Global Political Questions associated with Building a Space Elevator

The idea of a space elevator has long captivated various minds since it was both theorized in scientific circles by Konstantin Tsiolkovsky and introduced into popular culture by Arthur C. Clarke. This fascination is divided between the technical difficulties associated with its construction and the optimistic returns from its successful operation. The most prominent benefit of a space elevator is the presumed dramatic lower launch costs as travel into space would move from expensive single-use launch systems to the multi-use consistent space elevator. Some have attempted to dampen the optimism associated with a functioning space elevator by suggesting that a space elevator in general will not significantly affect the overall cost of space travel.

These suggestions are more than likely incorrect because they commonly fail to appreciate the eventual evolution of a space elevator for the first prototype for any form of new technology is always the most expensive and least efficient. Also the non-launch elements associated with space travel, that skeptics reference as a significant cost factor unaffected by a space elevator, should also see significant cost drops over time, through not immediately, as industries adjust to space travel being a more common occurrence than less than once per year. Therefore, those industries directly related to space travel, especially those that supply parts and consumables, will create more streamlined procedures to prepare for and supply launches. Costs will also reduce through the interaction between the private sector and the public sector as with lower costs associated with space travel governments will be more willing to fund space travel increasing the rate of private funding. Finally a space elevator should be an important achievement for humanity in general if it wishes to actually leave the confides of Earth to colonize other heavily bodies, be them planets, moons, asteroids, etc, with any level of success.

While a lot of effort has been spent on the technical issues and the back and forth of how valuable a space elevator will be, very little time has been spent on the political and secondary economical issues associated with a space elevator. This lack of attention is unfortunate because these issues are very important to the stability of a space elevator both physically and functionality. Therefore, it is important to understand these issues and how they can be successfully managed in order to effectively influence the positive operation of a space elevator after its construction.

The most talked about and analyzed secondary issue with a space elevator is protecting it from environmental damage. The list of possible threats to a space elevator is rather extensive including, but not limited to: lightning and high winds, oxygen and other atmospheric (both lower and higher) chemical reactions, radiation and electromagnetic fields, and space debris along with micro-meteors and other low-Earth orbiting objects like satellites. Concerning satellites it is expected that twice per day each orbital plane will intersect with the elevator and there will be times when both a satellite and the elevator will fill the same area at the same time threatening a collision that will damage both the satellite and the elevator. This problem is not viewed as critical in any real light because operating satellites commonly have a means to generate slight course corrections that can be used to avoid these potential collisions. Non-operational satellites and other space debris are more complicated for they cannot make any adjustments.

Meteoroids, especially micrometeorites, are even worse than space debris for they are much less predictable. Impacts from micrometeorites are almost guaranteed, forcing one of three possible strategies: 1) deploying some form of shielding that could be absorb the damage and then regenerate itself some how; 2) designing a different system for elevator continuity beyond the more conventional ribbon design. One example that has been discussed is the hoytether system, which involves a network of strands in either cylindrical or planar arrangement with multiple helical strands; 3) create an autonomous repair system to manage the various points of damage.

One common and almost universally agreed upon strategy for minimizing the damage potential from orbiting objects is to anchor the space elevator on a mobile controllable target like a large ship or ocean-going platform. By making the anchor point mobile, it should be easier to avoid negative weather patterns as well as non-controllable orbiting objects. Most want this platform in the Eastern Pacific Ocean due to its relatively calm winds and the low probability of lightning. Using non-conductive fibers and small cross-sectional areas that rotate with the wind can provide additional protection. Issues associated with ice formation have been a little more troublesome due to weight considerations. However, all told there may be some meaningful problems with this moving anchor strategy that are not discussed by its proponents, which will be highlighted later.

There is some question to whether or not oxygen corrosion in the upper atmosphere will actually be a significant problem. One way to test the problem potential of oxygen corrosion could be to send various potential elevator material to the International Space Station and expose those materials to the appropriate conditions for extended periods of time. If corrosion is a problem then either the tether must be made from corrosion resistant material like gold or platinum or be coated with such a material. Finally actual repairs to the space elevator are somewhat ambiguous with space elevator supporters simply reporting that there will be special repair climbers that handle this issue. However, it does not lend much confidence when it simply must be assumed that once construction is completed sufficient knowledge will exist to design these repair climbers.

Overall the previously mentioned issues may be the easiest ones when dealing with a space elevator. Very little work has been done on the political issues associated with the operation of a space elevator. For example suppose country A builds a space elevator, what would be the procedure for allowing another country, group or individual to launch something into space? Will the only requirement be the ability to pay some monetary sum established by country A? If so, would that allow a group like Hamas or ISIS to launch something into space?

These are important questions for multiple reasons, but most notably pertaining to potential weaponization of space. Note that for the purpose of this discussion the term “weaponization of space” will mean: “the placement of a device in orbit that can directly destroy, damage or
disrupt the normal functioning of one or more objects within the confines of Earth.” Some individuals would argue that space has already been “militarized” due to the use of satellites in military operations, but space has yet to be “weaponized”. Also note that this definition for “weaponization of space” does not include attacks against orbiting objects like satellites for such potential already exists, demonstrated by U.S. and China and thought to be had by Russia as well.

International agreements concerning space have been far and few between and are commonly negotiated in the United Nations. The first agreement and still governing one, due to actual ratification, regarding international relations within space is the Outer Space Treaty created in 1966 and officially signed by the United States, United Kingdom and Soviet Union in 1967 followed by all other major space “powers”. Unfortunately the Outer Space Treaty only notes broad legalities in association with space like no national appropriation through claims of sovereignty, state responsibility and liability for actions in space or damage, peaceful intent in interaction with celestial bodies, etc. While placing nuclear weapons in space is explicitly forbidden, there is no explicit prohibition of other types of weapons.

More extensive and specific attempts for an international agreement regarding the issue of weaponizing space have been put forward, most notably the two versions of the “Treaty on Prevention of the Placement of Weapons in Outer Space and of the Threat or Use of Force against Outer Space Objects” (PPWT) by Russia and China, but the United States has rebuffed these attempts citing security concerns over possible space assets, a lack of a verification regime and provisions that would directly prohibit possessing, testing and stockpiling weapons that could be placed in outer space. One might questions the validity behind the rationality of this rejection, especially the issue of space assets due to Article V of the PPWT explicitly granting no restriction on the right of self-defense in accordance with Article 51 of the Charter of the United Nations.

