A social ecology of wireless technology by Critical Friends of Technology
Wireless technology serves many valid human purposes. Wireless technologies have penetrated the remotest corners of the globe and will soon be ubiquitous, with billions of units in use. In this report we consider both costs and risks of wireless technologies, employing a holistic framework for evaluating technological impacts. We discuss wireless technology in developing countries, environmental issues associated with wireless, and health concerns.
Critical Friends of Technology (CFT) is a small informal team of researchers interested in promoting a holistic understanding of the benefits, possible adverse effects, and unintended consequences of different kinds of information and communications technology (ICT). CFT includes two computer scientists, two anthropologists, a reference librarian, and a physician. All of us work in the San Francisco Bay Area. In this paper we attempt to look systemically at wireless technology in hope of finding ways to anticipate and mitigate possible adverse effects and unintended consequences of this very useful technology.
Technological advances begin in the inventor’s garage and the laboratory and are eventually offered in the market place. Once adopted, they are followed by laws and regulations, sometimes years later and only in response to perceived crises. In the current economic downturn, one of the bright spots has been the spread of wireless communication technologies for telephone and data services. This paper is the initial effort of CFT to provide an overview of wireless technologies, those that use the radio spectrum for transmission.
Historically, radio spectrum has been viewed as a scarce resource. This credo is almost seventy years old and has been based on technology from the 1930s. In the United States the Federal Communications Commission has been at the center of the debates and battles to determine how to allocate what is perceived to be a scarce resource. This administrative process has been responsive to commercial and political forces. Spectrum use has been determined administratively and more recently by auction. These complex processes have shaped the kinds of services and products available to consumers. While there is considerable excitement and innovation taking place with wireless, earlier optimistic estimates have been tempered because the telecommunications companies have not recovered from the depression that hit in 2001.
This report is divided into three sections: Wireless in developing countries, environmental issues related to wireless technology, and health issues related to wireless technology. We could not cover all facets of wireless and decided that these three are useful for understanding the benefits, possible adverse effects, and unintended consequences of wireless. The section on wireless in developing countries discusses the immense potential of wireless technology to reach widespread populations with a smaller investment than landline systems. The section on environmental issues, by contrast, analyzes the unintended adverse environmental consequences of wireless, in particular in countries with no infrastructure for recycling and hazardous waste disposal. The health effects of wireless technologies are more ambiguous than environmental impacts, highlighting how difficult assessing the long-term effects of technology can be.
Wireless in developing countries
Availability of ICT in developing countries is not as widespread as it is in Europe and North America. However, the spread of wireless technologies, especially cell phones has been rapid. At the end of the last century these regions accounted for 22 percent of the new users. In several more years this may increase to 75 percent. The costs of extending land line networks for voice or data are high. New areas and new groups of users are able to have access to ICT services including cell phones, wireless local area networks, and long range wireless links between rural and urban centers. The use of prepaid calling cards has enabled people with little cash and no credit rating to use cell phones. Another encouraging development is the design of systems specifically for harsh environments in developing countries where the engineers better understand the conditions than those producing products for enterprise markets in the U.S. and Europe.
As wireless technologies become available in new markets all over the world, we need to consider the environmental issues. The very countries enjoying new benefits from the rapid spread of low cost cell phones are the same ones with few or unenforced laws and regulations related to the environment. A recent report from INFORM, Waste in the Wireless World: The Challenges of Cell Phones, calls attention to the hazardous materials used in the phones and batteries including arsenic, antimony, beryllium, cadmium, and lead. By 2005 the U.S. annually will send 65,000 tons of phones to the garbage heap, including disposable phones that are used for an hour or more and then tossed. By shifting the rhetoric from the concept of "disposable" to "recyclable," and by debating the role that manufacturers have in the process (as beverage companies already have), we can come to terms with the problem before we suffer the effects of a degrade environment as the dangerous materials leach into our soil and water.
The health of consumers is affected both by the applications of wireless technology and by the devices’ impact on the body. And proliferation of the devices in hospital environments can result in interactions and interference. Physicians’ use of wireless technology is expected to triple over the next three years. With increased adoption of a network, the technology usually becomes more useful. Some of the benefits include rapid access to information about a medicine, a condition, a patient; less time on hold for consumers; streamlining clinical trials to bring a drug to market sooner; real-time patient monitoring from remote locations; and, telemedicine for rural areas.
However, the increase in use of different devices that make use of radio transmitters has resulted in interference problems. In some hospitals in Scandinavia, cell phones are banned because they have caused ventilators, defibrillators, and dialysis machines to fail. Other studies have shown these failures to be very rare.
Finally, we discuss studies of the effects of wireless devices on humans. One study financed by the wireless industry association showed that the effects of wireless antennas is not enough to damage DNA but did cause genetic damage in human blood. The problems with reporting and summarizing both positive and negative findings is that variables and complicating factors are usually omitted when they are summarized in a newspaper article or for an introductory article such as this one.
Social, political and economic impact of wireless technologies in developing countries
Throughout the world, wireless technologies are being adopted at different rates and integrated into people’s daily lives in a variety of ways. These differences are the consequence of the economic, social, regulatory, and technological conditions that already exist in these different segments of the world’s population. Developed nations such as Japan and many parts of Europe were quick to adopt mobile technologies, and subcultures of users have developed. Howard Rheingold writes about "Thumb tribes" and "the power of the mobile many" in his recent book Smart Mobs. In developing regions of the world much has been made of the promise of wireless technologies to transform people’;s personal, economic and political situations. In these regions where land lines are often only installed in major cities and population centers, wireless technologies are being deployed to bypass the costs in time and money of installing land lines to the more remote areas.
