eHealth - An origami by Christopher Yuki Itoh

eHealth governance: Google, dot-health and privatizing the Internet

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On February 10th, 2015, Google announced the development of a new feature in their research engine to guide users towards sound evidence-based health information. It will take the form of a “knowledge graph” , an encyclopaedia providing users with information about an illness: from common symptoms to general treatment options [1]. Most users have seen knowledge graphs before when searching through Google, usually about a celebrity, a country or a historic event. The information featured in this graph comes from Wikipedia, Google Images and other diverse sources of information that Google is compiling using a clever search algorithm to judge the relevance of the source.

Google is partnering with the Mayo Clinic and other Google-affiliated health care professionals to review the medical information. The Mayo Clinic has been a strong advocate in online social media marketing, designing user-friendly and jargon-free medical charts and articles for over a decade through their Patient care & health info portal.

While this announcement is trivial news for most users (including most health care professionals), it really comes in the middle of a quiet storm. Public health institutions, governments and private firms are competing to hold the reins of the development of eHealth and put themselves in a leading position of a lucrative market with strong social implications. Some examples of eHealth issues include the policy on electronic medical records, the development of telemedicine health care with smartphones apps, and the use of social media for health promotion on targeted audiences, however these are just a glimpse at the overall picture. The collection and compilation of enormous sets of data that mix research and commercial intentions through the Internet is difficult (impossible?) to govern and regulate. We refer to this as simply: “big data” .

Last year, the “dot health” issue rocked the foundations of the World Health Organisation as a governing body in public health. Who would have control over the .health domain, which could become the strongest reference in online health?

The “dot health” saga

Providing users with reliable health information on the Internet has been a very pressing matter of concern for public health institutions since the late 1990s with the democratization of Internet. In 2000, WHO submitted a request to the Internet Corporation for Assigned Names and Numbers (ICANN) to be assigned host of the .health domain name at a time when ICANN opened a call for applications for top-level domain names. This request was rejected, out of fear that one institution would hold too much control over the content of health websites [2].

In 2008, ICANN opened a new call for applications for top-level domains (TLDs). Five requests were made for the .health domain name – all from private for-profit organizations. Each applicant had to submit a detailed report of their technical and financial capacity to manage the domain on the long term. In 2012, the .health domain was awarded to Dot Health, LLC who made a public statement to work for the public’s interest. Immediately, many organizations, including WHO and national and non-governmental public health authorities, made an objection to this domain allocation. This drove ICANN to delay the release of .health to 2014; the domain attribution remains in the hands of Dot Health, LLC, even though they have not done anything with it [3].

This situation angers WHO and public health authorities for what they see as a malicious attempt to privatize eHealth and, therefore, put profit-oriented business in a leading position in eHealth governance [4]. While the private sector is a recognized source of innovation, allowing it to play a regulatory role may create a geopolitical imbalance between the United States and the rest of the world.

Google stepping in: healthy competition for global eHealth policy coherence?

The involvement of the Mayo Clinic in Google’s project is promising news in public health. While the actual influence it will have on Google’s strategy is still unclear in comparison to the other actors involved in this project, Mayo Clinic brings some safeguards and medical expertise to the kind of advice that will be displayed.

The knowledge graph may just become the new reference for most Internet users and website developers. Google’s new feature may impact all the other websites in the way they present health information. As they consistently work their ranking in search engines (through search engine optimization, a.k.a. SEO), they do become more and more responsive to Google’s initiatives, taking the Internet giant’s lead to maximize their own success. Dot Health, LLC cannot stay insensitive to such competition and it will be in their best interest to cooperate with Google to optimize the ranking of their future network of .health websites. At least at first. Ultimately, this Google – Mayo Clinic partnership might just be the best way to efficiently involve public health authorities in the governance over eHealth.

This being said, nothing is better than a keen critical mind towards what you read.

Just because Wikipedia says it, it doesn’t mean that it’s true.


It’s Lindsay Kobayashi’s article that inspired this article. I recommend it, it is a very pleasant read:

Kobayashi, L. C. (February 18, 2015). Will Google’s new health search function change the way we manage health? [blog post]. PLoS Blog: Public Health Perspective. URL:



  1. Ramaswami, P. (February 10, 2015). A remedy for your health-related questions: health info in the Knowledge Graph [blog post]. Google Official Blog. URL:
  2. Illman, J. (2000). WHO’s plan to police health websites rejected. BMJ : British Medical Journal, 321(7272), 1308. URL:
  3. Mackey, T. K., Liang, B. A., Kohler, J. C., & Attaran, A. (2014). Health Domains for Sale: The Need for Global Health Internet Governance. Journal of Medical Internet Research, 16(3), e62. URL:
  4. Mackey, T. K., Liang, B. A., Attaran, A., & Kohler, J. C. (2013). Ensuring the future of health information online. The Lancet, 382(9902), 1404. URL:

Some good readings


eHealth - An origami by Christopher Yuki Itoh
eHealth – An origami by Christopher Yuki Itoh

The origami in the featured picture were made by Christopher Yuki Itoh, artist and graduate student at the Johns Hopkins School of Public Health in Biochemistry and Molecular Biology. His wonderful artwork is presented on his website.

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Gatien de Broucker

Économiste de la santé | Health Economist at Johns Hopkins Bloomberg School of Public Health
Gatien is studying health economics at Johns Hopkins Bloomberg School of Public Health. He has a keen interest for health literacy and the management and development of health knowledge. He was Editor-in-Chief of the IJHS between 2013 and 2014.

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