Nevertheless the General Assembly of the United Nations has passed two resolutions regarding the prevention of arms in space. The first resolution called on all States to contribute to the peaceful use of outer space, prevent arms races there and refrain from actions contrary to this major objective; it passed with overwhelming support with only two abstentions (Israel and the United States). The second resolution called for the “no first placement of weapons in outer space” and had less support, despite passing, with 4 countries (Georgia, Israel, Ukraine and the United States) voting against and 46 abstentions (including European Union member states). The use of the United Nations as a go-between may need to end in favor of more direct multi-national treaties due to the general lack of respect various powerful countries show the United Nations when it takes a position opposite to that of a particular powerful country as shown in the voting results on these two resolutions.

Also if an agreement is reached what would be the consequences for violating the agreement as all of the countries that could successfully build a functional space elevator have dubious foreign policy histories; thus what penalties could be levied that could reaffirm trust issues in an attempt to normalize relations if such an agreement were violated? Would the only appropriate penalty be the destruction of the space elevator or would operational control be transferred to another party? Should the idea of a treaty be scrubbed completely instead granting operational control of any space elevator to, ironically the most neutral available body, the United Nations? While such a possibility could manage future problems better, how would funding a space elevator proceed if the government of country A knew that it would not retain operational control despite providing the capital, labor and technology to construct it?

Apart from the issues of weaponizing space, the country that controls a space elevator will have an insurmountable economic advantage for launching objects into space, what would happen if this country monopolizes the technology not allowing any other nations access? Can a space elevator simply be treated as any run-of-the-mill commodity? Would anti-trust or global monopoly laws be applied? Should there be an international treaty that sets a firm price for all nations in the event of a space elevator being constructed or should the constructing country have the ability to set any price? These above issues are rarely, if ever, addressed when individuals discuss a future environment with a functional space elevator. The general mindset appears to be a “utopia-esk” societal arrangement where anyone who wants to use the space elevator can use it at cost. Clearly it is difficult to envision this particular environment as one that will develop in reality.

Managing the problems associated with a privately constructed space elevator could also be complicated. Referencing the previous major question of who would have access to the space elevator, suppose corporation A built a space elevator, what would stop them from allowing groups to use it that held political, economical and/or military beliefs that differed from those held by country A? Numerous corporations have demonstrated numerous times over the years that as long as enough money is involved they have no moral qualms against carrying out business relationships with individuals or groups that commonly engage in violent actions against other parties, even if the reasons are superficial. So what types of laws will manage private space elevators? Should it even been legal for a private corporation to have operating control over a space elevator with the severity of what could result from “bad behavior”? Once again should the United Nations take over operating control of the space elevator with all revenue going to corporation A?

With all of the above issues, if any individual or group wants to take the possible construction of a space elevator seriously then the international community must establish guidelines, rules and agreements that address these issues, especially on the issue of access. Access is the most important element because it will establish the general expectations regarding how society will utilize the space elevator to evolve both in a positive or negative manner. Without a binding and known understanding when it comes to these above issues, the probability for the successful construction of a space elevator drops dramatically because uncertainty will more than likely cause some party with the capacity to engage against the construction process in a negative way. Basically if country A does not know whether or not they will get access to a space elevator they may utilize violence to ensure the elevator is never completed.

The issue of potential violence speaks to the location of the space elevator. As noted earlier one of the more popular strategies associated with locating a space elevator is placing it on a movable anchor, most likely a ship out in the Pacific Ocean. What type of protection should this ship have to ensure the safety of the elevator? Would this ship need to house and feed a police force? Would this ship need some form of anti-aircraft defense system? What type of no-fly zone and no-sail zone, if any, would encompass the ship? While the placement of the ship in international waters would eliminating any direct issues of jurisdiction with a single country it would also eliminate a number of problems associated with launching an attack against the ship as well, for attacking a ship in sovereign waters may represent an act of war that would prevent some parties from actually launching an attack. How maneuverable would the ship be if it has to engage in combat for sharp movements may create shearing and tensile stresses on the elevator causing meaningful damage?

Another issue that must be addressed in association with a space elevator is how to manage space debris. The successful operation of a space elevator could dramatically increase the number of objects in LEO or even GEO, which will increase demands on available orbital space as well as provide additional threats to damaging the space elevator. What type of international accord will govern the procedure for managing space debris?

The most significant authority regarding space debris is Article VIII of the Outer Space Treaty which states that all countries retain their ownership rights on all objects launched into space even if those objects are no longer functioning or are pieces off of existing functional objects and the 1972 Convention on International Liability for Damage Caused by Space Objects. There is no salvage aspect to space objects, unlike oceanic objects, which are covered by maritime law. Thus for any country or agency to interact with non-functional satellite A they need legal consent from the launching nation. The biggest problem with this current standing is that small objects that break off of a satellite or other larger space object with no functionality at all are still considered owned by the launching nation, thus technically to remove these objects there origin source would have to be identified making legal removal difficult.

One way to deal with this issue is for all “space” nations to reverse the legal standing of space objects. Basically instead of country A retaining legal standing over all launched material and its resultant components, country A would need to explicitly state what space objects they hold legal standing on, thus if no chain of custody could be established for a given object then no country could have claim on that object and it could be freely removed by an appropriate party.

The two most common removal methods for space debris are: 1) moving the object to a “graveyard” orbit where it will be unable to interact with functioning satellites; 2) launching a projectile at the object to remove it from orbit and return it to Earth. An operational space elevator would ease the obstacles associated with these two above methods as well as possibly provide a third removal method involving attaching the object to a climber and transporting it down to Earth on the elevator itself.

It is also worth noting that Article VII of the Outer Space Treaty covers liabilities; strict liability standards exist for space objects that cause damage to the surface of the Earth or aircraft and fault standards are assigned for damage occurring to a non-Earth based location. This liability would have to be transferred to any organization responsible for removing these objects. Unfortunately for those desiring a competitive marketplace for debris removal, the best strategy would actually be limiting all removal activities to the controlling operator of the space elevator due to this group possessing the most relevant knowledge and access. Competitors would not have access to the elevator and their strategies for removal would typically be more risky. Flat and fair rates should be charged for debris removal.

Due to the increased ease at removing debris, would it be appropriate for each country to replace all satellites older than x years (x to be determined by an international agreement) including all associated parts at cost before allowing the use of the space elevator? Basically with the development of a space elevator would countries be able to launch as much as they could afford or would each country have a specific quota based on the some factor (size of economy maybe) that could even be brought/sold/traded?