Many reports suggest that wireless services are taking hold in developed and developing countries alike, spreading even faster than radio, television and telephones and promising to revolutionize telecommunications. Between 1978 and 2000 the number of subscribers grew to 500 million worldwide, but it took just two years more to double to one billion users. International Data Corporation estimates there are more than 1.5 billion cell phone users, including 250 million mobile Internet users. Thus we need to consider the consequences of widespread adoption of wireless technologies.
Donors, foundations, policymakers and leaders in developing countries are looking for ways and means to improve the infrastructure base. Wireless networks for telephony and data are often cited as the most economically feasible solution to the lack of existing infrastructure in these countries. The expectation is that because fixed wires do not need to be installed, mobile networks can connect places that previously had no telephone service relatively quickly and cost effectively. In some cases people would be able to get a mobile connection by simply paying for the card that activates their handset and the use of pre-paid phone cards would turn mobile handsets into portable, personal pay phones. Pre-paid service allows users who might not have the means to afford a subscription-based service to become mobile users. When a cell phone provider began offering service in Kenya in 2000 they projected a market of 50,000 users. Now, three years later, there are more than 1.3 million subscribers. In some developing countries mobile communications are viewed as a competitor to sluggish government-owned fixed line telephone systems, which can create obstacles to acceptance of mobile technologies.
Is it possible for non-industrialized countries to essentially skip an entire stage of communication development, and successfully utilize wireless technologies? Could this be a step up in communication that kick starts a more complete industrialization for these nations? Probably not. The popular concept of "leapfrogging" ignores the reality that the existing telcos have invested in other technologies (fixed phones and copper lines), and frequently these companies have a great deal of influence through market domination and ties to the government — if they are not actually part of the government. They are not going to abandon their infrastructure just because cell phones and wi-fi (802.11 series network protocol) are popular and cheap elsewhere. However, many companies will build on top of the older technologies, and many incumbent monopolies or duopolies have introduced cell services or have seamless links between the mobile and fixed systems.
The proponents of wireless technologies believe that by working to fill the communications void where many people do not have access to any telephone service, wireless will be central to the new global telecommunications growth of the future. The Cellular Operators Association of India claims that for every one percent increase in telephone penetration there is a three percent increase in GDP. Figures show that in 1999, 22 percent of the new wireless users were in developing countries; and industry analysts expect that by 2005 this proportion will have increased to 75 percent.
Much is being made about the benefits that will come to people in developing countries as a result of unfettered access to communication. Some have suggested that cultural barriers to understanding and sharing will be reduced, as nations and individuals take advantage of the ability to communicate. Access to the virtually unlimited information from all over the world will be available to remote workers and those without access to a computer through wireless Internet connections. It is possible to sketch attractive visions of information rich, resource conserving paths to enhancing rural livelihoods in developing countries.
It is even suggested that telecommunications can help empower rural people to voice their concerns and defend their interests. Many individuals and groups are exploring how electronic mail and other computer mediated communications can help empower those concerned with social justice, environmental preservation and other causes. Clearly though, cell phones have been popular in places like Africa because of the predominance of oral cultures and the relatively low literacy rate. People simply want to talk with friends and relatives; cell phones in villages have cut down on travel time for users who had previously gone to regional towns in order to make a call.
Most media such as radio, television and newspapers have been developed for one-way broadcasts of information. In contrast to the hierarchical patterns of broadcast technologies and exclusive private networks, decentralized networks of communication through the public telephone network can strengthen civil society. Telephones provide interactive two-way communications. Telephones can help empower people to talk back, to ask questions, make deals and maintain networks of social relationships. Thus they can be tools for the strategies people employ in coping with the opportunities and threats brought by globalization. Telephones are use in concert with technologies such as community and commercial radio for call-in programs. In some countries radio stations receive calls by phone as well as letters and walk-in requests for Internet information. In a Sri Lankan project in Kotomale the station searches for the information, translates the results into Singalese, and broadcasts the answer to the listeners.
Some analysts have optimistically suggested that advances in telecommunications may even act to end urban dominance, demolishing the tyranny of distance and transport costs that support urban centralization. In this view, rural areas may no longer suffer under disadvantages relative to cities. So largely rural developing countries might not be fated to repeat the transformations that made the developed countries largely urban. Instead there might be other pathways, allowing greater decentralization and more opportunity to sustain the best elements of rural lifestyles.
However, many villages without telephones remain isolated from the electrical power grid and decent roads. Telephones are an enabling and facilitating technology (Pool, 1977), but their impacts are not automatic or obvious, depending critically on how they are employed. Impacts also depend heavily on other conditions such as the power relationship with urban areas.
So far there is little to indicate that telecommunications are doing much to change long-standing patterns of urban dominance as some have argued. There is some indication that increased access to ICT increases the net flow to the cities and to market centers. Policy choices influence how rural telecommunications develop, and the opportunities may be created for more diverse and decentralized patterns of development to counteract some of the centralizing effects of increased communications infrastructure.
Cell phones may offer an alternative to widespread pollution and unrealistic costs required by establishing more traditional hard-line forms of communication. Most of this is thanks to the wireless aspect of cell phones. Because of it, governments do not have to establish the same type of infrastructure they would have to with older technologies, saving time, money, and the environment. This phenomenon, called wireless local loop or using wireless as one would use a fixed phone is especially taking off internationally where telephone infrastructure is scarce and very expensive to install.
The implications for developing nations and non-democracies may be more serious. Cellular phones are a challenge to authoritarian governments whose means of survival is the suppression of information in order to subdue the population.
