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New information and communication technologies are increasingly present in our daily lives. In recent years, they have converged into a single place: the modern-day cell phone. Originally intended only for conversation between two people, this device has gradually acquired several additional functionalities. We can send and receive messages by email, install a communication application such as WhatsApp to send text messages and images and even talk to another person anywhere in the world for free, take pictures and make videos, and then send them to another person anywhere in the world at no additional cost. We can also listen to music and watch a movie. Alarms can be set to wake us up in the morning and an agenda used to schedule and remind us about appointments. With the help of a search engine, we can visit a library or search for a school. If we get lost in a city, we will be able to locate ourselves and be guided by the fastest route to reach our destination. We can receive news that interests us, as well as enter social networks and share information, experiences, and knowledge with many people. Smartphones have become small pocket-sized computers with Wi-Fi capabilities. There is an increasing trend in the number of applications that serve the most diverse interests. Access to these services occurs in fractions of a second. Spatial distance matters little. Thanks to the mobility inherent to the mobile device and the network infrastructure, we can receive or send information regardless of location. So, the cell phone currently assists in countless activities, besides talking on the phone.

Change occurred very fast, and those born before 1970 followed this unfolding closely. Fifty years ago, no one imagined that a device with so many functionalities would be in the palm of their hands. In this short period of time, the cell phone began to store increasingly more memory and operate at an increasingly faster speed. Most impressively, memory, speed, and features improve even more with each new device released. All these innovations have been accompanied by the progressive decline in prices of this equipment. Not surprisingly, there are currently about as many cell phones as there are people in the world, including in Brazil. According to data from the Brazilian Institute of Geography and Statistics (IBGE), there are 194.4 million cell phones in operation in a country with 185.7 million inhabitants. The data for 2017 also indicate that Brazil holds the fourth spot in the global ranking of nations with the largest number on online gamers.

Michael Haneke, 76, acclaimed Austrian director and screenwriter, winner of the Oscar for the best foreign movie in 2013, recently said that the smartphone has become an extension of our bodies. Haneke’s view aligns with the results of “The Phone-Life Balance Study” (Etcoff 2018), conducted between November 30 and December 26, 2017. The survey, designed to gather information on the behavior of mobile phone users, involved 1100 users aged 16–65 in four countries, namely, Brazil, France, India, and the United States. The results suggest specific trends. A third (33%) of the respondents said that they prefer to use their cell phone instead of paying attention to people around them. Half of the respondents (53%) describe the smartphone as their best friend. Only 48% of Brazilians think they need to have a life separate from the smartphone, compared to 62% of French, 60% of Indians, and 69% of Americans. Another fact that has caught our attention relates to the feeling that users have when they think they have lost their cell phone: 56% of Brazilians panic, against 59% of French, 66% of Americans, and 77% of Indians.

As we mentioned earlier, the presence of smartphones in our lives is relatively recent. We are still living in a time when digital natives mingle with those born before the Internet and computers. Behavioral patterns and social perceptions of people’s relationships with new information and communication technologies blend into a tangle that deserves in-depth understanding.

Are these new information and communication technologies, the epitome of which is the smartphone, different from traditional means of communication? We believe so. Let us see why.

Television, radio, and print media all have an information production center. Following this communication model, the users’ role is restricted to receiving this information. Media owners decide what users should or should not know. With the new media, this power has increasingly shifted to our hands. We now have more power to choose what we want to know and see! If we access, for example, YouTube or Netflix, we decide which movie we want to watch. The channels geared to specific interests in these platforms multiply incessantly. The traditional media has been renamed mass media because it is targeted toward an undefined population. In contrast, post-mass media, such as through the Internet, deals with niches: fragmenting the traditional mass media consumer population into increasingly isolated audiences. Also, the media in mass media are limited, although there are hundreds of cable channels or radio stations. On the Internet, this number is incalculable. Furthermore, digital users are not just passive participants of streams of information. They comment, direct, and actively produce more content. In theory, they can dominate the entire creative process by building their community of users, establishing open links between them, neutralizing intermediation, and interacting directly with a market full of niches. These are a few of the differences that lead us to conclude that mass media are entirely different from post-mass media.