Overall there are a number of important political and diplomatic issues that have yet to be discussed let alone resolved regarding the construction of a space elevator. One might suggest that discussing these issues is akin to putting the cart before the horse for the technology to construct a space elevator is still in its basic infancy; however, that fact highlights the necessity of discussing these issues for if these issues cannot be successfully managed and resolved then the construction of a space elevator would produce wasted effort and resources. Managing the political issues go hand in hand with the technical issues for successfully operating a space elevator, so it is important that all aspects of a space elevator be discussing in realistic terms over some dreamy utopic ideal.

Discussing the Realities of Telemedicine Expansion

The passage of the Affordable Care Act (ACA) has opened the door to insurance coverage for all Americans, especially those who have chronic pre-existing conditions. One of the major concerns with this expansion of insurance is the additional stress it will place on organizing medical appointments and general care from non-specialists. While the most effective solution for this problem, training more general practitioners, is a long-term one requiring years before any implementation will see a positive effect, some individuals have argued that the widespread adoption of telemedicine could offer more immediate relief to this future stress. The chief benefits surrounding the implementation of telemedicine that could aid this overall problem are saving time born from a reduction of hospitalizations due to more efficient physician time utilization, reduction in on-site registration congestion and increased physician collaborative efficiency increasing the rate of patient turnover without sacrificing care quality.

In a general sense telemedicine (and its synonym “telehealth”) involves the use of telecommunication and information technologies to provide healthcare when patient and physician (or other medical resources) are in different physical locations. More technically it is generally thought that telehealth involves only patients and their personal health management using technology and telemedicine involves physician interaction. For the purpose of this post telemedicine will be used to cover both of these definitions. Telemedicine is typically broken down into three main categories: 1) store-and-forward (asynchronous); 2) remote monitoring; 3) real-time interactive services (synchronous).1

Store-and-forward is the most “hands-off” type of telemedicine where various important medical data is collected and transferred to doctors and/or medical techs for analysis at a future time offline. Store-and-forward is convenient because the data can be collected without the involvement of a doctor; however, any diagnosis is deferred to another time. The delivery of this information typically needs to be contained within a properly structured electronic medical record if done online. With the omission of actual patient-physician communication, store-and-forward demands patients produce medical histories as well as audio and/or video information.

The concerns about store-and-forward is that the electronic nature and format of the information (in more modern mediums apart from the telephone) along with the reliance on the patient to perform most of the work could provide undue burden on elderly and less tech savvy individuals (note all of the problems people had filling out forms to apply for insurance in state marketplaces after the ACA went into effect). In addition the possibility exists to produce some initial information gaps because of the lack of a physician to ask clarifying follow-up questions, which could cause future problems. While certainly not insurmountable, these concerns must be managed.

Remote monitoring is a more advanced version of store-and-forward where physicians monitor the vital signs and other specific characteristics relative to a patient’s given medical condition using appropriate devices. Application of remote monitoring is typically reserved for patients will chronic conditions that could benefit from constant monitoring where significant changes provide early warning to a potential acute detrimental change in health.

Real-time interactive services are what most people think of when discussing telemedicine and involve the patient and physician communicating in real-time. Interactive services follow the same pattern as in-person visits with a review of medical history, physical examination, general health questions, etc. except the interaction is through an online video service or telephone. Not surprisingly real-time interaction is the most valuable form of telemedicine, but is also the most complicated. Overall the success of telemedicine to make significant cuts in healthcare costs and increase access is largely contingent on the success of real-time services versus store-and-forward and remote monitoring.

Three major areas of technology are utilized for telemedicine: portable medical imaging devices, portable data transfer devices (in modern times these elements usually involve smart phones with certain apps) and the stable wireless infrastructure to ensure accurate transfer of information, especially in real-time. The most problematic element of the above technology is ensuring access to portable medical imaging. There is some hope that smart phones will be able to provide high quality resolution images that could substitute for on-site medical imaging, but at the moment it is difficult to anticipate MRI, fMRI, CT, PET scans, etc. being conducted from a private residence versus at a hospital or local medical site.

One of the immediate concerns about the judgment of whether or not telemedicine is medically and financially efficient is the contradiction between the numerous studies that have been conducted regarding these questions. Conflicting studies are usually created because different researchers use different assumptions when producing their results. For example a recent meta-analysis studying reviews of telemedicine determined that twenty reviews concluded telemedicine works and has positive medical and/or economic effects, nineteen reviews concluded telemedicine could work and has potential to produce positive effects, but required more research to fully identify this potential and twenty-two reviews concluded a lack of evidence for any significant positive effects of telemedicine.2 Clearly such a wide divergence of opinion is concerning. The development of a universal standard to govern the questions and assumptions surrounding investigations into telemedicine would provide a means to effectively judge meaningful and valuable studies versus less valid studies and eliminate this conflicting confusion.

Despite this contradiction one of the major problems with telemedicine reviews in general is that only a small number actually explore how telemedicine influence clinical outcomes, which is the most important question regarding whether or not the application of telemedicine is appropriate.2,3 The most promising sub-categories of telemedicine that have some empirical evidence for increasing positive outcome potential are teleradiology, telepsychiatry, echocardiographic analysis and communications between primary and secondary healthcare providers.4,5 As alluded to above currently a significant problem in the debate about the viability of telemedicine is that both parties (proponents and opponents) are attempting to push the application or rejection of a technology without proper evidence that telemedicine does or does not produce positive outcomes at a comparable cost to traditional medicine.

Telemedicine proponents theorize numerous potential advantages including, but not limited to: 1) increased physician accessibility in isolated communities that lack easy transit access to hospitals and medical complexes; 2) reduced of outpatient visits due to remote patient monitoring and reduced total mortality due to increased monitoring; 3) reduced probability for pharmaceutical mistakes due to removed prescription verification and increased administration oversight; 4) reduced probability of infectious disease transmission due to eliminating interaction between infected and non-infected patients in common hospital areas; this benefit could also be enhanced due to the higher probability of the infection being antibiotic resistant; 5) some argue it will increase the level of medical education by allowing subordinates and students to better observe practitioners; 6) reduction of negative psychological associations with visiting a doctor due to existing “creature comforts” of home; 7) grant the ability for physicians to provide consolations to other physicians and/or patients without additional travel;

Overall outside of some specific goals the general idea of telemedicine is to reduce physical office crowding, which will increase overall efficiency and reduce costs, and increase physician/patient interaction efficiency in part achieved by easing the ability to interact with multiple physicians at the same time. Despite the above goals, at the moment the greatest demonstrated benefits from telemedicine comes from remote monitoring in patients with chronic conditions and interacting with specialists that rely on verbal interaction versus physical contact or cues.2,6

While proponents sing of the economic benefits of telemedicine, these potential benefits are only in the long-term, if they exist at all. In the short-term the economics of telemedicine are actually negative due to capital costs associated with the telecommunication and data management equipment as well as the technical training for all relevant medical personnel. Other economic challenges are unclear legal regulations, both within states and between states, and the ongoing lack of recognition by insurance companies for certain aspects of telemedicine as “valid” services.7 Private insurance appear to have numerous barriers due to administrate rules regarding reimbursement of telemedicine services. This lack of recognition could create a “chicken or egg” problem where telemedicine may not make significant advancement until insurers cover it, but insurers may not cover it until significant advancement is made and its overall efficacy to produce positive medical outcomes is demonstrated.