Some have argued that the wireless Internet is a logical next step in developing countries because mobile phones outnumber PCs and can provide a platform for delivering Internet services and because mobile phones exceed fixed lines in a growing number of developing countries. At the moment this is only a promise in that most of the mobile phone handsets cannot access the Internet and there are few Internet services that are accessible via mobile devices. The very popular Japanese service NTTDoCoMo iMode has been greeted in other countries with a very modest rate of acceptance.
The Congo, is offered as an example of a poor country where WAP (Wireless Application Protocol) was installed in June 2000 by Celtel. A year and half later, Celtel had grown to be the largest telecom operator in the Congo with 14,000 subscribers. Celtel’s WAP users can access content such as local news, exchange rates, travel schedules and overseas WAP sites. However, in most places WAP has proved to be a business failure.
Another benefit touted for developing countries is the potential of so-called m-commerce or the ability to buy goods and services using a mobile phone. Cash is still king in many developing nations where citizens do not have credit cards nor would many qualify for one. This limits their ability to purchase over the Internet. But some have suggested that mobile phones could be used as mobile wallets with Internet purchases deducted from mobile bills or pre-paid balances.
As the evolution of wireless continues, third-generation (3G) technology is expected to transmit data much faster than is now possible, enabling mobile phones to receive Internet data, video communications and graphics faster than traditional fixed lines, and even receive television broadcasts. The economic downturn for telecommunications companies has forced many to curtail 3G projects and to seek relief for the overpriced spectrum they bid on in recent years.
Wireless technologies are also being used to connect laptops and PCs to the Internet by using unlicensed spectrum and standards such as 802.11b (aka Wi-Fi) and 802.11 a/g which allow for much greater bandwidth. Hybrid systems that bring a connection to a village by satellite redistribute the bandwidth inside a building or common area and also via point-to-point systems that can extend the connection many kilometers using a special antenna and line-of-sight. However, in some countries the regulations crafted for these technologies are not being enforced, and the signal and throughput degrade. In Nigeria the government has changed its regulations to outlaw the use of this spectrum on the grounds that networks are causing too much interference with other wireless users.
The start of the new millennium is witnessing a telecommunications world that is very different from even the recent past. Clearly challenges lie ahead. But driven by the power of mobility, the world is going wireless and an ever increasing number of people everywhere are reaping the rewards of communicating in a world without wires.
Technical know how is a challenge for the spread of any technology from water wells to television broadcasting. The success of outside investment companies in building cell phone systems is due to local cadres of technicians being trained and gaining work experience under the guidance of more experienced employees.
Stable power supply: In many countries the availability of electrical power is limited by the size of the market, the state of the transmission system, and the cost of alternative or backup systems. Solar and even pedal-powered systems offer an alternative, but do not scale up easily in countries where these are used in isolated pilot projects. Gasoline generators are useful during grid failures (some of which has lasted months, not days) but the cost of fuel has been prohibitive.
There are a number of things that need to happen if mobile Internet is to be viable in developing countries. First developing countries need to understand the potential (including downside) of mobile technologies and they will need to develop a policy for introducing such networks and counteract a mindset that has focused on fixed line analog networks.
A key issue is how to award licenses. Auctions are usually introduced to encourage competition from outside companies since incumbent operators are unwilling to give up their market advantage. Auctions for Internet licenses can drive up the cost and slow investment, even as they provide funds for the government coffers. On the other hand, controlling who can provide mobile services has huge political, social and economic implications for developing countries. License requirements to support universal access or service can be added to the bidding rules, but this can scare some investors away because of the extra costs.
Another factor that should be considered is the means to develop locally relevant content. The Open Knowledge Network being advocated by OneWorld in the United Kingdom is an ambitious attempt to generate, catalog, and share salient information among poor nations and underserved populations. While the latest stock-market information or ability to purchase cinema tickets from a mobile phone may be attractive to elites, applications such as health information, commodity prices and transportation schedules may be more suitable in other contexts. Voice recognition applications might be useful in countries with high levels of illiteracy.
Telecommunications act to greatly lower transaction costs of dealing with people outside the local area. Telephones lead to better informed choices. However, telecommunications is certainly no panacea. It accelerates ongoing processes, for better and worse. A faster pace of change and increased international linkages are key parts of globalization, and telephones play a major role in contributing to this process. Telecommunications benefits come as an enabling factor, whose impact depends on and interacts with the availability of other infrastructure such as roads and electricity. Realizing the potential of telecommunications to enable people to cope with changes in better informed ways depends crucially on the availability of services and affordable access.
A Few Success Stories
Several programs indicate that deployment of wireless phone and Internet systems can be a success in developing countries, but it is not guaranteed.
In 1997 Telnor, a Norwegian telecommunications company and the Grameen Bank, noted for its microloan program that has reached more than two million people, invested in a program called GrameenPhone. This Bangladesh company sells phones to people in the city and its rural component is called Village Phone where people take out small loans for the phone and buy small amounts of air time. There are not more than 500,000 subscribers in 12,000 villages. This is going to be expanded to 45,000 villages, and the same process is being tried in other countries.
Over the past six years Uganda has successfully deregulated much of the telecommunications industry and opened up the country to outside investment (mainly from South Africa). This has spurred continued growth in both cell phone services and Internet use. The cell towers near the main arteries leading out of Kampala, the capital, are also being used by ISPs to redistribute their own signals using Wi-Fi and other standards. In this case the Internet grid is following the same geographic path as the spread of the cell phone. It, too, is wireless in many rural areas.
The Foundation of Occupational Development (F.O.O.D. at http://xlweb.com/intercity/) helped a group of more than 120 community organizations in India set up a closed cell phone network to help market locally produced goods supplied to people in different cities. The goods are produced by poor uneducated women who have increased their incomes by a significant amount using this technology. More importantly, the phones have helped form social capital and solidarity among the groups as well as modest amounts of financial capital.
