Abstract
Global public health (GPH) continues to be a challenging field. It focuses on health-related issues that transcend national boundaries and thus requires global cooperation for implementing solutions to public health problems. Information and communication technologies (ICTs) have the potential to contribute to GPH by improving the quality of healthcare services. The purpose of this commentary article is to discuss the nature and characteristics of the existing link between ICTs and GPH. The key underlying questions discussed in this article are (a) whether ICTs can truly reduce the burden of current GPH problems and (b) how to effectively achieve it. We selected three widely recognized GPH challenges: diarrheal disease among children under 5 years old, malaria, and type 2 diabetes mellitus. These are considered to be examples of salient global issues that, despite the availability of cost-effective preventive and therapeutic interventions, still remain a major burden of morbidity and mortality worldwide. We conclude that there is a growing global interest in ICT-related solutions in GPH. We recommend the development of more transparent frameworks, more theory-informed solutions, and clearer translational links between ICTs and GPH matters. Ten further specific recommendations are also discussed in this article.
Background
This article aims to push forward our current understanding of the relationship between information and communication technologies (ICTs) and global public health (GPH). We debate the editorial of Doarn and Merrell 1 and expand the debate by presenting three challenging GPH issues. We briefly discuss current evidence and knowledge on the different reported contributions of ICTs to diarrhea, malaria, and type 2 diabetes mellitus and its mixed success in the developing world. 2 –6 We summarize the evidence-based benefits and risks of ICT solutions to GPH matters. We then present 3 general and 10 specific recommendations to follow in the development of a global understanding of the role of ICTs in urgent GPH concerns. Hence, the purpose of this article is to re-discuss the nature of the link between ICTs and GPH as it has been reported in the international literature and to propose some general recommendations to expand and improve current knowledge. The key underlying question is whether ICTs can truly reduce the burden of current GPH problems and, if so, how they can achieve it.
Globalization is a complex, multifaceted phenomenon often referred to as the world's economic, political, social, and cultural integration. 7,8 Trends from past decades show that people, goods, assets, and information have moved within and across national boundaries at an increasing rate. 9 Globalization includes international trade liberalization as well as increasing flows of technology, information, and capital across country borders and increasing international labor migration. 10,11 GPH is a challenging field that focuses on health-related issues that are able to transcend national boundaries. It requires global cooperation for the development and implementation of effective solutions, it embraces both disease prevention in populations and clinical care of individuals, and it is highly interdisciplinary. One of the major objectives of GPH is to promote health equality, 12 and it continues to be an exigent arena that provokes great interest to several audiences. All these aspects make GPH a particularly complex and multidimensional field. The eight Millennium Development Goals 13 have been raised as a fundamental purpose, target, and scope for GPH, but in many countries and for many health conditions, this has not been accomplished to its full—or partial—extent. 14
The rapid technological developments and innovations that have facilitated worldwide interactions and interdependence are one of the most important features of globalization. 15,16 One growing domain of interest is the contribution of ICTs in GPH issues. ICTs have been defined as a range of technologies for gathering, storing, retrieving, analyzing, and transmitting information. The basic assumption for the promotion of ICT solutions is that information is a key element to skills. A vast amount of worldwide research conducted over the past decades describes how the improvement of information is the first necessary step toward changes in attitudes, knowledge, and, in the long run, behaviors that affect health. The United Nations, the World Bank, and the International Telecommunication Union agree that ICTs improve the development of low- and middle-income countries (LMICs). The links between ICTs and public health have been discussed by different researchers and policymakers worldwide, and models for public e-health have been proposed in the past. 17 The World Health Organization defines e-health as the cost-effective and secure use of ICTs in support of health. 18 The public e-health strategy seeks to improve access to and quality of healthcare services through the use of ICTs. These technologies are expected to increase the efficiency of time and resources and to improve inputs for complex yet everyday decision-making processes, including the diagnosis, treatment, and rehabilitation stages in healthcare. In addition, they typically promote shared responsibility in healthcare, particularly between the supplier side (health providers) and the demand side (the populations) of healthcare systems. The public e-health model implicitly suggests that every population has health needs that can be controlled or solved by developing innovative community and patient-centered strategies with an ICT component. 19 –21 Consequently, training in ICT-based interventions would be necessary in, for example, LMICs (e.g., the model developed for Latin America by D'Agostino 22 ).
