The World's Knowledge for All Mankind
by Pocock L, Abyad A



The human population has a history of regional and national advances in science, industry and enlightened thought, taking us from the building of simple tools to an understanding of the beginnings and the nature of the universe, which we inhabit. Being a relatively early form of life, in a relatively newly formed universe, human thought may even be the most advanced level there is, in this point of space-time.

Obviously our thirst for knowledge has been linked to our advances as a global population, with technology, art, philosophy, science and medicine contributing to our greater understanding, and the ability to have some degree of authority over our own lives.

Much of this knowledge has extended to the reach of most humans - and the internet, in modern times, has allowed for greater access to repositories of information and education, both good and bad, though this paper focuses on the positive aspects of equity of access to education.

There are areas of education however, with a huge financial premium on them and much of this is for the right reasons. Those practicing in various scientific, educational and medical fields, need to be properly schooled to ensure that when they put that education into practice, it is achieving the often complex aims of the education.

Unfortunately the price of access to some of this knowledge means that potential scholars in many countries cannot afford it and in the case of medical education this is possibly the most problematic and restricted, while being a basic right for all humans - that is, access to proper medical care.

This leaves some countries with few or no trained doctors and even in the wealthiest countries there are shortages. It also means that those in low-income nations who are able to access medical education because of money or luck, use their degrees as a ticket to a better life in a developed country, looking for their skills. On an individual basis you cannot blame people looking for a more advantageous life for themselves and their families but generally it just perpetuates the drain of resources from poor countries to wealthy countries, where the shortages in trained medical personnel also exist.


Now is the time is to look at inequities of access to medical education particularly, in an age when Information and Communications Technology (ICT) does provide for strategies for innovative and strategic means of better and cheaper distribution of, and access to, vital knowledge not just in the interests of individual access for the student, but universal access to the means of making it a better world for all.

Knowledge leads to enlightenment of thought, creativity, compassion and empathy and possibly world peace via better public and academic education.

Attempts have been made, in recent times, to look at the global problem of inequities in medical education and practice.

The dearth of high quality educational resources in some regions is self evident, with many global doctors practising in fields in which they have no formal training whatsoever. These doctors however are filling vital roles and doing the best they can under the 'local' circumstances.

Good global education needs to fit the requirements of a greatly diverse consumer, with diverse values, diverse levels of prior training, and be accurate in all situations.

These problems are magnified when dealing in medical education, particularly primary care, and when dealing with a multinational approach and a multinational endpoint.

The Applied Sciences of Oncology Distance Education project

The International Atomic Energy Agency (IAEA) and the Regional Cooperative Agreement for Research, Development, and Training Related to Nuclear Science and Technology (RCA) financed a Distance Learning Course on the Applied Sciences of Oncology, to be delivered on multimedia CD ROM. This training course is an outcome of an IAEA Technical Cooperation Project implemented under the (RCA). RCA is an intergovernmental agreement among seventeen Member States of the IAEA in the Asia and the Pacific Region.

Following the identification of the shortage of well qualified radiation oncologists in the region, the Member States of the RCA decided to address this problem through the development of distance learning material. The National Project Coordinators also assisted in the pilot testing of the training material. Three RCA Member States, three AFRA (Regional Cooperative Agreement for the Africa Region) Member States and two ARCAL (Regional Cooperative Agreement for the Latin America Region) participated in the pilot testing of the distance learning material.

The requirement was to 'educate without teaching', for fear that an untrained doctor may follow the instruction by rote, for example, in every case of breast cancer, when it is the lymph nodes that are involved, that indicate appropriate treatment. Any prior level of medical knowledge was also not to be assumed, so the project also involved complementing or reviewing 'basic training'.

Essentially the task was to combine science with socio-economics and to look in depth at the many issues involved. While initially developed as a training aid, it was deemed in 2005 a successful TC by the IAEA and accepted as global curriculum to train 900 oncologists in developing nations every 5 years.