Ithiel de Sola Pool (editor), 1977. The Social Impact of the Telephone. Cambridge Mass.: MIT Press.
Wireless technology and the environment
An influential report, Waste in the Wireless World: The Challenges of Cell Phones  from INFORM , a New York-based non-profit think tank, has drawn attention to the considerable hazards posed by the volume of wireless devices and their inherent toxicity, as currently manufactured. All such devices contain toxic chemicals: Arsenic, antimony, beryllium, cadmium, copper, lead, nickel and zinc. These chemicals are contained in the batteries and components of the devices. In addition, brominated flame retardants used in plastic components are toxic. These substances leach into soil groundwater from landfills. When incinerated or processed for recycling, they form toxic dioxins and furans. Because of the enormous number of wireless devices being manufactured and sold, the release of a massive amount of toxic garbage is at hand. The impact of the release of toxins is of concern everywhere, but is especially troublesome in the context of developing countries which have less infrastructure for establishing recovery and recycling programs.
Disposable cell phones
Several companies have developed disposable cell phones to target teens, seniors, those with poor credit histories, and consumers in developing countries. Some disposables are full-featured and can make and take calls. Others, designed on a "phone-card" model, offer outgoing calls only.
Some disposable models are made to be thrown away after only 60 minutes of use. The media refers to disposable phones as "talk-and-toss," or "chat’n'chuck." They will be sold at convenience stores, drugstores, K-Mart and other outlets. Disposables have not yet entered the market but phones from New Horizons, a Florida-based company, are imminent. One of their products can be "refreshed" for a fee so it will not necessarily be thrown out after its initial use.
Some of the designs of disposable phones are ingenious, incorporating dedicated 911 buttons and well designed keypads. One phone is manufactured mostly of paper.
This phone, from Hop-On, has a hard-to-miss 911 button.
This phone, from Dieceland Technologies, prints its circuits on paper with metallic ink.
Disposable cell phones combine utility and toxicity in one indivisible package. It is likely that the environmental hazard from these phones will be significant because they have a large potential market, promising immense usefulness and usability to currently underserved customers. Hop-on Communications, based in Garden Grove, California, is developing disposable phones. As the Hop-On Web site declares, with disposables, there’s no contract, no roaming charges, no long distance fee, no activation fee, no hassles! The conventional cell phone industry has created a useful but expensive and cumbersome technology. Disposables solve many user problems and will be accessible at outlets people are already familiar with such as K-mart. Disposables should do well in the developing world because they bypass a huge infrastructure cost for both companies and consumers. It currently costs about $400 to enroll a conventional cell phone user in the U.S., as well as additional large costs of continued customer care personnel. While the exact cost for disposable rollouts is not yet known, they will be substantially lower.
Critics have pointed out the negative environmental impacts of disposable cell phones. Most manufacturers are unapologetic though they give lip service at least to recyclability. "We are encouraging people to recycle the phones, although they are priced so that they are disposable," a spokesperson for New Horizons said. Hop-On says on their Web site that their phones are "recyclable and disposable."
One manufacturer declares that other products pollute more. In response to charges of environmental irresponsibility, Randi Altschul, inventor of the Phone-card phone to be offered by Dieceland Technologies of Cliffside, New Jersey, said, "I believe diapers do more damage to the environment than I do" .
How feasible are recycling programs? In Europe, there is a fighting chance because of a strong widespread environmental ethic at least in the Scandinavian and Germanic countries. In developing countries with widespread infrastructural problems, effective recycling programs would seem to be problematic. In the U.S. there is a cultural problem as the "talk-and-toss" rhetoric suggests. Altschul of Dieceland told the New York Times, "The greatest asset I have over everyone else in this business is my toy mentality. An engineer’s mentality is to make something last, to make it durable. A toy’s lifespan is about an hour, then the kid throws it away. You get it, you play with it and boom it’s gone." .
Conventional cell phones and other wireless devices
Of course all cell phones are disposable, just on a longer time horizon. There are millions of discarded phones. INFORM's report Waste in the Wireless World notes that cell phones are typically only used for about 18 months before being replaced. By 2005 about 65,000 tons of cell phones will be retired annually in the U.S. Many will languish in desk drawers and dusty cubbies before being finally junked. By 2005, there could be about 500 million used cell phones entering the waste stream. Accessories such as adapters also create considerable toxic waste.
In Europe and Japan, manufacturers have eliminated lead and brominated flame retardants from electronic products, or plan to. The EU will soon mandate that all products manufactured or sold in the EU phase out these substances. U.S. companies have no such commitments, though they are working on alternatives. U.S. electronics producers and trade associations lobby against available alternatives arguing that they do not perform as well and might be even more damaging to the environment.
A single standard
INFORM recommends a single standard for cell phone carriers. Such a standard would reduce the number of cell phones in circulation and allow for more environmentally sensitive regulations. A spokesperson for the Cellular Telecommunications & Internet Association (CTIA), a U.S. trade association, registered opposition to this idea, remarking, "The wireless industry was built on competition between carriers and between standards" .
Design for disassembly
INFORM recommends following "design for disassembly" practices that facilitate recycling and reuse. They believe that product design is a key point at which positive changes can be made. They recommend putting formal recycling mechanisms in place, noting that collection points, reporting, and enforcement are all necessary. Voluntary take-back has none of these mechanisms. INFORM observes that deposits for cans and bottles have been effective in increasing recycling significantly. They suggest financial incentives for recycling wireless devices. They urge us to get creative; in Austria customers receive free lottery tickets when they return old batteries.