Despite emerging evidence of the benefits of applying ICTs as key components or “active ingredients” in effective GPH solutions, there is more that needs to be untangled and understood in this relationship. How exactly do ICTs reduce the burden of GPH problems, especially in LMICs where ICTs might need to be imposed and therefore might be perceived as de-contextualized? In order to promote a debate in this matter, we summarize the most salient theories and evidence of ICT solutions for three different GPH challenges. We have developed the article presented here on the basis of the recent publication by the Journal's editors Doarn and Merrell, 1 in which they highlight the crucial importance of social networks for effective health technology solutions worldwide. As seen in this article, there is a complex relationship among access to information, social networks, technology, and the health and wellbeing of a population. There is the potential to influence global health promotion through the prevention, timely diagnosis, and effective treatment of ill health when such interrelated dimensions interact in a positive and fluent manner. Social networks, as framed by Eysenbach 20 in 2008, are at the heart of such interaction because they enable peering, collaboration, and filtering of information. These characteristics could be the ideal context for ICTs to be developed and sustained to tackle major GHP issues in any particular region or country. That is, technology could represent a social change agent for global health. 1,23
Discussing Three Pending GPH Challenges and Related ICT Solutions: Where Does the Evidence Take Us?
Literature Search
We conducted three separate scoping searches of international literature in November 2012 without restrictions of any kind, with the exception of gray literature, in four electronic databases: PubMed, ISI Web of Knowledge, Scielo, and Lilacs. The first search was devoted to exploring evidence of ICTs and diarrheal disease. From a total of 436 hits, after title and abstract revision we selected and fully read nine articles. We excluded articles unrelated to this specific search, narrative reviews, and non-research articles such as descriptions of experiences without any pre- and post-intervention evaluation (n=427). The second search was for malaria. From a total of 125 hits, after title and abstract revision we selected and fully read six articles. Large proportions of the articles were unrelated to this specific search or were narrative reviews or non-research articles (n=128), and 75 of them were conducted before the year 2000. Finally, the third search was conducted for type 2 diabetes mellitus. Only 14 hits were found, and after title and abstract revision, we selected and fully read just one article, as the rest were not relevant to this particular review. The literature search strategy appears in detail in Table 1.
Description of a Scoping Review Conducted for Information and Communication Technologies and Three Global Public Health Issues, November 19, 2012
Diarrheal Disease
Diarrheal disease is the second leading cause of death in children under 5 years old worldwide, and it is both preventable and treatable. It is responsible for 1.5 million child deaths every year, and, globally, there are about 2 billion cases of diarrheal disease annually. Children who die from diarrhea often suffer from underlying malnutrition, which makes them more vulnerable to diarrhea. The three most cost-effective strategies to control and reduce mortality caused by diarrhea are access to safe drinking water, improved sanitation, and improvement of underlying malnutrition. 24
From our literature search, the majority of the evidence highlighted the social causes of diarrhea, typically lack of clean water and malnutrition. Some simple preventive measures could be taken to control this GPH problem at the level of the community (access to safe drinking water, improved sanitation), 25 household (breastfeeding, safe manipulation of food, clean sanitary facilities when available), 26 and individual (washing hands and good hygiene, using only clean sources of water, and education about treatment of diarrhea). 27,28 Solar disinfection technology was the most frequent solution reported in the literature, 29,30 but the evidence consistently demonstrates that diarrhea and underlying malnutrition will not be eradicated unless parents acquire the knowledge, ability, and desire to undertake a few simple, but critical, preventive and therapeutic activities. 26
It is noteworthy that there is no single ICT solution that can be used to tackle diarrhea as contexts are very different between communities. 31 Nevertheless, there are similar pathways for intervening in individuals' health behaviors that could be considered, which supports the significance of a GPH approach to this problem (e.g., similar health beliefs, misconceptions, attitudes, perceived social norms, etc.) that could be modified to improve the uptake of preventive measures for diarrhea. It not only relates to individual level behaviors but also to shared understandings and experiences at the community level (i.e., what is considered by the community to be appropriate in terms of water usage, sanitary facilities, childhood malnutrition, mass media campaigns, etc.). These generally similar pathways of low uptake of preventive measures for diarrhea might be reflected, however, in very different ICT solutions. For example, despite the fact that social marketing strategies appear to have been useful for oral rehydration therapy to treat diarrhea in the past, the ICT solutions that some researchers were able to implement in Gambia and Honduras were somewhat different. 32 Both countries adapted lessons learned from past experiences: Gambia was successful in the implementation of a “Happy Baby” lottery (a test of knowledge for mothers of young children), whereas Honduras emphasized community-level diarrheal control and infant feeding practices and then expanded to the national level. That is, ICT solutions might share common underlying mechanisms to the existing GPH problems, but also require highly context-specific or tailored interventions for their true success.