In Brazil, we use the verb “navigate ” when we refer to accessing the Internet and looking for something or trying to communicate with someone. Brazilians believe the Internet is like the sea. In 1997, Brazilian singer-songwriter Gilberto Gil announced in his song “Pela Internet” that he would like to “create his website” and make his homepage to have “a boat that sails through this infomar”: a word he created by joining two words, namely, info for information and mar for sea. He wanted to get into the “network and promote a debate.” He wanted to gather “groupies from Connecticut” via the Internet and send an “email to Calcutta.” He hoped “to contact the homes of Nepal and the bars of Gabon” through the network. This was the first song streamed live over the Internet in Brazil. In 2018, 21 years after the first edition, Gil released a second version with the same melody but with revised lyrics.Footnote 1 Before his presentation on a YouTube channel, the composer, born in 1942, said: “That’s the way it goes: we’re getting old, and the world is getting new.” He admitted, in his new composition, that “everything is very well planned on the Internet!” In the 1997 lyrics, he stated that he could create a boat that sailed the infomar with 5 gigabytes. Now, 21 years later, his new fan page needs a terabyte.Footnote 2 “Each day is a new invention” – says the composer.

Statistics suggest that the desire to navigate the infomar is not restricted to the Brazilian musician. At the start of the century, the Internet had only 400 million users or 6.5% of the world’s population. In 2015, according to the International Telecommunication Union (ITU) – a body linked to the United Nations – the number of Internet users in the world already reached 3.2 billion people, which is 43% of the world’s population. The proportion of homes connected to the network reached 46% that year. The ITU also released data on the mobile Internet use. It reports that, in 2000, there were 738 million mobile connection subscriptions worldwide. By 2015, the cell phone was used by 4.4 billion people. This number is expected to reach 5.07 billion people by 2019 (Statista 2018).

Gilberto Gil and Michael Haneke are right: new information and communication technologies are becoming more and more pervasive. They tend to spread, infiltrate, propagate, or diffuse throughout human life. They bind us. They integrate different realms of people’s lives throughout the world. Gil announces: “I am trapped in the net, like a fish when caught.”

The sensation is that we live in another world. This new digital reality is where all or almost all economic, social, political, and cultural activities develop through new information and communication technologies.

In political terms, we can mention the “Movimento Cinque Stelle” in Italy, the “Podemos” in Spain, and the “En Marche!” in France. Ideologically different, all three share the fact that they carried out their political campaigns based mainly on digital communication. In 2009, Iranian youths took to the streets organizing themselves through the Bluetooth of cell phones. In 2010 and 2011, the “Arab Spring” was organized via Twitter. In 2013, it was Brazil’s turn. Castells (2015) and many other social thinkers around the world have emphasized the singularities of social movements via the Internet.

The impact of digital networks affects not only political mobilization but also new economic opportunities. The Forbes’ list of billionaires (2018) can serve as a yardstick for measuring the economic importance of new information and communication technologies. Who is the richest citizen in the world? Jeff Bezos who was born in 1964. Does he own a factory? Is he a farmer? No. He owns Amazon – the leading e-commerce company in the world. He became the richest man in the world, surpassing Bill Gates, founder of Microsoft because his company’s stocks soared 59% in 2017. His fortune went from $72.8 billion to $112 billion.

Another example can be identified in collective financing. Crowdfunding has become a feasible alternative to obtain financing and to achieve successful new ventures. In fact, companies built with collective financing ensure a significant share of new jobs generated each year. This funding model has not only created a billion-dollar global market but has added value to projects by drawing businesses and consumers even closer together. The company comes to know firsthand the tastes and needs of its customer. It often invites its potential clients to participate in the development of a new project. The consumer becomes a collaborator and an investor, who receives exclusive benefits, pre-acquires products, engages in social causes, and may even own a stake in the company.