In addition there is a concern about increased costs associated with a greater probability of diagnostic error due to the inability of the physician to actually physically touch and interact with the patient. For example certain physical tests that could produce certain symptom clues will not be available and expecting untrained patients to produce the same results even under instruction is not reasonable. This lack of interaction also raises questions regarding the theoretical time saved with regards to real-time telemedicine. The issue of time saved is not from the perspective of the patient, for unless a patient resides very close to his medical practitioner’s practice, the elimination of travel time and time in the waiting room will produce less wasted time.

However, this time issue could be a legitimate concern from the perspective of physicians. For example some have estimated that virtual interactions involving teledermatology take around thirty minutes where traditional in-person consultations typically take 15 minutes.8 The nature of overcrowding mentioned above is based upon the idea that a physician’s time will be spread too thin with the continuous addition of newly insured patients, if telemedicine increases examination times it will be a detriment not a benefit to physician access.

In addition one of the biggest problems with the expansion of telemedicine is that it appears not to be living up to one of its highest theorized benefits, expansion of medical care in rural communities, especially to elderly individuals. For example despite Medicare rules being in place from 2001 to pay distant practitioners 100 percent of the rate under the physician fee schedule the volume of telemedicine services utilized by Medicare beneficiaries remains low. One recent review found that only 38,000 telemedicine visits were claimed in 2009 up from only 26,000 in 2006.9 Some proponents may try to spin the 32% increase as impressive, but the base increase of only 12,000 individuals reveals the truth that telemedicine is struggling to catch on among the elderly; a group proponents state will be significantly aided by telemedicine largely due to access issues. Worse is that these claims are actually lower than reported for a number of practices inappropriately billed Medicare for video consultations taking place in the homes of urban patients.9

Another foreboding trend is that only 369 practitioners submitted claims for 10 or more telemedicine services in 2009 with only 14 counties having more than 300 telemedicine sessions among its residents.9 Therefore, even in the counties that have telemedicine services that are being used, the volume of use is very small, which could make it difficult for these centers to justify both the capital costs and administrative costs of telemedicine over the long-term.

Also there appears to be a significant lack of local medical specialists who are willing to service rural areas through telemedicine (and maybe in general). General practitioners typically provide telemedicine services, which is unfortunate because one benefit of telemedicine is that it is supposed to “bridge the gap” between the glut of specialists in urban environments and the lack of them in rural environments.

There are numerous reasons why specialists appear unwilling to use telemedicine to acquire more patients in rural areas: 1) specialists already have a sufficient in-person patient population and do not have time for new patients; 2) the money provided by Medicare (in general) is not enough for specialists to bother with taking new patients (opportunity cost is too high); 3) some argue there is a lack of confidentiality and pervasive liability concerns in telemedicine; 4) other inconveniences associated with telemedicine, outside of direct monetary payment, not worth it (licensing, moving between in-person and electronic interaction, general change in routine, managing new operations and costs for the video networks, etc.); 5) prior negative experiences have soured specialists on future attempts at adoption;10-12

One bright spot in rural telemedicine utilization appears to be telepharmacy. Numerous pharmacies can be managed and/or supported by outside pharmacists producing lower fixed costs, especially in rural communities with populations so small that traditional pharmacies cannot be financially supported.9 Telepharmacy appears to be more successful than telemedicine involving specialists largely because of relative reduced in-person workloads between pharmacists and specialists making the acquisition of more patients less time intruding.

The issue of reduced cost may also be questionable for those attempting to utilize telemedicine while on Medicare or Medicaid. Currently due to the Benefits Improvement and Protection Act, Medicare has to pay 100% of the fee to the distance practitioner as well as an additional facility fee to the telemedicine site where the patient travels.9 As of 2013 this fee was $24.9 At a basic level this additional fee makes telemedicine 24 dollars more expensive than traditional patient-physician appointments; multiply that single payment by x number of patients (assume 36,000 from above) and telemedicine costs the government at least 864,000 dollars more than traditional medicine and would only increase with more adoption. In addition to that extra cost there is some evidence to support remote interpretation in medical encounters to be more expensive than its alternatives.2,13 Therefore, the economic realities of simply administering telemedicine need to be more carefully and specifically studied before presuming that they reduce costs.

There is also some concern that real-time telemedicine may increase costs due to individuals increasing their utilization of healthcare services born from the convenience of telemedicine. Interestingly enough some preliminary data suggests the exact opposite based on a change in psychological tendencies regarding a commitment to general health. In simpler terms the convenient nature of telemedicine may induce individuals to view medical check-ups with less meaning. For example in one study telemedicine users were less likely to follow up with an additional physician visit in a reasonable period of time (only 6% of users) versus 13% that visited a physician’s office and 20% that visited an ER.14 A similar mindset is commonly seen in committing to physical exercise where when one attends a gym it sends a psychological cue to an individual that it is time to exercise increasing the probability of meaningful exercise versus if that individual attempts to exercise within his/her home.

Another more minor concern regarding telemedicine is the overall privacy and safety associated with the transfer of medical data over a wireless network both for single issue transfers and real-time remote monitoring. Also while standardization from the practitioner is potentially politically complicated, ensuring transmission quality from the patient if telemedicine is conducted from the patient’s home is questionable. Would it be the responsibility of the patient to ensure security and bear the cost of any breach? Or should real time telemedicine from the patient’s home be managed with a strict protocol only allowing certain technologies and if the patient does not have access to these technologies it would be recommended that the patient abstain from utilizing telemedicine at his home?