Malaria
Malaria is caused by the parasite Plasmodium, which is transmitted via the bites of infected mosquitoes. If not treated, malaria can quickly become life-threatening by disrupting the blood supply to vital organs. Key interventions to prevent and control malaria include use of insecticidal nets by people at risk, prompt and effective treatment with artemisinin-based combination therapies, and indoor residual spraying with insecticide to control the vector mosquitoes. Through global collaborative work, deaths from malaria have been reduced by 20% worldwide. However, major preventive strategies are often poorly implemented in rural areas and in zones of conflict and war, most often in LMICs. 33
From our review, we found one model for ICTs on diagnostic telemicrobiology workstations that could be used in any country in the world. 34 A second broader model for mobile telemedicine applications for tropical diseases has also been proposed via deployable handheld devices. 35 Five further articles discussed the implementation of ICTs for malaria disease. Howitt et al. 36 recently published a review of technologies for global health that included the control and prevention of malaria. Similar to our own ideas, they stated that although healthcare systems in high-income countries make extensive use of technology, people in the world's poorest countries often lack the most fundamental drugs and devices. Global efforts to encourage the development and use of health technologies could therefore benefit the poorest people in the world. Gupta and Bala 37 conducted a bibliometric analysis of malaria research in India during 1998 and 2009. They found that the quantum of Indian research output in malaria research is high, but their citation per paper was low compared with select developing countries (South Africa, China, and Brazil). Nevertheless, little discussion was presented on ICT solutions for malaria. Kasam et al. 38 used computational grid infrastructures for malaria screening and indicated that this technology could be relevant to fight the infectious diseases of the developing world. Sipe and Dale 39 suggested that spatial statistical analysis is a promising ICT solution for malaria. However, this is a newly developing field, it is not easy to understand, and there is no agreement on standard methods of analysis. These articles discuss different ICT solutions, were published in different years, and are not clearly linked to each other.
Type 2 Diabetes Mellitus
Approximately 346 million people worldwide have type 2 diabetes mellitus. In 2004, an estimated 3.4 million people died from consequences of high blood sugar, and it has been projected that deaths from diabetes will double between 2005 and 2030. More than 80% of diabetes deaths occur in LMICs. Access to medical treatment, a healthy diet, physical activity, maintaining a normal body weight, and refraining from tobacco use can significantly prevent or delay the onset of type 2 diabetes, and adequate compliant treatment can significantly reduce its complications and related deaths. 40
Our literature search uncovered only one publication relating to ICT. Engelgau et al. 41 recommended the implementation of promising new interventions that could prevent diabetes among those at high risk. Given the breadth of our search, the lack of articles assessing ICT solutions for the diagnosis or treatment of diabetes mellitus was surprising. We did not include a description of experiences because they do not allow readers to understand the true benefit or potential harm of a particular intervention in a particular context and time. 42
To summarize our key findings from the literature reviews, current evidence suggests that ICTs are useful in: • Connecting millions of people all over the world, including those in remote and rural areas.
43
Symbiosis of the Internet with other technologies like television or radio could lead to more powerful and sustainable interventions to promote health, security, and wellbeing.
44
• Unprecedented amounts of freely available information are transmitted via the Internet daily.
45
Through the use of ICTs people in the most remote locations can access and be informed about any particular issue of interest. Potential solutions to virtually any problem are available,
46
which is especially useful when there is a lack of health personnel in remote locations.
47
However, the quality and effectiveness of such solutions need to be tested and certified. • Improvements in transportation networks and technology have reduced shipping costs of goods all over the world.
48,49
More efficient and faster industrial and transportation processes have been implemented, with better management, reduced related costs, and shorter periods of time devoted to in the transportation of goods between countries.