The United Nations’ Sustainable Development Goals (2020/2030) consist of 17 goals aimed at eradicating poverty and promoting economic growth, social inclusion, environmental sustainability, and world peace through collective partnerships. In a broadcast available on the Internet (ITU 2018), Ban Ki-moon (UN Secretary-General) said that “people everywhere can reap the benefits of connectivity.” He concludes by stating: “We will empower individuals with these transformative technologies so they can advocate and innovate for our common future.”

Ubiquitous. This word means that something is or can be everywhere at the same time. Omnipresent. This is another expression that has been associated with the reality of new information and communication technologies in people’s everyday lives. The emerging trend is the “Internet of Things” that connects items used in our daily routines to the World Wide Web.

However, let us not be naive! The expansion of new information and communication technologies is taking place in a turbulent sea with numerous storms. It involves tense, complex navigation, where caution is necessary.

One of the obstacles is the important social dimension: not everyone has access to the Internet. Despite the aforementioned growth, barriers to connect online are almost always associated with peoples’ living conditions. The ITU warns that, although access has increased over the past 15 years, 4 billion people are still disconnected worldwide. Digital exclusion is highest in less developed countries, where only 89 million people have a connection out of a total of 940 million. They reside in places where wireless networks do not reach them. Also, many people do not access the Internet due to its high cost. Considered the creator of the World Wide Web, Tim Berners-Lee recently stated that “unsurprisingly, you’re more likely to be offline if you are female, poor, live in a rural area or a low-income country, or some combination of the above.”

There is also a substantial proportion of users with access to the network but do not know how to deal with the innumerable functionalities inherent to the new information and communication technologies.

Thus, digital exclusion is also associated with mastering specific skills required to use these technologies. In this group, worth noting is the illiterate population residing in the impoverished parts of the planet and not taking advantage of these technologies. Either way, digital exclusion is the current metaphor of social exclusion. Also, the sea of information is turning into a deluge. It is the arena where correct information clashes with incorrect and unreliable information. In many cases, fraud is virulent. Recently, the issue of fake news involves political personalities in Brazil and the United States and has become a weapon for those interested in interfering in a country’s political debate.

Another problem is associated with the IP (Internet Protocol ) of each computer or cell phone. When a user sends information over the Internet, someone knows. For example, when we buy a plane ticket to a specific location over the Internet, we immediately receive restaurant ads that we should go to in the city we are visiting. If we send many messages related to the environment, we will soon receive product promotions for extreme sports or organic or macrobiotic food. These agencies build our profile and start selling our IP according to our standard of production and consumption of information. That is why people with an environmental profile will hardly receive messages or advertisements advocating genetically modified agricultural production. Gradually, a bubble is formed where green-oriented people only receive messages that value organic and natural production. These ads and messages are not sent to adepts of pesticides.

Information has currently become the primary asset in the economic environment. Data that each of us unpretentiously makes available daily is transformed into value and generates fortunes. Its importance is so evident that it is often referred to as the “Information Society.” In this context, the richest companies in the world are those who know best how to manage and convert information we inject daily on the Internet into money and competitive advantage. Thus, information posted or obtained on the Internet is collected and stored by information and business agencies such as Google and Facebook. This information is sold to other companies. For this reason, they are two of the most profitable companies in the world. Tim Berners-Lee stated that “what was once a rich selection of blogs and websites has been compressed under the powerful weight of a few dominant platforms.”

Digital information does not only have a commercial value. Government bureaucratic systems appropriate information flows and communications for the interests of national security, surveillance, and political control. In this regard, Edward Snowden is an exemplary case. He made public the details of the programs used by the information system of the United States’ intelligence agencies to establish a global surveillance program of each of us, especially public persons. One thing seems increasingly clear: our privacy is strongly threatened. The freedom to insert and send messages, found in the original design of the Internet, seems to be in jeopardy, as it has become a high-value commodity. Furthermore, autocratic regimes are also known to track dissidents’ online activities and police web content perceived as threatening. If political unrest occurs, the first move by repressive governments is to shut down Twitter and other social media.

In these terms, digital exclusion and privacy on the Internet are some of the challenges that compromise the initial design of new information and communication technologies as universal, free, and secure by their very nature.