Both batteries and the phones themselves need to be recycled. The U.S. has a Rechargeable Battery Recycling Corporation, an industry consortium. INFORM notes that this body does not report regularly on recycling rates and has failed to meet its targets, but there are no consequences for these deficiencies. Some take-back programs donate used handsets to charities or developing countries. CTIA runs a Donate-A-Phone program that has collected more than a million cell phones , many of which are resold in developing countries. Verizon has a program to give away used phones to victims of domestic violence. The victim does not actually get your used phone; phones are refurbished and resold, with the proceeds going to non-profit domestic abuse advocacy groups which then purchase phones to aid victims.
While well-intentioned, such programs off-load the recycling problem to those least able to manage it. These programs are an interesting example of the need for true lifetime management of technology. Where does the toxic waste finally end up? Who’s in control of it? Who is responsible for it? Surely the victims of domestic violence should not be the final arbiters of the disposition of industrial waste.
The scale of the problem
INFORM is concerned about the cell phones designed to be used for 60 minutes and then thrown away. Such designs are a symptom of an out of control throw-away mentality. The sheer number of wireless devices being manufactured is staggering. Exuberant marketing scenarios of disposable give-aways take on a different light when considering environmental consequences. WirelessFuture Magazine enthuses:"From rental-car companies to fast-food restaurants and food and beverage producers, corporations use them [disposable cell phones] as promotions. Consumers find private-branded phones in cereal boxes, soft-drink six-packs and bundled with running shoes. Wireless resellers use them to advertise their service, and production studios push their movies with them. "Our phones were literally created to be merchandising tools," says Randi Altschul, president, CEO and founder of Dieceland Technologies in Cliffside Park, N.J., who considers her credit-card phones as merchandising real estate." 
The numbers of wireless devices will, INFORM remarks, "place additional burdens on municipal waste systems and the taxpayers who fund them." Currently there are no systematic ways to track and assign responsibility for such shifted, hidden costs. Again, the question arises: Who is responsible for the toxic waste produced by wireless devices?
The philosophical problem
To return to the issue of a standard for cell phones, Travis Larson of CTIA told the New York Times:"If we had had a government standard in the beginning we’d still all be speaking on analog phones. And that means no e-mail, no text messaging, no Caller ID. Competition equals innovation in this case."
Arguments opposing government oversight such as standards and mandatory programs are often pitted against innovation and "progress." The assumptions behind such arguments are that innovation must proceed unfettered because it is unquestionably good, and innovation cannot take place in an environment of regulation.
On reflection, I think we would all agree that some innovations are good and some are either useless or damaging. The argument against regulation continues to carry weight, though time and time again companies have found ways to make money even when regulated (e.g., seat belts, pollution controls, increased airline safety regulations). The discourse has managed to put on the defensive those who would manage innovation with goals beyond profit. It makes broad leaps of logic. Going from the suggestion of a standard to reduce the kinds of cell phones to the stifling of all innovation is a grand jump. Larson invoked key innovations to make his point ’ e-mail, text messaging and Caller ID ’ none of which would in any way prevented be by the adoption of cell phone hardware standards.
An optimistic scenario
It is possible that cheap, easy-to-use recyclable (not disposable!) cell phones could provide great phone service for underserved markets, and eliminate hassles for those of us who do not enjoy being forced into lengthy contracts and poring over monthly statements to make sure the charges are correct. A great deal of our wireless infrastructure activity from buying phones to refreshing to recycling could take place at any familiar convenience or drug store. With effective recycling, we could enhance connectivity, a social good, by offering phone service in locations that already offer related services such as film processing and mailing. And the lottery tickets are already right there.
We should stop talking about disposable devices and shift the rhetoric to recyclable devices. This could happen because it already has in Europe, or at least is starting to. INFORM observes that while there is no national legislation under discussion in the U.S., the European models are being considered at the state level in California, Massachusetts and Minnesota. Measures are being studied that would "make producers responsible for paying the costs of managing the waste generated by their electronic products." Some companies, such as Hewlett-Packard and Sony, have extensive recycling programs. With government partnership, such programs could be effective.
Both policy and hearts-and-minds are at stake in considering the environmental consequences of wireless technology. Wireless is an area that everyone can understand as it directly touches the consumer in everyday ways. People often wonder what they can do about environmental problems. Recycling wireless devices is a simple action anyone could take if the infrastructure were in place and the consequences of not doing so made known. There are opportunities to educate people about the health risks of improper disposal of wireless devices as well as about important tactics such as design for disassembly.
For the purposes of this review, "mobile" is considered to be a subset of "wireless", since some wireless solutions are fixed. In this section we will discuss handheld or wearable devices, connecting technology, and centralized information systems, following the schema outlined by Turisco and Case in their October 2001 report for the First Consulting Group on "Wireless & Mobile Technologies in Healthcare".
1. Waste in the Wireless World: The Challenges of Cell Phones, INFORM, Inc. 120 Wall Street, 16th Floor, New York, N.Y. 10005. The print copy of the 109 page document is US$30. See also www.informinc.org/cellphone.htm for download in pdf.
3. See http://www.metropolismag.com/html/content_0701/ob/ob08.html, July 2001.
6. http://www.wirelessnewsfactor.com (8 May 2002).
Wireless technology and health
This section considers data related to three ways in which wireless technology and health intersect:
- applications of wireless technology in healthcare (technology considered more or less by itself)
- interactions of wireless technology with other devices used in healthcare (technology interacting with other technology)
- effects of wireless technology on human health (technology interacting with humans)
For the purposes of this review, "mobile" is considered to be a subset of "wireless", since some wireless solutions are fixed. The technology discussed includes handheld or wearable devices, connecting technology, and centralized information systems, following the schema outlined by Turisco and Case in their October 2001 report for the First Consulting Group on "Wireless & Mobile Technologies in Healthcare".