32,50
• ICTs have the potential to provide new opportunities to both developed and developing countries to improve market efficiency, social and food security, and healthcare.
51,52
• Reliance on paper instead of information technology is inefficient, wastes money and resources, and compromises quality, monitoring, safety, and confidentiality in healthcare.
53
• There is some evidence of the use of ICTs in LMICs. The effective use of ICTs had prevented avoidable maternal deaths in Peru, Egypt, and Uganda. In South Africa, mobile phones have improved compliance with healthcare in some chronic conditions like tuberculosis. In Cambodia, Rwanda, South Africa, and Nicaragua, mass media ICTs are increasing awareness of human immunodeficiency virus and AIDS. In Bangladesh and India, global satellite technology is helping to track outbreaks of epidemics,
54
and in Kosovo, a telemedicine program has proved to be cost-beneficial for continuous medical education.
55
• Wireless technology is a more cost-effective way of providing ICTs to developing countries as it avoids the cost of installing traditional landlines.
56
–58
• ICTs could provide an ideal opportunity for many LMICs to emerge from decades of stagnation and decline. Furthermore, ICTs could easily convey health information to marginalized groups, thereby empowering them to take steps to improve health-related conditions.
59
Different ICT solutions have proven to be useful in various countries, but important theoretical and implementation issues, in addition to a lack of research, mean that their effective link to GPH challenges remain unresolved, particularly in: • The unequal distribution of ICT solutions worldwide. In 2001, it was estimated that the size of information technology–enabled healthcare services was about $3.1 billion (USD), of which about 80% belonged to developed countries.
54
• Poor acceptance of ICTs in some local areas, such as rural India, where health information is considered to be private and a delicate matter.
60
This may be due to a limited understanding of the possible benefits of ICTs by communities, as well as a limited understanding of communities' needs and beliefs by researchers and public health practitioners. In this regard, e-health readiness has been conceptualized in order to assess, understand, and improve the preparedness of healthcare institutions and communities for ICT implementations.
61
• There are great social challenges related to the long-term acceptance of ICT interventions, such as gender discrimination and cultural barriers to ICTs, that severely compromise their effectiveness.
62
• There is a well-recognized urgency for strengthening multisectorial collaboration to effectively implement ICT solutions in GPH matters.
63
• Despite a general reduction in cost, the implementation of ICT solutions can be more expensive than other community-based interventions that promote communities' self-efficacy and self-reliance.
26
• Some development agencies have too readily adopted the approaches of high-income countries, which are inappropriate to the development requirements of LMICs.
64
• A critical mass of professional and community users of ICTs in health has not yet been reached in many developing countries.
54
• There is conflicting evidence about the power of mobile phones to improve health outcomes in LMICs,
65
for example, text message systems for healthcare professionals in Botswana.
66
More needs to be understood in terms of how to synthesize available evidence and how to adequately assess its quality to improve our knowledge on the use of ICTs in the world.
67
• In addition to uncertainty and a poor understanding of ICT solutions for GPH matters, there is little sound evidence on its cost-effectiveness. This issue needs urgent consideration globally. • ICTs and related globalization processes are not a substitute for appropriate national policies. The ability to benefit from ICTs and globalization requires good governance. For that reason, before introducing any ICT solution, each country should (1) assess how the ICT solution would affect vulnerable subgroups of the population, (2) reduce uncertainty by determining whether changes in the implementation of the ICT might enhance the benefits and avoid harm, and (3) design and implement compensatory schemes and safety nets where needed.
68
• ICTs are not a panacea for economic and social change. There is an erroneous underlying assumption that underdeveloped countries would be able to join the industrialized world simply by utilizing modern technology. A greater understanding of why ICT solutions frequently do not work when they are imposed from outside their own beliefs and values is required.
69
As seen through these examples and reported benefits and risks involved in the implementation of ICT solutions, the strategies required to attain GPH goals depend on the type of health problem and the context within which these health problems occur. 70 –72 For example, the extent to which communications have been facilitated on a global scale is partly due to the unprecedented decline in the cost of transferring information over the last decades. 73 –75 Nevertheless, the implementation of ICTs in most LMICs is still limited by financial constraints and a lack of infrastructure. 45,50,76,77 Given this complexity, the introduction of ICT solutions might be expensive, slow, and not automatically centered in the communities' social values and social norms. In many cases, rather than novel interventions, it is strategies that allow for simple preventive and therapeutic interventions among those who need them at the time they need them that are required. For example, it is evident that the most cost-effective preventive and therapeutic interventions for diarrheal disease and malaria are basic sanitary interventions rather than ICT solutions.