Another problem that some believe could be an obstacle to the expansion of telemedicine, especially real-time telemedicine, is the regulatory issues that make it difficult to obtain licenses to practice medicine across multiple states and gaining privileges at multiple facilities. The total extent to which this obstacle is actually restrictive is unknown. The mindset that establishes this obstacle as meaningful is questionable because it seems to imply that a large number of physicians will never choose to utilize telemedicine in their practices, thus the expansion of telemedicine is dependent on the smaller few that do choose to practice it. Due to their smaller number these physicians will need more lenient regulation in order to practice in multiple healthcare markets across multiple states to ensure that potential telemedicine consumers will have access.

Interestingly this “obstacle” appears to only be one in the minds of proponents who believe all concessions should be made to foster the growth of telemedicine. The reason this obstacle of licensure fees and licensing is somewhat hollow is that most of the individuals seeking telemedicine have an in-state physician and it is very difficult to envision an environment where the only telemedicine option is out-of-state. To weaken safety regulations for the sole purpose of providing convenience to more than likely less than 1% of all individuals who will utilize telemedicine in the future seems foolish.

One possible solution to the licensing issue is the creation of a national telemedicine license. However, the immediate problem with this solution is how to “define” telemedicine as significantly different from traditional medicine in that the national telemedicine license cannot also act as a national traditional license to practice medicine. For example real-time interactive telemedicine is basically a patient visiting a physician, but from home or designated secondary site instead of in the office. However, if the appropriate practicing credentials are different between real-time telemedicine and traditional medicine within a given state it can be suggested that there is a fundamental difference in how real-time telemedicine and traditional medicine is practiced, which makes no logical sense. It would be akin to saying that water in the Pacific Ocean is comprised of two hydrogen atoms and one oxygen atom while water in the Atlantic Ocean is comprised of something different. A secondary issue with this solution is numerous states already have differing policies on telemedicine licensing; how can states that have such differing viewpoints as Oregon and Texas come to an understanding regarding the qualifications for a universal license without creating a contradiction with the first above problem?

Another important issue is differentiating the different fundamental legal principles between traditional medical care and telemedicine. While clearly certain things are going to be the same including, required informed consent, confidentiality, etc., other elements will be different like more responsibility on the patient for providing their own medical care and the security of transferred data. One potentially controversial issue would be what defines malpractice in telemedicine? Depending on the quality of the video feed it is reasonable to suggest that certain physical indicators could be more easily misinterpreted by physicians leading to a misdiagnosis; therefore, should physicians be held less liable for misdiagnoses in telemedicine?

A significant disadvantage of telemedicine is the inability to immediately start treatment for severe cases. While telemedicine may offer some alleviation from the fear of hospitals and/or doctors, it does not address general ambivalence of potential medical conditions. There are some individuals that will simply not go to the hospital until the very last moment. In these cases a delay in treatment may be critical. This lack of immediate treatment is also relevant in antibiotic treatments where injections may be required over oral or topical treatments.

Some individuals are concerned that widespread personal objection to telemedicine will prevent significant growth, especially resistance from physicians themselves. A review of literature suggests that, regardless of specialty, once telemedicine is initially explained to patients they have little problem with the results identifying the greatest advantages as the reduction of travel time and stress.15 However, physicians are typically slower to adopt technology in their practices. Within hospitals this slower adoption is irrelevant as only a small number of the attending physicians will have to be sufficiently trained and accepting of telemedicine for hospitals will primarily remain areas of direct contact medicine. The real issue regarding adoption is how fast will physicians accept telemedicine in their personal practices and will it even matter? Widespread adoption may not be important because it would be not be necessary to establish rules and regulations for telemedicine.

One caveat is clear when analyzing survey results underlying patient acceptance and satisfaction with telemedicine is that one must acknowledge the presence of utilization/sample bias. Individuals who engage in the use of telemedicine do so because they are inherently more accepting of it. A similar example could be seen in a survey result that indicates 81% of people that rode Roller Coaster A were satisfied with the experience. Such a high number is not surprising because people who do not like roller coasters will not ride Roller Coaster A and therefore do not participate in the survey. Overall because of this inherent utilization bias simple satisfaction surveys do little good in determining whether or not telemedicine is advantageous for a given community. Note that studies identified that most telemedicine services are utilized by younger, more affluent patients with a high level of tech knowledge lending credence to existing sampling bias.14,16

Instead of focusing on simplistic issues like “Do you like telemedicine or not?”, surveys and their associated analyses should focus on specifics regarding what consumers like and do not like about telemedicine. Furthermore one must ask the question: is the goal simply to provide telemedicine to those who want it or to convince those who don’t of its supposed virtues?

Not surprisingly tutorial training has been suggested to ease the learning transition for more technologically wary physicians before fully engaging in the utilization of telemedicine. However, these tutorials must be smartly designed and lack easily producible technological glitches to limit frustration with both the tutorial and telemedicine in general. Fulfillment of these expectations depends upon overcoming and improving upon the limitations of certain telecommunication equipment as technological issues can restrict physicians’ enthusiasm in some cases. For example and not surprisingly researchers testing low-cost technology have found that poor imaging can limit the usefulness and perceived effectiveness of technology.2

When individual practices or hospitals seek to establish telemedicine programs certain planning steps are critical for success. The most important principle step is to establish a vision for what will embody the telemedicine program. As mentioned above there are multiple aspects of telemedicine, so the first element in planning for a program is to determine which of these aspects will be represented. The development and application of a clear vision reduces the probability of mistakes and increases motivation due to a specific understanding of the goal of the telemedicine program.

In addition to the three general categories of telemedicine the motivation of vision will typically involve at least one of three factors: 1) telemedicine is used to deliver care to remote locations with little traditional access; 2) telemedicine is used to provide alternative methods to deliver care at reduced costs; 3) telemedicine is used to expand market share and improve competitive advantages against other healthcare providers. Note that this third option is a viable one because hospitals are businesses although it would be unfortunate and troublesome if hospital A used telemedicine services to poach hospital B patients when hospital B still had adequate resources to support the care of those patients.

After establishing the vision the medical organization must establish the financial plan that will be necessary to achieve that vision, both short-term and long-term. Part of establishing this financial plan will be incorporating how the telemedicine vision will achieve maximum utilization because if people do not consistently use the program then justifying it financially is a losing proposition.

Another important element in a telemedicine program is properly integrating it into the overall healthcare service organization within the hospital. Physicians cannot view traditional medicine and telemedicine medicine as opposing forces or an “us vs. them” type of model. Physicians must realize that the overall goal of both models is to provide the highest quality medical care at appropriate cost to patients.