Where does Brazil stand in this process? How is access to the Internet evolving? Two different trends converge in this country: digital exclusion and increased access. Digital exclusion is closely associated with the structural problems of Brazilian society. Recent data released by IBGE indicate that 25% of the population lives on or below a household income equivalent to US$ 5.50. Class differences intersect with racial hierarchies. In the bottom quartile of the population comprised of some 50 million, the African-descendant population makes up 78.5% of this strata compared to whites who account for 20.8%. Despite recent efforts in the opposite direction, Brazil continues to be a country with high levels of income inequality, even when compared to other Latin-American nations. Furthermore, illiteracy rates are incredibly high. In 2016, IBGE’s National Household Sample Survey (PNAD) revealed that the illiteracy rate reached 7.2%, which translates into approximately 11.8 million illiterates aged 15 years or more living in Brazil.

Digital exclusion can be measured in numbers. The “Internet Steering Committee (CGI.br)” frequently conducts national surveys to verify the expansion of the Internet in the country. Data of the study published in 2017 show that only 59% of households in urban centers are connected. This rate drops to 26% in rural areas. The population’s income levels and years of schooling explain in part this reality. The CGI.br data indicate that the Internet is present in 29% of households with income of up to one Brazilian minimum wage per month (which corresponds to approximately US$ 300), against a rate of 97% in those earning up to 10 minimum wages. Also, private telephone companies must cover 80% of the urban area from the center of the municipalities that encompass up to 30 square kilometers. As a result, companies concerned about their profits disregard places where the population is small and resides far from urban centers.

Increasing access can also be verified. The data provided by the United Nations Conference on Trade and Development (UNCTAD 2017) places Brazil fourth in the world ranking of Internet users: 120 million Brazilians are connected, which corresponds approximately to 57% of the population! In absolute numbers, Brazil lags behind only China (705 million), India (333 million), and the United States (242 million). After Brazil, we find Japan (118 million), Russia (104 million), Nigeria (87 million), Germany (72 million), Mexico (72 million), and the United Kingdom (59 million). The same report also evaluated the growth rate of Internet access in recent years, considering the 2012–2015 period. According to this study, Brazil’s average growth in the period was 3.5%, behind Mexico (5.9% %), Nigeria (4.9%), Japan (4.6%), and India (4.5%) (UNCTAD 2017). Rich countries, such as the United States, Germany, and the United Kingdom, have seen a slower Internet access growth pace, as most of the population already has access.

The “Brazilian Telecommunications Association” (Telebrasil 2018) released a survey conducted in the third quarter of 2017, which indicates that data revenues (e.g., over the Internet) from mobile operators surpassed voice revenues (i.e., phone calls). It also found that there are already 95 million 4G and 92 million 3G cell phone handsets in Brazil.

What role can new information and communication technologies play in health?

In a premonitory text, Eysenbach (2001) sought to answer this question by defining the concept e-health. Stating that the Internet-health interface transcends the technological realm, he argues that it is an emerging field characterized by the intersection of different spheres, practices, and knowledge (such as medical informatics), public health, and business. His vision of e-health, therefore, surpasses the mere technological realm and highlights a state of mind, a way of thinking, and an attitude. Finally, he emphasizes that using information and communication over the Internet can improve health care.

In the same text, the author associates ten other expressions, beginning with the letter “e,” like e-health, which would characterize this emerging field. We grouped them into two categories of questions and concerns the author had 17 years ago.

The first group refers to the quality, efficiency, and comprehensiveness of health care through the Internet. The author advocates that e-health should translate into efficiency and thus lead toward decreasing costs. Also, he argues that e-health is based on evidence proven through rigorous scientific evaluation. Internet-based medical care, now called telemedicine, could extend the scope of health care beyond its conventional boundaries. This is meant in both a geographical sense and in a conceptual sense. These services, in his view, can range from simple advice to more complex interventions or pharmaceutical products. New information and communication technologies could allow for standardized exchange of information and communication between health-care establishments.