Discussion and Some Recommendations
How then to create a clearer and more visible link between GPH issues and ICT-related solutions? As described in the cases of diarrhea, malaria, and type 2 diabetes mellitus, some experiences suggest the potential contribution of ICTs in alleviating local healthcare problems. Some of them are also supported by interesting theoretical and conceptual propositions at a global level. 1,19 In most cases, ICTs offer a bridge between isolated communities and their healthcare systems, allowing the efficient use of time and resources. ICTs have also become a valuable tool for education in health prevention and health promotion and have provided a unique opportunity for linkage of routine data. 17,70
Based on current literature, the most frequently reported mechanism by which ICTs can contribute to the control and reduction of pending GPH challenges is via the improvement of the delivery and quality of healthcare. As a consequence of an improvement in healthcare globally, an improvement in populations' health and wellbeing is often expected. However, at least three broad gaps in the evidence have become clear: (a) the development of theoretical models that examine the contribution of ICTs in population health in wider social aspects and beyond their application in healthcare; (b) a more evident purpose, or attention to equity-based public health solutions; and (c) the urgent need of a more transparent translational approach to the link between ICTs and GPH. These and 10 further specific recommendations are suggested here.
General Recommendation 1: Our Theoretical Understanding of the Problem
First, we need a conceptual model that clearly links all GPH goals, components, and processes with existing and improved evidence on the effectiveness of ICTs, linking together sound evidence on efficacy, effectiveness, cost-effectiveness, and impact evaluation. A formal systematic approach to uncertainty when there is no (or inadequate) evidence should also be included in this model. This has been understudied in ICT research so far, both in GPH and more generally. Current models have been adequately developed for specific countries, but a global perspective remains pending, as particular ICTs may not be embedded as a social value in many communities at the local level in LMICs. There is great variation in the type and use of ICTs between countries, 78 which makes evidence more difficult to synthesize and translate to other scenarios.
In locations where ICTs are not part of the culture and history, other alternative solutions could be more effective to start with (e.g., financial provision, infrastructure, availability of treatment, effective face-to-face educational strategies) while ICTs become available and, most importantly, while they become relevant to a community's beliefs, traditions, and behaviors. In other words and coming back to the salient editorial of Doarn and Merrell, 1 ICTs can become an agent for social change only when embedded in societies, broadly, and communities, locally, if they make sense and are perceived as important components by the people that create such social networks.
General Recommendation 2: A more Equity-Centered Practice
A profound understanding of the social, economic and political roots of pending GPH challenges is necessary. As with most countries in the world, a significant proportion of ill-health is unfairly concentrated among the poor. For this reason, a healthcare approach to GPH will always be limited. In our opinion, a broader understanding of the potential contribution of ICTs beyond healthcare systems needs to be considered. For example, it is not only the installation of primary care centers in isolated areas that is required, but also the provision of adequate transport links, education, clean water, and food. As stated by McDermott et al. 79 in the 1970s, there is a clear discrepancy between healthcare and disease pattern, and it is unrealistic to expect a significant improvement in health without a change in the social and environmental situation with resultant improved housing and sanitation. It is interesting that Grant 80 pointed out that major improvements in health in LMICs have invariably been associated with the political will to increase equity in a society. A clear conceptualization of how ICTs can contribute to these broader domains of GPH, beyond healthcare systems, could shed some light on the real global scale of ICT solutions in health. In other words, the adaptation of current ICT-related theoretical models with broader and clearer links to tackle not only healthcare systems needs, but also wider social issues, such as poverty, poor health literacy, social exclusion, discrimination, and stigma, is urgently required.