While telemedicine exams will not involve patients being present at the hospital, the room in which the physician conducts the examination must have as much similarity to a typical exam room as possible only making exceptions for specific types of lighting and technology. The technology footprint of the room must be as reserved as possible. The intent of telemedicine is not to dazzle and impress the patient with flashy technology, but to provide quality medical care. In addition telemedicine should follow the same standard protocols used in traditional medicine for equipment use, examination and documentation.

Not surprisingly a telemedicine program will only be as effective as the staff running it, so training will be an important aspect in providing quality care. The first element in training will be establishing a leader or coordinator that will run the training sessions and even the telemedicine program itself. An effective leader will make sure that all personnel have an outlet to voice concerns as well as ensure that those working with telemedicine are not ignored or displaced by the technology. After establishing a leader, a training schedule should be established with clear objectives for each session including an early and late call participation session so individuals have a benchmark to how their performance has improved from before training to after training. Training should be as realistic as possible and include multiple technical difficulties to ensure that a strategy exists to manage those difficulties.

Finally it is important for a telemedicine program to have an efficient response structure where both staff and patients have the ability to provide feedback regarding their experience and the operation of the system. All staff should be surveyed frequently (once every two weeks) to ensure the fluid and efficient operation of the program. Patients should have the option of completing a survey electronically after their telemedicine session. The results of these surveys should be compiled and analyzed by a small committee that will act if deemed necessary on the rendered opinions.

One of the biggest problems with the manner in which telemedicine proponents conduct their real world applicatory analysis is that they seem to believe that praising the benefits of telemedicine is enough to drive hospitals and other private practices to adopt the necessary technology. Clearly this belief has proven false for most medical institutions have been slow to adopt even the simplest elements required for “modern” telemedicine, electronic medical/health records. If telemedicine proponents want to more efficiently expand telemedicine they need to produce individualized analyses for specific medical institutions that demonstrate the benefits of telemedicine rather than simply using blanket statements of how it is good and saves money no matter what.

Proponents of telemedicine dream of a system that lowers the total costs of healthcare, for both the patients and the practitioners, as well as increases the level of access and ease at which medical care is administered. This ideal is thought to be achieved through eliminating time wasting activities like physical travel to a medical institution, elongated check-in (instead modern check-in simply would utilize a code number and password), reduced overhead, more efficient data collection, etc. Unfortunately this ideal has not proven easily achieved and may not even been viable. The first problem is that there is no uniform evaluation system to determine whether specific aspects of telemedicine help to achieve this ideal instead just a hodge-podge number of reviews claiming contradictory results. A second problem is that private insurance has been slow to cover real-time telemedicine procedures and current Medicare payment structures make telemedicine more expensive for the government versus traditional medicine.

Another concern is the idea of using telemedicine to address the anticipated general practitioner shortage. If telemedicine does not reduce the average time that a physician spends with a patient while at least maintaining overall quality of care then telemedicine will not be a useful strategy for this particular goal. Unfortunately at the moment there are very few studies that have addressed patient-physician time versus quality of care. In their theoretical musings regarding patient turnover telemedicine proponents appear to think that there are numerous general practitioners simply sitting in their offices out of boredom with no patients to see, thus they are freely available to video conference with patients outside of their “treatment area”. This vision is rarely, if ever, accurate, thus turnover times are critical to determining whether or not telemedicine will be a boon to any overcrowding.

Further problems stem from the fact that even when given the opportunity to utilize telemedicine, most individuals elect to continue to engage in traditional medicine despite travel concerns. Compounding this problem is the demographics that are taking advantage of real-time telemedicine: young urban well-off individuals with knowledge of technology; these individuals facilitate a small benefit from telemedicine from a standpoint of the healthcare industry in general. If this trend continues the public perception of telemedicine could shift to it being an economic burden that has to be absorbed by the poor and the middle class to accommodate an additional convenience to the wealthy, which could create significant resentment towards telemedicine in general.

Overall the idea of telemedicine, especially real-time interaction, is a strong one with significant potential, but proponents have to separate hopeful theory from reality. While positive steps have been taken for the store-and-forward and remote monitoring aspects of telemedicine, the major savings and benefits from telemedicine come from real-time interaction, which is much further behind in its utility and usefulness. Without sufficient work telemedicine will never be anything but a niche market hardly capable of producing the benefits dreamed of by its proponents.

Citations –

1. Allely, E. “Education and training in telemedicine: synchronous and asynchronous telemedicine.” J Med Syst. 1995. 19:207–12.

2. Ekeland, A, Bowes, A, Flottorp, S. “Effectiveness of telemedicine: a systematic review of reviews.” International journal of Medical Informatics. 2010. 79:736-71.

3. Hailey, D, Roine, R, and Ohinmaa, A. “Systematic review of evidence for the benefits of telemedicine.” J. Telemed. Telecare. 2002. 8(Suppl. 1):1–30.

4. Roine, R, Ohinmaa, A, and Hailey, D. “Assessing telemedicine: a systematic review of the literature.” CMAJ. 2001. 165:765–71.

5. Bee, P, et Al. “Psychotherapy mediated by remote communication technologies: a meta-analytic review.” BMC Psychiatry. 2008. 8:60-73.

6. Hersh, W, et Al. “Telemedicine for the Medicare population: Update” (AHRQ Report No. 131). Rockville, MD: Agency for Healthcare Research and Quality. 2006.

7. Rogove, H, et Al. “Barriers to Telemedicine: survey of current users in acute care units.” Telemedicine and e-Health. 2012. 18(1):48-53.

8. Moffatt, J, “Barriers to the uptake of telemedicine in Australia – a view from providers.” The University of Queensland, School of Medicine. 2011.

9. Gilman, M, and Stensland, J. “Telehealth and medicare: payment policy, current use, and prospects for growth.” Medicare & Medicaid Research Review. 2013. 3(4):E1-E14.

10. Luo, J. “Telemedicine: Is it time now?” Primary Psychiatry. 2008. 16(2):27–30.

11. Whitten, P, and Buis, L. “Private payer reimbursement for telemedicine services in the United States.” East Lansing, MI: Michigan State University. 2006.

12. Grigsby, B, et Al. “The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation.” Telemedicine and e-Health. 2007. 13(6):645-656.

13. Azarmina, P, and Wallace, P. “Remote interpretation in medical encounters: a systematic review.” J. Telemed. Telecare. 2005. 11(3):140-45.

14. Uscher-Pines, L, and Mehrotra, A. “Analysis of teladoc use seems to indicated expanded access to care for patients without prior connection to a provider.” Health Affairs. 2014. 33(2):258-264.