The second group of questions and concerns considers the impact that changes in access and use of the information obtained and shared over the Internet have on the doctor-patient relationship. Eysenbach (2001) highlighted the empowerment of consumers and patients. In this case, e-health opens new avenues for patient-centered medicine and enables evidence-based patient choice. He further said that information and communication technologies encourage a new relationship between the patient and health professional, toward a true partnership, where decisions are shared. Accordingly, Eysenbach predicted that the treatment decisions adopted would be in the hands of the patient or would be shared with the doctor. The doctor-patient relationship would not be asymmetric. Therefore, education would be necessary for both physicians through online sources (continuing medical education) and consumers (health education, tailored preventive information for consumers, etc.). This new relationship should impose new types of ethical conduct, insofar as e-health involves new forms of patient-physician interaction and poses new challenges and threats to moral issues, such as online professional practice, informed consent, privacy, and equity issues. Accordingly, health professionals, ranging from primary physicians, specialists, pharmacists, and other caregivers, can share vital patient information to ensure complementary health care. With a lot of information at their disposal, individuals could compare the services provided and choose the one that suits them best. Where health services are rendered in a market governed by the free competition between companies, this attitude is seen as something that enhances the quality of care.

Dr. Muir Gray, director of United Kingdom’s National Health Service, believes we are in the “midst of the Third Health Revolution.”Footnote 3 The first was public health, and the second was the revolution promoted by high-tech medicine. Now, the three revolutionary forces are knowledge, the Internet, and the patient. He concludes his interview by stating: “We have to recognize that the Internet changes everything, including clinical practice.” Many of his warnings have turned into questions or problems.

The decreasing costs resulting from the efficiency of e-health remain a controversial issue. Health information available on the Internet is not always based on the rigorous scientific evaluation. The problem concerning the quality of health information on websites is constant. Despite this, many people follow these guidelines. Some medical practitioners, represented by professional associations, often resist telemedicine, especially for the diverse set of services it can provide. The changes in the doctor-patient relationship advocated by the Eysenbach (2001) are still in the making. Patient empowerment through online information is increasing, but the decision about the most appropriate treatment is hardly shared. The survival of the asymmetrical doctor-patient relationship seems evident to us.

In our view, the weight of tradition is the main challenge to be faced in Brazil by those who understand that new information and communication technologies play a prominent role when it comes to health.

In the first place, it is crucial to highlight mass media’s current hegemony in Brazil. This leadership has been conquered over the last two centuries. The ordinary citizen continues to prefer information obtained through television broadcasts. In fact, it should be noted that the situation is very critical in Brazil since five families control the main communication vehicles with the largest audience in the country. The case of the Globo Group stands out. It maintains the largest audience on open channels, cable channels, radio stations, and various print media. Globo’s audience is larger than the sum of the four other groups (Intervozes 2018).

This tradition extends to health managers, who still print paper leaflets that are distributed to people gathering in public places, as they have done for over a hundred years. In government agencies, online communication continues to play a residual role. Tuberculosis is a case in point. Brazil is included in the list of the 22 countries that concentrate 80% of the cases of this disease in the world. In spite of this, only 12 of the 27 state health secretariats in the country had a tuberculosis website or webpage. In municipal health departments, the situation is even worse. Of the 5570 municipal health secretariats in Brazil, only 8 had a tuberculosis website or webpage.

The “Internet, Health and Society Laboratory” (LaISS) of the Oswaldo Cruz Foundation in Rio de Janeiro researched the quality of information on 20 dengue, 12 tuberculosis, and 19 breastfeeding sites linked to public and private institutions. The results showed that only 14 of these sites achieved 60–70% of the compliance criteria and indicators used in the assessment (LaISS 2018).

The weight of tradition can also be observed in Brazil’s academic sphere. Research and debate about the interfaces between the Internet and health are practically ignored in scientific associations and journals related to public health.