General Recommendation 3: The need for a Stronger Translational Approach
Some authors have noted that development agencies worldwide have too readily adopted approaches from high-income countries that are inappropriate to the development needs of LMICs. 64 Others have recognized the inefficiency and ineffectiveness of most curative and much preventive technology in current use. 81,82 Moreover, some time ago it was stated that when all the evidence is considered together, a vast range of medical technology has shown to be worthless, harmful. and a tremendous waste of public and private funds. 83 –85 In this respect, an assessment of the ability of a technology to develop or undermine individual and community self-reliance to health is critical. Health will not improve unless individuals and communities make rational choices to improve basic sanitary conditions in order to prevent diseases that are preventable and to seek early treatment for conditions that are treatable. 26 A technology should ideally be able to identify the cause of a problem, propose a solution, test the solution, and apply the best possible solution to those who actually need it. 26
Ten Specific Recommendations for Improving the Link between ICTS AND GPH
In order to synthesize the key ideas of this document and provide a more concise direction toward how to improve the link between ICTs and GPH, we propose 10 specific recommendations, which were raised from a sequence of evidence-informed discussions among the authors: 1. Make explicit use of the concept of development and acknowledgment of available frameworks in the link between development and health in the context of globalization.
86
–89
This should promote theories and models that take into account multiple local and international social factors that interplay in the development of any ICT-related solution. 2. Make explicit use of the concept of sustainability and acknowledge available frameworks in the link between this concept and health in the context of globalization. It is particularly important to separate this concept from the idea of profitable technology, especially in LMICs.
90
–93
3. Develop equity-centered ICT solutions that promote GPH in every country in the world while always assessing the risks for the vulnerable ones and how to avoid harm. Hence, there should be explicit use of the concept of vulnerability and acknowledge available frameworks in the link between this concept and health in the context of globalization.
94
–96
4. Develop tailored and culturally aware ICT solutions for GPH matters. This requires attention to language and the cultural appropriateness of any solution implemented in a community.
97
5. Generate evidence-informed ICT solutions for GPH issues. This is quite challenging as a great amount of current literature on ICTs is mostly anecdotal (a description of experience rather than a randomized assessment of their effectiveness) and because MeSH terms and taxonomies are changing over time, making it more difficult to search for articles in different electronic databases and expert organizational Web pages. 6. Develop evaluation models for ICTs that take into account and measure the existing degree of uncertainty around the expected benefit and potential harm of any ICT solution. This is largely done in other fields like economics and epidemiology through well-designed and robust simulation models. 7. Develop frameworks that explicitly show the link between ICTs and GPH.
1,20
–22,54,98
8. Create effective links that are deeply embedded in upstream governmental policy-making processes in each country and also deeply informed about low-stream community level structures, processes, and opinions.
99
9. Create explicit use of the concept of transferable knowledge and acknowledge available frameworks in the link between this concept and public health in the context of globalization.
100
–102
Such transfer of knowledge should be conducted carefully and ideally with the support of international organizations like the World Bank, United Nations, and other independent agencies. 10. Ensure that every new technology is accepted and ideally generated by the same community in which it will be implemented. Allowing communities to develop self-resilience, self-esteem, and empowerment is one of the most powerful tools to successful interventions. Local ownership of ICTs solutions for GPH should be one of the central purposes of any new technology introduced in LMICs. Imposition of alien technologies that do not have a relevant meaning attached will not become sustainable at the local level, beyond budget issues that always come attached to their implementation.
Conclusions
The link between ICTs and public health has been discussed worldwide, and different models for public e-health have been proposed in the past. These technologies could speed up healthcare processes and improve the allocation of resources available via the promotion of digital inputs that might better inform urgent and complex decision-making processes. In addition, they could promote shared responsibility in healthcare between the supplier side (health providers) and the demand side (the populations) with potential lasting effects in the prevention, prompt diagnosis, and treatment of a wide range of health conditions.
Overall, ICTs offer a bridge between isolated communities and their healthcare systems, allowing the efficient use of time and resources. Nevertheless, it is not only what ICTs can do to tackle GPH issues that matters, but also how, which, to whom, and when. Evidence on ICT-related solutions to GPH problems is rapidly growing in the international literature, and a broad, sound, and evidence-informed global approach to it is necessary. With this achieved, the link between GPH and ICTs would become more transparent, theory-informed, and, most importantly, context-specific and culturally aware. Moreover, such frameworks could become very easy to translate to other widely used models on translational research, the social determinants of health models, and others. A more translational and equity-centered approach to the relationship between ICTs and GPH is urgently required. We hope this article promotes the debate on this matter among GPH practitioners, policymakers, researchers, and healthcare services providers globally.
Footnotes
Disclosure Statement
No competing financial interests exist.