Wireless healthcare applications: Introduction
As healthcare becomes more information intensive, clinicians and administrators alike have increasingly looked to wireless/mobile technology to link to information without being physically tethered. Although the familiar doctors’ pagers have been in widespread use for over 30 years , the growing capabilities of devices that can connect wirelessly have excited visions of information delivery "anywhere, any time, to the right person."
Thus, the first point to be made about wireless healthcare applications is that demand and actual use is growing. Beyond the nearly ubiquitous pagers, use of other wireless technology among physicians has been projected to triple in the next three years from 18 percent currently to 55 percent, according to a recent report from Technology Assessment Associates . This estimate is consistent with the technology diffusion curves of other medical technologies.
In addition, this growth in demand and use will likely accelerate, at least for a period of time. The acceleration has two causes: So-called network effects, and co-development of technology and markets. According to the former, the more people or information sources a network encompasses, the more useful it is. (Classic examples are the telephone and the fax machine.) According to the latter, innovations may spur adoption and greater adoption may spur more innovations. In the case of wireless technology, these capabilities include more sophisticated applications, improved form factors, greater reliability, higher data transfer rates, and longer battery life.
The accelerating proliferation of wireless devices and applications in healthcare brings us to a third point: As with many technologies with a steep S-shaped diffusion curve, understanding of the social and second-order effects often lags behind the enthusiasm for the technology. We outline some of the less obvious effects in this report.
Finally, we acknowledge that a proper analysis of wireless devices and applications in healthcare is quite complex. As we’ll see, analyzing just the physical effects of radiofrequency (RF) radiation is difficult enough. In addition there is an extensive literature on technology diffusion; competition and market equilibria among firms, including those producing network goods; the effects of regulations on markets; and other topics that are beyond the scope of this paper.
Quicker access to data
Wireless handheld devices offer the promise of fingertip access to electronic medical records (EMRs), practice guidelines, patient referral data, drug information, textbooks, and a wealth of other data sources. A large hospital may move several tons of paper medical records a day; even small clinics and offices spend time, energy and money physically moving information around.
Many hospitals will concede that even if they’re able to retrieve a paper chart within an hour or two, returning it to a "ready to retrieve" state once it’s been used and altered may take days or even weeks. This delay is due to inefficiencies in getting notes and orders dictated, co-signed and re-filed in offsite archives.
Not only is access to hardcopy data often slow sometimes it never occurs at all because of ineffective retrieval or misfiling. Up to 30 percent of patient encounters may occur without a medical record, and up to 20 percent of paper medical records contain at least one item with a different name or patient number than that on the record jacket .
Less time "on hold"
Illegible or ambiguous prescriptions result in roughly 150 million phone calls from pharmacists to physicians a year in the U.S., with each phone call requiring an average of 10 minutes wait before a pharmacist or physician becomes available . Electronic prescriptions and wireless platforms have the potential to reduce or even eliminate this inefficiency by supplying point-of-care advice to physicians about appropriate drug choice, format, dose, and health plan coverage.
Reduced documentation time & quicker turnaround times
Home healthcare nurses typically see four to six patients a day, and many accrue significant travel time not only between patients, but between their home or patientsy’ homes and the office in order to pick up or drop off charts, orders, and other documentation. As might be expected given this situation, personal digital assistants (PDAs) and other communications devices have been shown to cut time spent on documenting home health nursing activities by up to half .
In offices, clinics, and hospitals, many physicians rely on offsite transcription services to convert dictated notes from operations and patient visits into documentation that can be shared with other clinicians and with health plans for reimbursement. Often, it takes a day or more for the typed notes to come back to the clinician; significant errors or omissions may require another round of corrections. In this arena, too, the use of wireless PDAs can reduce turnaround time for transcribing physician dictations by half .
In the domain of pharmaceutical clinical trials, processing of paper forms related to patient enrollment, adverse event reporting and outcomes data can add 12-15 weeks to the time needed to complete the trial. Since the cost of delay in bringing a blockbuster drug to market can be US$1-2 million/day, even a modest contribution of wireless technology to streamlining clinical trials would be of keen interest to pharmaceutical companies and the contract research organizations that often conduct Phase 1, 2 and 3 clinical trials. The British telecom firm Orange is exploring interest in such a service among roughly 15 pharmaceutical companies .
Improved charge capture
Another area of keen business interest is that of charge capture and billing for medical services. Annual lost billings (due to inadequate documentation, invalid codes or failure to submit) is estimated to be roughly US$60,000 for each of the 450,000 actively practicing physicians in the U.S. . Given this US$25 billion market, increasing charge capture by even a few percent would be a valuable business, and a number of systems have been introduced to capitalize on the potential for wireless handheld technology to enable direct charge entry at the point of care.
As in the home healthcare or outpatient setting, PDAs have been shown to improve in-hospital charge capture by 10 percent and cut turnaround time on billing by eight days. The combination of more complete billing and shortened revenue cycles is another driver of increased adoption of mobile technologies in healthcare .
Real-time physiological monitoring
Although possibly a bit Orwellian for current U.S. sensibilities, the prospect of continuous monitoring of vital signs and other physiological parameters could make a large difference in healthcare, particularly that of elderly people with chronic conditions. Although the famous "I’ve fallen and can’t get up" commercial has become a humorous tag line for almost two decades, the concept of having either an active or passive alarm to summon emergency responders has high intrinsic appeal to anyone with an elderly family member. This has apparently become the basis of a viable business model for a number of vendors, who offer monitoring systems costing families roughly US$1/day. Various elaborations of this concept have been explored in both the civilian and military arenas  .