The major challenge in the ASO project was the learning environment. In the case of the ASO project the environment was multimedia CD as it required complex scoring and tracking, access to web based services from the CD itself - video, pfd, and animations plugged in, date stamp recorded on course certificate/report as each module was completed.

If using an English language platform there are both technical and language issues to be overcome. Even an apostrophe can turn into a foreign character on a non-English language PC, but the most important aspect is the level of language used. Unambiguous, clear and simple language is best but certainly hard to achieve when dealing in quantum physics for example.

Obvious issues are the recommending of certain facilities, equipment, medicines and so on that may not exist in the country in which the doctor is practicing.

There was also no ethnic or cultural viewpoint, no geographical location, no national approaches, and level of language at ESL (English as Second Language,). In many cases it was actually very difficult for the authors to mentally remove themselves from a national viewpoint to an international viewpoint.

To localise content you need to look at both ends of the process. In the case of global medicine the source of the medical education is as important as the endpoint (the global doctor, registrar or medical student). Medical education is usually written for the audience it is going to teach, within a process and with certain facilities, which match the conditions within which the resultant medical graduate will practice.

The second aspect is the learning environment on the CD based courseware itself. Intuitive navigation for the student was the goal, and several visual techniques were employed. All units in the same subject areas were colour coded for familiarity, where possible easily recognized symbols were used e.g. forward and back arrows for screen navigation and so on.

Once patterns were struck they were repeated again for familiarity - this applied to question styles and graphic styles,

Pilot countries involved were Egypt, Morocco, Malaysia, Pakistan, the Philippines, Argentina and Uruguay, and also included students from Costa Rica, studying in Argentina.

The success of the project has seen it achieve curriculum status and ongoing maintenance is intended, to ensure that the course remains current as oncological practice changes. It is hoped to translate the modules into Spanish, French and possibly Chinese, Russian and Korean, after 2007.

It is estimated that a fully functional and regularly updated course in English, plus these major languages, could support the training of up to 900 radiation oncologists every five years.

Access to global medical education involves three basic issues, and the first is the content and the focus of that education. It is the experience of the authors that medical education currently tends to stop at borders and that education within national boundaries can have a focus that depends on the wealth of that country. In wealthy counties there is much education and focus on diseases of wealth, for example cardiovascular disease, diabetes type 2, but little focus or need for the same on malnutrition, malaria, typhoid, cholera and other even preventable disease.

This can disadvantage both ends of the spectrum.

The global community misses out on the contribution to real education needs and also the wealthy community, through the medicalisation of what is often lifestyle or cultural or media induced trends. With emphasis and money spent on cure and amelioration, there is less emphasis on self-help, prevention and discipline.

The second aspects are affordability and accessibility. With few quality education facilities within a country, or with poor access due to war, famine, national catastrophe or other ignorance, the potential scholar has to finance their own solution. This is not as big a problem to the wealthy in the community, but the wealthy have greater access to all forms of education and therefore greater choice. If we focus on those who have the commitment and the ability but not the money, that is, the vast majority of international medical students, then both accessibility and affordability are the major problems, but in the solving of this conundrum, it provides a great solution to the inequities of the healthcare of the global population. And it is good economics and good epidemiology, as pockets of illness and disease have an even greater ability these days to affect the global population, such as our experience with SARS, avian flu and HIV-AIDS

Issues of affordability

Even giving that the individual developing nations' medical student could afford the course at an overseas institution (not withstanding the high degree of variability of quality in institutions even within countries) there is also travel, accommodation, cost of bureaucracy, cost of personal support and issues of loneliness, isolation, cultural differences and other compounding factors.

And affordability must always have a national perspective. If a doctor practising in a developing country, earns the equivalent of $US 200 year, most sources of outside education are immediately placed out of reach.

The reverse of the national exchange rate however, can be put to good use. Spending 'outside' money within a developing country however sees costs greatly reduced, and a solution taking advantage of existing infrastructure, is even better.