15. Witten, P, and Love, B. “Patient and provider satisfaction with the use of telemedicine: Overview and rationale for cautious optimism.” J Postgrad Med. 2005. 51:294–300.

16. Exploring the Digital Nation America's Emerging Online Experience, 2013, U.S. Department of Commerce: Washington, DC. p. 9-15.

Defamation and Internet Reviews

The balance between free speech and defamation has frequently been a tricky one with free speech understandably given significant lenience. However, as times have changed and the power of the Internet as a commercial tool continues to grow the emergence of social critiquing websites have become important enough that a positive majority opinion can result in millions in additional revenue and a negative majority opinion can result in millions of lost dollars for authors as well as consumer and service businesses.

Unfortunately the anonymity provided by these websites and the general simplistic nature of their review system has created an environment where the “public” evaluation of services and products can be easily manipulated by political and/or competitive elements. Sadly still there are frequent instances when these websites do not behave as reasonable and rational stewards when issues of defamation arise continuously differing to 1st Amendment protection for their users failing to even ask the question of whether or not an act of defamation has even taken place, an obvious abdication of their responsibility.

Defamation occurs when an individual(s) make false statements about another individual or group that harms its reputation. There are typically three elements to supporting a defamation charge: the statement must be false, cause harm psychologically, socially or financially and be made negligently and/or deliberately (i.e. the individual did not take time to determine the truthfulness of the statement or flat out lied). Also defamation is commonly divided between written statements (libel) and spoken statements (slander). With respect to the Internet almost all defamation cases are libel due to written statements on message boards or review websites and because almost all products reviewed cannot be viewed as “public entities or officials” proving malice is not necessary to prove defamation. Finally with the commercial nature of these types of product review statements neither type of privilege, absolute or qualified, can be applied to avoid defamation charges.

The most common defense against defamation charges, and only real defense with regards to reviewing a product, is that the statement rendered is simply an opinion rather than a statement of fact. Frequently opinions, due to their personal and somewhat subjective nature, are not viewed as falsifiable. However, the Supreme Court has ruled that the “opinion defense” has certain conditions and cannot be treated as a third universal privilege. Other common defenses for defamation where individuals believed in statement accuracy due to a secondary source provider (i.e. newspaper or television report) or emotional/satiric utterance are not applicable to reviews because there is no secondary source provider and the review is considered a statement that is supposed to be believed.

Beyond opinion the only other reasonable defense for libel in a product review environment is if the reviewed product is not reasonably capable of further damage to its reputation. Obviously if the reputation of an entity has “bottomed out” in the eyes of the public then no further negative statements regarding that entity, true or not, can damage the reputation of that entity. However, for this defense to work the accused individual must demonstrate that the review did not create a “chain-reaction” that caused the reputation to bottom out due to the “pile-on” nature of the Internet.

So if there is no opinion privilege what defines a review that is negative and legal versus one that is negative and libel? Largely the deciding factor is whether or not the review contained information that a reasonable analysis could disprove. Basically the more detailed an opinion the less likely an individual is able to make a successful “opinion” defense against a libel charge. Of course this characterization is an interesting element because the most valuable reviews are those that are thoroughly detailed.

Reviewing in general, but especially online reviews, typically creates a reverse bell curve in the respondent spread that then creates an intermediate based mean. This characteristic occurs because most people do not take the time to review products they view as average (i.e. 2 – 3.5 stars). Instead most non-paid reviewers have to feel strongly about what they are reviewing, which commonly will result in 1, 4 or 5 star reviews. Therefore, for a number of products these reviewers tend to somewhat neutralize each other resulting in a large number of products receiving an average 2.5-3.5 star ranking (out of 5). With this typical result it is important that reviewers be expected to provide sufficient reasoning for why their experience with the reviewed product/service was positive or negative for the general extreme nature of these reviews can produce significant movement for products that lack a large number of reviews.

Unfortunately a number of reviewers do not provide sufficient depth, reasoning and logic to their reviews instead substituting emotion and personal political/philosophical beliefs, which are subjective and uncharacteristic to all potential future users. In addition this reasoning is marred by a lack of consistency in the rationalization. The lack of a consistent format in the review process can also lead to confusion and inaccuracy when determining why an individual enjoyed or did not enjoy a particular experience. This confusion and inaccuracy can then result in libel suits. Realistically this problem should be solved by all websites that conduct structured product reviews having a universal format. The following format is an example of what could be used in the future:


User Name:

Location:

Ranking the Experience (out of 5 stars in half star increments):


Reason 1 for the Above Ranking
Subject:
Text/Rationality:


Reason 2 for the Above Ranking
Subject:
Text/Rationality:


Additional Comments:


While it would be preferable for individuals to use their real names when reviewing items/services, it is not required because the important element is the content of the review not the simple star measure. If the generally used star system is retained then it should include the ability to evaluate with half star increments because there are a number of times when an experience is not bad enough to warrant 2-stars, but not quality enough to earn 3-stars. Without the ability to award a 2.5-star ranking the review is inherently inaccurate.

In all types of reviews the rationality for why an experience produces a certain ranking is paramount. There should be at least two major rationalizations to why an individual evaluated the experience his/her particular way. These reasons need to be clearly identified and transparent instead of potentially hiding in a large wall of text. Initially some may argue that contemplating at least two significant reasons why the product/experience was good or bad is too much work. This reasoning is foolish because if one cannot met this requirement then why is that individual taking the time to write a review in the first place because clearly the product/experience was not memorable or did not have a significant impact.

Also these reasons need to be included for the review to be accepted by the particular website. Basically these reviews would be encoded as required fields. If additional commentary is desired a non-required space would be available after the two principle rationality sections. This additional commentary section is largely reserved for individuals that had a significantly positive or negative experience.

This new review format would create significant transparency and clarity behind the rationality leading to the ranking produced by the reviewer. In addition this new format actually demands the reviewer apply some effort to the review of the product eliminating the “drive by” review of a single sentence stating that the product is “awesome” or “sucks” thereby eliminating poor quality reviews, either positive or negative, from consideration for the average ranking. This elimination is important because not all reviews provide equal value, yet in the simplistic “average score” system used by review websites they are treated equally. Changing the format of the review process should not be difficult for these review websites. Reviews using the old method could remain in the database, but would need to be isolated into a separate category where a viewer could select to view either reviews with the old system or reviews with the new system.