Wireless technology Technology interactions
The promise and proliferation of wireless technology outlined above raises concerns about interactions between the RF (radio frequency) radiation produced by such devices and other technology used in healthcare. Indeed, links between cell phone use and failures of life-support equipment such as ventilators, dialysis machines, and defibrillators have led to bans on their use first in many hospitals in Scandinavia and then in other countries, including some parts of the U.S.
Before reviewing some of the literature, however, it is useful to remember that wireless technology includes a range of connecting modalities, such as wireless LAN, infrared & other line-of-sight modalities, wireless Web applications using protocols such as WAP (wireless application protocol) and WML (wireless markup language) to communicate via cellular phone channels, and mobile but intermittently wired data synchronizing techniques such as the common PDA cradle. These modalities work in different parts of the electromagnetic spectrum.
[Source: FCG report on Wireless & Mobile Technologies in Healthcare]
Recognizing that the airwaves were becoming increasingly crowded, in June 2000 the U.S. Federal Communications Commission (FCC) allocated new frequency bands in which medical telemetry could operate in the United States as a "primary user" (Report and Order FCC No. 00-211). This designation means that medical telemetry has priority over other uses in those frequency bands. The FCC order also appoints an administrator or frequency coordinator to deal with the question of how competing medical telemetry devices within those bands will co-exist .
Although an upcoming conference on electromagnetic interference in healthcare settings describes itself as the first such forum , in fact research in this field has been growing for over a decade. Overall, the results are mixed, with some studies detecting significant and quite concerning interference, while others are more equivocal.
An early study from Australia showed that the electric fields from analogue mobile phones only exceeded the immunity level of 7 V/m recommended by the U.S. Food and Drug Administration (FDA) for medical electrical equipment at very near range, whereas digital mobile phones can exceed this limit at longer distances and cause various artifacts and alarm conditions .
Another relatively early report from Canada warned of a range of interferences, from the annoying to the dangerous, from television transmitters, police radios and cellular phones , but a large German study two years later which included 224 life-support medical devices such as apnea monitors and ventilators found interference to be very rare .
A study from the University of Oklahoma tested 29 pacemaker models with five different phone standards; this study nicely illustrates the difficulty in drawing blanket conclusions. In 8,296 runs, during which any interactions detected were classified by type and regularity, a small number of pacemakers were responsible for a disproportionately large number of interactions. Interactions occurred during 21 percent of the tests using one particular phone technology, but there was little or no interaction resulting from use of the other four standards. Other significant factors included the relative orientation of the phone and the pacemaker case, as well as the presence or absence of an injected ECG signal. The authors recommend maintaining a separation distance of at least six inches between pacemakers and wireless phones, but noted that each pacemaker reverted to normal operation when an interfering phone was turned off .
Similar results were obtained in a study from the Mayo Clinic, which tested 980 patients with cardiac pacemakers against five types of telephones (one analogue and four digital). The incidence of any type of interference was 20 percent in 5,533 tests, and the incidence of symptoms was 7.2 percent. The incidence of clinically significant interference was 6.6 percent .
As the reader may have already noticed, part of the problem with the literature in this field is the scarcity of standardized tests, or even of thoroughly documented field studies of interference from cell phones, pagers, and other portable transceivers . While professional groups have issued general policies regarding electromagnetic interference , most studies would do well to emulate a detailed Canadian investigation of the susceptibility of 65 electromedical devices to a wireless LAN system. The authors report that the LAN operated at 2.42 GHz with an output power of 100 mW and the telemetry system operated at 466 MHz with an output power of 4 mW used the ANSI (American National Standards Institute) Standard C63.18. None of the devices were affected by the telemetry system. Of the 65 devices tested, only two hand-held Doppler ultrasound units were affected by the LAN system; these emitted a beating sound which could be misinterpreted as coming from the patient only when held within 10cm of the LAN system. Electrosurgical devices operating at 0.5 to 1 MHz did not affect the LAN system at distances up to 3 m .
Another carefully done study reported that two mobile phones (Siemens C25 and Motorola CD930) transmitting in the microwave range (~900-1800MHz) were found to generate field strengths in the range 0 to over 100 volts per meter, with the higher values closer to the phone, and at the beginning of a call. Three of four personal electronic dosimeters, two of four portable dose monitors, and one of two contamination monitors showed abnormal responses when exposed to mobile phone transmission. One dosemeter (Siemens EPD-2) registered doses equivalent to a dose rate of 99 mSv/hour (for comparison, the European Directive 96/29/EURATOM of 13 May 1996 sets the annual dose limit for the public at 1 mSv/year). Thus, this study incorporated temporal ("beginning of a call") as well as spatial parameters, and took care to give a perspective on the clinical or policy implications of an erroneous equipment reading resulting from interference .
A recent Japanese study suggests that interference is caused by a complex interaction among factors including the strength of radio waves from both inside and outside the hospital, magnetic-flux density at welding points in a building, electric fields induced by a linear motors such as those in conveyor systems, shielding capacity of hospital walls, shielding capacity designed into commercial devices, intrinsic immunity of individual pieces of electronic medical equipment, and EMI from cell phones and other personal handsets. Recommendations include measuring each of the above effects, plus installation of electronic gate equipment at building entrances to screen for handsets .
Wireless technology Human interactions
Finally, let’s broaden our concept of the wireless device ecosystem to include the people who monitor or are monitored by the devices. People (clinicians, patients, other hospital staff) in healthcare settings such as the ICU are bathed in a sea of both information and radiation.
