based on networks (see Sakellarides 2008 and Kickbusch 2008).

From within this context Sakellarides asks how we can move from a
focus on the Electronic Health Record (HER) focused on individual
ownership of data for use in health decision-making to the Electronic
Personal Health Information System (ePHIS) framed as a “collaborative
innovation system” that promotes health literacy and citizen
empowerment. Below is a diagram of the building blocks of the ePHIS.
ePHIS Building Blocks

Source: Sakellarides (2008:185)

This vision of a collaborative innovation system founded on the

building blocks above has been characterized as follows (ibid
2008:192):

• Networks of personal health information users originating from

citizen/patient associations as the core building block
 • The users are involved in the design and implementation of an
openly accessed technologic platform that enables customized
development of personal health information systems

• The system enables ways to ensure effective communication and

cooperation with local health professionals and services for
personal care and in public health

• Citizen-based consultative and support structures organized at

improving health and digital literacy, knowledge translation
initiatives and market intelligence on improved health
information offers

• New kinds of expertise such as “health information brokers” are

developed to assess content quality and confidentiality

• Different financing modes for “start-up phases” and “sustainable,

scaling up” phases.

One of the value adds of the system is to avoid the embedded

dependencies in personal health information systems tethered to
existing health care providers or EMRs and the design values of the
healthcare system rather than local communities. This could
provide a mechanism to develop the systems of trust and social
capital that are sorely lacking at the moment in the US health care
system.

With the social media platforms and tools that I’ve presented in this
report we could envisage a collaborative platform that goes well
beyond the platform pictured above. Already cities are creating
collaborative platforms for catalyzing “collaborative communities”25.
The technological tools are here for creating a more open,
collaborative form of public health-citizen engagement if we look at
the tools below.

Public Health 2.0 Social Media Ecosystem

25
See the Future Melbourne example here:
http://cpd.org.au/article/collaborating-crowd-better-policy-development
While the literature of the “social media revolution” continues to
expand almost daily, less attention has been given to the political or
socio-technological aspects of what could drive the next generation
of public health practice. It is clear that new forms of cooperation
have emerged and are having important political, social and
economic effects. We are obtaining a better understanding of the
roles that social networks can play in health outcomes and there is
an increasing amount of attention paid to new organizational forms
and I have touched on each of these trends.

To move forward with the opportunities that these technological and

social trends may provide we will have to think about some of the
following issues:

• The notion of the ‘digital divide’ has proven to be problematic

but we will need to have a clearer understanding of how social
inclusion, the rights to the conditions that provide for access
to healthcare and good health or wellness are co-evolving
with not only social technologies but other more traditional
ways of thinking about innovation in health and healthcare
such as biotechnology and medical technology

• What role will the emerging social entrepreneurship/social

business field have in public health and what are the
limitations of this way of thinking?
• While open innovation platforms have been used for scientific
and technology development in corporate settings we are at
the early stages of experimenting with crowdsourcing and
open innovation in the social sector. What sort of standards,
ethical issues need to be addressed to maximize return on
investment while making sure that these platforms serve the
interests of marginalized communities?

• How will our growing knowledge of social networks and

government 2.0 impact research and advocacy on social
disparities in health outcomes?

• How can we design platforms and social design systems such

that the end users needs are integrated into technology
development farther upstream? While many of these
platforms evolve as users engage with the platforms and co-
creation has become a central motif in the social media world,
what are the power relations in actually existing communities
and whose voice prevails?

The socio-political dimensions of social media, while being a side

bar to the technology discussions for the most part, are going to
grow as this field continues to develop. This paper has provided
a very basic scan of the field and provided examples that we
hope will create some foundation for more robust conversations
on social innovation in public health going forward.
 Appendix 1: A framework for assessing ROI on social
media

http://blogs.forrester.com/groundswell/2007/01/new_roi_of_blog.html
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