Vol. 17, No. 2	July 1996

Health services in countries of the Americas are undergoing different processes of change which require effective and timely information systems to permit diagnosis of health situations, planning and programming of activities for specific problems, and evaluation and monitoring of interventions for solving these problems. Geographic information systems (GIS) represent an alternate computerized tool for these processes, since they make it possible to store, handle, analyze, and visualize data and information that have been referenced geographically. Although the usefulness of GIS is being recognized increasingly, there is a technological gap in the countries both in terms of developing the system itself and developing the human resources to incorporate the system in routine public health tasks.

In response to this need, the Program on Health Situation Analysis (HDA) of the Division of Health and Human Development of the Pan American Health Organization has included a technical cooperation project among its efforts to strengthen epidemiology in the health services. The objectives of the program are to facilitate and disseminate the use and development of GIS and to provide technical assistance for its application to epidemiology and public health (GIS-Epi). Project activities consist of support for training, development of cartographic databases, epidemiological analyses and preparation of thematic maps of priority areas, all within the context of developing simplified applications for direct users, i.e., health services, educational institutions, planning offices, etc. Given the difficulties encountered in obtaining the basic maps, an important goal of HDA is to become a depository for country border libraries, which will be shared with users in Member Countries as a part of the cooperation.

Due to the magnitude of requests for cooperation in this area, HDA has prometed the establishment of a network of Collaborating Centers to facilitate training and development of GIS in the countries of the region. To date, three Centers are involved: one in Chile (Department of Epidemiology, Ministry of Health, and Department of Cartography, Metropolitan Technical University), another in Cuba (Department of Biostatistics and Computation, Pedro Kourí Institute and Unit for Analysis and Trends in Health, Ministry of Health), and one in Mexico (University Health Sciences Center, University of Guadalajara). Two additional Centers are being established in Guatemala (Health Authority of Petén, Ministry of Health and in Regional Delegation IV, SEGEPLAN) and in Colombia (Bureau of Information Systems, Ministry of Health). The Collaborating Centers have enabled increased coverage in training, greater development in different areas of GIS, more numerous and varied simplified applications, and maximized opportunities for direct technical assistance to users interested in GIS.

As part of its human resource development activities, HDA has facilitated the organization of six Workshops on GIS Applied to Epidemiology (GIS-Epi) for direct users, from which more than 120 participants from 8 countries have benefitted in a period of less than a year and a half (Figure 1).

To date, there have been workshops in Tampa (USA), Havana (Cuba), Guadalajara (Mexico), Kingston (Jamaica), Bogota (Colombia) and Managua (Nicaragua) and others are being planned for this year. These workshops have been designed with different levels of complexity, including a basic level and an intermediate level; the advanced level is referred to other institutions. It is hoped that the basic level can be studied by managers of local health services, whereas the intermediate level is more pertinent for regional or national health services and for academic and research institutions. Equipment and training requirements are summarized in Table 1. The basic level includes use of the EpiInfo and EpiMap packages, while the more advanced level uses MapInfo and ArcView.

	Level of Development
Requirements for implementation of the GIS at each level	Local Level (Basic)	Regional Level (Intermediate)	Central level (Advanced)
GIS software	Epimap 2.0	MapInfo, ArcView	ArcInfo, GenMap
Cost of GIS software	Free distribution	Affordable (ca. US$1000.00)	Considerable (> US$1000.00)
Computer equipment	PC with 512K of memory	PC with at least 8 Mb of memory	PC with 8 or more Mb of memory
Computer operating platform	MS-DOS	Windows	MS-DOS, Unix
Type of training	Simple, possible self-instruction	Specific, more complex	Specific, advanced programming
Training time	Days	Weeks	Months

The first training workshops revealed the need for more materials in the field of epidemiology and public health with language and content more suited to the needs and skills generally found among users. This material should serve as a reference after the workshop. Thus, participants from the Collaborating Centers and HDA have contributed to the preparation of several theoretical manuals and practical exercises for each level of training and for the respective GIS computer package. It is hoped that these materials will be available for other workshops during the third quarter of 1996, once they have been validated.

Considering the need for simplicity in programs and menus applications (programs or routines) are being developed to summarize processes and perform analytical operations that are more suitable for public health activities. These have not yet been included in the GIS software packages. Operations and procedures that users have mentioned for incorporation include merger of different databases within a single geographical unit, calculation of rates and other risk indicators, procedures for adjusting indicators for comparisons among geographical units, identification of time and spatial aggregations, and monitoring of time series to determine trends. These products are being developed primarily in collaboration with the Centers in Cuba and Mexico.

This collaborative effort seeks to promote the development of other projects in different areas of epidemiology and public health in the countries of the Americas. The Collaborating Centers and the HDA program have developed some GIS applications related to the situational analysis of mortality in regions and communes in Chile, morbidity due to malaria in localities in northern Guatemala, morbidity in health jurisdictions in Jalisco (Mexico), certain epidemic diseases in Cuba, environmental risks in Colombia and basic health indicators in the Americas. Unfortunately, there are few published or well-known works that could be used as examples for other interested parties. An additional effort will be made to disseminate these developments in different forums and publications.

Source: Division of Health and Human Development, Health Situation Analysis Program, SHA, PAHO.

Note: In the last issue of the Epidemiological Bulletin (Vol. 17, No. 4, March 1996), Figure 6 of the article on Epi-GIS makes reference to an epidemic of meningococcal infection in Cuba during 1993. In reality the figure presented a cumulative data from 1983 to 1993. Most of the cases occurred in 1983. In 1989 a mass vaccination program was carried out when the epidemic was already declining. From 1984 to 1994 mortality rates by meningococcal infection decreased from 14.1 to 0.8 per 100,000.

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