Many wireless phones operate at 300 MHz and 6 GHz at power levels <1.6W/kg, as mandated by the FCC. International guidelines protect humans from thermal effects, but studies of non-thermal biological effects have yielded conflicting results  . For example, a large-cohort mortality study among 195,775 employees of Motorola comprising 2.7 million person-years during a 20-year period showed rate ratios calculated from Poisson regression models near 1.0 for brain cancers and below 1.0 for all lymphomas and leukemias . Before concluding from this study that RF is safe, however, we should note that the authors mention that the workforce population in this study was relatively young. In addition, workplace exposure to RF may not be equivalent to everyday exposure. The antennas of some devices are in close proximity to the user’s head, thus possibly producing locally excessive energy deposition. Furthermore, radiofrequency (RF) signals emitted are amplitude-modulated at extremely low frequencies, potentially eliciting different biological effects from those of unmodulated RF radiation .
While some researchers have focused on thermal effects of RF radiation exposure, not many seem to share one author’s opinion that "there are no mechanistic theories that support 'non-thermal' interactions with biology" .
Interestingly, some evidence for increased risk of brain cancer associated with use of wireless technology actually comes from the Wireless Technology Research (WTR) program, a seven-year, US$27 million effort funded by the wireless industry in the United States to both review the scientific literature and to conduct original research. While evidence suggests that RF radiation from wireless phone antennas is insufficient to cause DNA breakage, this same radiation appears to cause genetic damage in human blood as measured through the formation of micronuclei. The WTR cohort study observed an increase in the rate of brain cancer mortality among hand-held cellular phone users as compared to car phone users, though this was not statistically significant. A statistically significant increase in the risk of neuro-epithelial brain tumors was observed among cellular phone users in another case-control study .
As with studies of electromagnetic interference, there appears to be a need for standard tests in studying the effects of RF radiation on humans. Unfortunately, the usual method of determining exposure, SAR (specific absorption rate), may not yield uniform results. As we all might suspect from everyday experience with microwave ovens, suspensions or plates of cells exposed to RF radiation can experience levels of energy that can differ by up to 40 percent or more, depending on the geometry of the radiation source and the cell culture . In addition, many studies are also limited by incomplete description of the exposure and poorly characterized dosimetry .
Wireless technology, like any technology, has both intended and unintended effects (Sproull and Kiesler; Nardi and O’Day). The intended and anticipated effects underlie the forecasts of technology optimists, while the unintended or second order effects are often the basis for skeptical critiques. In the case of wireless healthcare applications, clearly more work remains before we can claim a comprehensive understanding of the promise and perils of this technology.
As might be expected, most considerations of the technology by itself (presented in the first section of this review) are quite positive. However, closer examination of the evidence relevant to effects of wireless devices on other technology and, most importantly, on humans (presented in the second and third sections of this review), raises several issues.
The first issue is the clear need for more careful research. Healthcare environments such as hospitals are exceedingly complex and fluid configurations of technology in both time and space. Studies of the effects of exposure to RF radiation can only hope to approximate the more common scenarios. Apparently small or transient changes in position, distance and timing of measurements can interact with factors ranging from hidden building frame welds to evanescent biological signals such as cardiac depolarizations. Likewise, studies of health effects of RF radiation from cell phones in everyday use require standardized tests to avoid confounded results.
A second issue is the need to put the research findings in perspective. If interference is detected, is it "significant"? Is the significance measured with biophysical, clinical, or societal metrics? Over what time horizon? In what context? A statistically significant elevation of an ultraprecise thermal reading as a result of proximity to a wireless antenna may or may not translate to an actual increase in illness. An absence of detectable equipment malfunctions over several minutes in the lab may not make it safe for a wireless device to be present in the room of an ICU patient who will be spending several weeks on life support. A falsely high reading on a radiation dosimeter may have very different implications during a bioterrorist incident than during a rat lab experiment. When reporting a detrimental effect of wireless technology on either other devices or on human health, it might be helpful not only to include the benefits of the technology (e.g., better healthcare due to quicker notification of abnormal lab results), but also to frame the risk in relation to other, possibly more common risks such as smoking or driving without wearing a seat belt.
Finally, an interesting issue is raised by the apparent disconnect between the rapid and accelerating adoption of wireless technologies in health and the uncertainty about both their direct and indirect (through interference) health risks. What does it say about human nature or our society that the phrase "technological imperative" has become commonplace, while the Precautionary Principle struggles to convince? Is it merely a question of vivid short-term gains balanced against hidden long-term costs? Is it a triumph of "Don’t just stand there" over the injunction to "First, do no harm?" Our choices in the realm of wireless technologies and how we make them, deserve mindful intention.
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Wireless ICTs include numerous interrelated technological systems of invention-productizing-standards making-marketing-adoption-regulation-use and abuse-disposal-long term effects-and eventual obsolescence when a subsequent technology enters the marketplace. Individuals, organizations, and governing agencies may find it difficult to decide where they can intervene, except as consumers, because many of the processes are neither democratic nor transparent. By describing some aspects of the process we hope to encourage other research and holistic discussions of different parts of these systems.
About the Authors
Critical Friends of Technology (CFT) is a small informal team of researchers interested in promoting a holistic understanding of the benefits, possible adverse effects, and unintended consequences of different kinds of information and communications technology (ICT).
E-mail: Correspondence should be directed to Bonnie Nardi at firstname.lastname@example.org.
Readers are encouraged to post comments about this paper to a QuickTopic discussion board at http://www.quicktopic.com/14/H/x9VKHTUnT2Fb.
Paper received 5 July 2003; accepted 25 July 2003.
Copyright ©2003, First Monday
Copyright ©2003, Critical Friends of Technology
A social ecology of wireless technology by Critical Friends of Technology
First Monday, volume 8, number 8 (August 2003),
A Great Cities Initiative of the University of Illinois at Chicago University Library.
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