World CME

Our World CME project was born out of these very circumstances. The situation was compounded by the countries that greatly needed this repository of medical education and training, were those who could not afford it, at all, in some cases.

Usually this is where it ends. The market place, in this case universities, have finite costs they must cover and if the student does not have the means, then the quest ends there.

Information and communications technology however, has given us the means of distributing and authoring global public and professional education. Even in developing countries most educated people would have email and access to a PC. Using these as mass distribution tools, in a strategic and focused way eliminates huge costs and makes education dissemination viable.

So do developed nations leave quality medical education on the shelf which is needed by half the world, simply because they cannot afford it? We were faced with this dilemma and World CME ( was our solution.

The two issues were money and distribution, in other words, 'sustainability'. The solution was to put it on the Internet for countries to 'help themselves' but needs of accreditation and standards and quality assurance - to allow national medical standards to develop - were the next priority, and so the full World CME service was developed, and utilising different ICT solutions for different nations.

History of World CME
We have taken a three tiered approach to pricing of education based on National Income Status (World Bank pdp 2005)1, with low income nations receiving education free as long as we can cover distribution costs. Putting it on the internet has allowed us to distribute it at no end cost to the user and given the relative socioeconomic status of our students (doctors and medical students) this has been a viable approach. Other strategies have been using CD where internet is not prevalent, and medical centres can usually provide a PC. Rights to issue on paper are given where ICT is not readily available.

Re-writing and revising content
As the internationalisation of medical education has not yet occurred we have had to devise it ourselves and it looks at much the same issues as with the ASO project.

But mostly education has to be both understood and relevant to the local situation. This may mean instead of prescribing iron tablets to an impoverished anaemic pregnant woman who cannot afford them, the recommendation is the growing and eating of green leafy vegetables; and it may mean using the ancient medical arts of history taking and physical examination, when expensive tests are not available,

World CME is now used in 6 developing nations and is just as much the brain child of those participating countries who have made the leap of faith to do something positive about the national situation. Indeed the leap of faith has not seen World CME as a poor substitute, rather as an enhanced interactive format as a positive advantage and a means to leap ahead nationally by using the advantages of ICT and interactive education.

Other global or regional approaches can include face to face teaching, via focused medical education delivered regionally in conference style formats, such as with MEAMA the Middle East Academy of Medicine for Aging4.

The number of older people is growing and they frequently have health-related problems with a mixture of physical, mental, social and behavioural aspects. In the past, these problems were seen only in a few older people and the families were able to take care of their parents or old relatives. However, societies are changing as a result of the demographic and cultural developments and they face the increasing possibilities of modern medicine. The MEAMA was founded in 2002. The first course was held 2003/2005 to stimulate the development of health care services for older people in the Middle- East area. The course has been built up with 4 sessions, each of 4 days, that will cover important topics of the health-related problems in older people. The second course will follow the same format and will start in April 2008.

The organisers of the MEAMA conduct this course with support of the European Academy for Medicine of Ageing, the European Union of Geriatric Medicine, the Geriatric Medicine Section of the European Union of Medical Specialists and the International Association of Gerontology. MEAMA is the first organisation in the Eastern Mediterranean Region dealing with education of the health care professional in the art of elderly care.

Following on the acceptance and use of these approaches to strategic international medical education, has been the development of a multimedia medical university (MMU) built on the same principles and due for launch in 2008.

Its distance learning formats using ICT, will allow it to cater to the postgraduate medical needs of doctors and medical students worldwide.

The education will also offer enhanced formats, for example, interactive video of surgery procedures and a range of clinical topics in interactive formats. The global multimedia aspects also allows MMU to select the best academics/teachers globally, to provide and write the medical courseware.

The aim is to provide the highest standards in the delivery and content of medical education, to meet the real needs of international health and to make such affordable to all doctors in all nations, in an attempt to provide both genuine equity of access to education and genuine equity in the delivery of national healthcare.

1. World Bank Report 2005