Despite the weight of tradition in Brazil, some initiatives related to new information and communication technologies deserve to be highlighted. They reveal current trends and challenges to those who work in and analyze this social phenomenon. Many of these issues are covered in this book that examines these trends and delves into some of the problems mentioned above. To begin this journey, Monica Murero, an Italian Internet researcher, introduces her vison about the Internet and e-health care as an interdigital field of study in the foreword text preceding this chapter.

The subsequent body of this book is divided into six parts.

The first part will address the emergence and development of the Internet in Brazil. It consists of four chapters. The second chapter analyzes the construction of Brazil’s Internet between 1995 and 2015 to contextualize its origins and growth amidst the global spread of the web. The third shows how Brazil succeeded in passing progressive legislation establishing principles, warranties, rights, and duties governing the Internet. The fourth describes one of the first cities to offer free access to the Internet in the world – Piraí, a small city in Brazil’s interior. The fifth analyzes a political experiment in e-participation, focused on the “Nossas Cidades” (Our Cities) network, that was developed to facilitate civil society groups’ demand-making on local public authorities. They are, thus, chapters that highlight Brazil’s uniqueness and pioneering efforts in the expansion and consolidation of the Internet.

In the second part, we will explore four key audiences at the interface of the Internet and health: the patient, the young, the elderly, and the social media user. In the first case, the impact of available and shared information on the Internet and the emergence of the “expert patient” are addressed. In this case, action profiles of virtual communities that gather patients with chronic diseases will be shown. The next chapter concerns how young people from different social classes access the Internet and use the available health information. The third chapter in this section discusses how the elderly should access the Internet for active aging. The last chapter in this section details the most popular Facebook page about health and the Internet.

In the third part, we will discuss some of the main challenges related to the expansion and use of the Internet throughout the world by covering important health topics: information quality, safety, cyberbullying, and medicines. The four chapters that integrate this third part adopt different theoretical perspectives. The chapter on the quality of information shows Brazil’s innovative experiences on the subject. The next two chapters provide conceptual reviews of health risks associated with the Internet. The first reviews various problematic issues that excessive online activity has on the cognitive and physiological development of young people. The next chapter illuminates the Brazilian experience of how digital technologies mediate bullying and cyberbullying. The following chapter highlights the new opportunities and risks the Internet offers in relation to medicines by considering its global dimension and contrasting cases of the United States and Brazil.

The fourth part is devoted to experiences in health education conducted through the Internet. It consists of four chapters. The first describes an e-learning experience and shows some of the challenges it faced to achieve its goals. The second shows Brazilian massive open online courses (MOOC) initiatives in the field of health. The third details about the experience of the University of São Paulo Medical School in the training physicians using digital innovations. The fourth shows the impact of an online professional training course on community health workers enrolled in the class.

The fifth part of this book highlights and analyzes some practical applications of new information and communication technologies in health. This part consists of four chapters. The first examines smart wearable devices and the barriers toward their widespread adoption given a challenging local context. The second showcases Brazilian experiences using new information and communication technologies for health promotion. The third demonstrates Brazil’s contribution in the use of online games and their importance for health. The next chapter discusses the Internet of Things (IoT) applied to health in Brazil.

The last part and final chapter provides a global overview of future trends and challenges along with an overview of how to evaluate the introduction of new digital technologies.

The majority of authors include professors and researchers from Brazilian academic institutions of excellence located in different regions of the country. Some have written more critical and reflective texts. Others highlight new and innovative experiences. Some chapters analyze the academic research and publications in a particular field of knowledge or action.

In sum, the chapters offer an overview of Brazil’s unique experiences with the Internet in general and its relationship to health in particular. They show the various trends and challenges faced by multiple stakeholders, including civil society groups, government officials, corporate interests, and individual end users. The rollout of new digital technologies in Brazil will retain a dynamic unto itself. Nonetheless, the trends illustrated throughout this book are not exclusive to the country. Like any new technology, the hopes and promises, as well as the challenges and pitfalls, the Internet encompasses will continue to play out throughout much of the developing world and even parts of the developed world. The lessons provided throughout should help illuminate others interested in navigating this complex digital web that draws us together in new ways but that also continues to highlight essential differences in our society as well as in our health and well-being.