It is also important to note that defamation is a legitimate challenge to the 1st Amendment. There are some individuals who seem to believe that attacking any negative comment on a review website is a violation of the 1st Amendment and is somehow inherently bad business. The common statement by these individuals to that effect is something along the lines of:

“How does company A expect to get more customers when they are suing review website A over some bad reviews. Clearly company A cannot take criticism, so they lack flexibility and cannot cater to their potential customer base. Instead of adapting their only response is to sue. I would never do business with company A.”

Of course this statement is inherently flawed because it assumes all negative comments as valid, truthful and constructive criticism. Clearly any rational person who has ever viewed the comments that certain products receive on these review websites understands that this assumption is frequently not valid. Basically these individuals need to understand that there is a difference between a justified negative review that uses facts and evidence to support its stance and an unjustified negative review that embellishes and lies to “support” its stance. All parties should herald the above changes to the review process because it makes defining and supporting a defamation charge easier by eliminating the ambiguity that sometimes leads to fair negative reviews drawing legal attacks from individuals/groups.

Overall one of the biggest problems in the relationship between professional review websites and the businesses/products that are reviewed on them is that the review websites largely view themselves as only a platform to host the reviews with no responsibility for the content of those reviews. It is this attitude that leads to the “surprise” when they receive numerous complaints from individuals and companies for libel reviews. Changing the review system to demand more clear and transparent rationality from reviewers would be a significant step in better controlling the content of a review while no stripping the ability of reviewers to make a positive or negative review on a whole. This change should also limit the tension between these review websites and product developers/companies changing the certainty and validity among the number of complaints and potential libel inquiries and lawsuits. In the end something needs to change in the way these review websites handle their roles in modern business otherwise the merry-go-round of complaint/lawsuit – denial – complaint/lawsuit will continue, simply with continuously increasing stakes.

What to do about Coral Reefs

Although coral reefs have had periodic moments of distress and bleaching in the past, these events were frequently isolated to a given weather anomaly, most often El Nino. Unfortunately these events have become increasingly more common in the recent decade forming a troubling, yet predictable trend that can no longer be ignored. The importance of coral and the reefs they form cannot be understated; the mass death of coral will not simply increase the probability of oceanic bio-diversity loss, but rather guarantee its loss; a loss that will be a death knell for the oceans themselves.

It is important to understand the elements of the problem before suggesting a course of action. In large part coral is comprised of a colony of genetically identical polyps. After a significant amount of growth these polyps extend vertical calices that sometimes form a new basal plate; the formation of enough basal plates give rise to coral reefs. While coral can procreate either through asexual reproduction or sexual reproduction, sexual reproduction is typically favored. The release of gametes characterized by sexual reproduction fosters faster new colony construction whereas asexual reproduction typically strengths colony foundation and maintenance through coral head expansion.

Coral has the capacity to catch small animals like fish and plankton, but most coral have evolved to form a symbiotic relationship with zooxanthellae algae. This symbiotic relationship is why most coral are found in very shallow water (no less than 60 meters, but normally 2-10 meters) so that sunlight can be utilized by the zooxanthellae in order to undergo photosynthesis providing food for the algae and coral. Also while the calcium carbonate skeletons usually give coral a chalk white color on their own, their resident algae host a wide variety of colors which give coral its noteworthy color arrangement. Note that coral can also demonstrate a non-white color scheme on its own based on its protein synthesis pattern. Not all corals share a relationship with algae, but most of these non-algae coral specimens also do not commonly associate with reef formation and are typically found at much greater oceanic depths.

There are many different ways that coral can die, but the two reasons that seem to be the most associated with the recent bleaching trend are higher ocean temperatures and an increase in ocean acidity. Higher temperatures produce excess thermal stress on the coral which cause them to eject their algae in effort to reduce overall stress. While the algae has helpful attributes it also lives within the coral creating additional stress, thus when faced with a change in environmental conditions that increases stress further, the coral acts to lower stress to increase survival percentage and the easiest way to do that is to remove the algae. If the environmental change is only temporary then once environmental conditions return to ‘normal’ levels the coral typically reacquires the algae. Higher ocean acidity results in the inability of the coral to form and maintain their calcium carbonate exoskeletons lead to skeleton deformation and collapse. Coral responses to a reduced ability to form calcium carbonate structures is still unclear beyond the fact that such a situation eventually leads to premature coral death.

Unfortunately there appears that little can be done about increasing ocean acidity beyond dramatic reductions in human derived carbon emissions. One of the bigger problems with ocean acidity is that it is fairly uniformly distributed relative to ocean temperature (ocean temperature is important because the temperature of a liquid directly determines the solubility of a gas like CO2). Although an idea for a technological stop-gap for ocean acidity has been proposed on this blog here, addressing localized temperature flux may be a more effective strategy in the near-term if the goal is to increase coral lifespan within detrimental environmental conditions.

Local environmental cooling may be possible because of the natural uneven distribution in water temperatures relative to depth. Most of the threatened coral species are near the surface of the water exposed to higher temperatures than those creatures that live at a greater depth. Based on that principle if a device could be developed which could ferry water from a lower depth and deposit it closer to coral reefs cooling the region near the coral could be possible. Note that because the colder deep water would not be able to effectively mix with the warmer surface water the overall system could be thought of as similar to a fountain. Water is pumped up from a specific depth and then that water is released near the surface in close proximity to the coral reef where conduction briefly lowers the surface water temperature before the water descends once again.

One possible design for such a device could be to develop a buoy which would float on the surface of the water almost directly above the coral bed. Within the base structure of the buoy would be a pump and associated tubing that descends about 800 ft. below the surface. The reason 800 ft is selected is to focus on water collection beyond the thermocline ensuring a significant temperature differential between the collected water and the water surrounding the coral. Water would be pumped up to the buoy where it would be released back into the water near the surface. The release methodology should probably favor sparse droplets instead of a stream to avoid unnecessary damage to the coral due to excess water pressure/force. Power could be provided to the pump and any other electrical elements through a solar power panel and lithium-ion battery storage.

The biggest problem with this strategy is that a huge volume of water will need to be displaced to generate any significant cooling. At first glace the difference in total volume of displacement seems insurmountable, but the continued incessant movement of water over the course of months and on into years could generate a meaningful change. Remember that the purpose of this device is not to regionally eliminate the temperature increases threatening the coral, but slow the increase to buy time for humans to reduce carbon emissions and positively reverse the ocean from a sink to a source temporarily (over a few decades) returning ocean CO2 load to recent generational normalcy (CO2 concentration in the 1700s). A useful attribute of this system is that it is testable, especially in conjunction in the Argo float systems, can be isolated to a single environment without damaging other non-related environments and does not require any special systems.

While determining an exact price for a single system is difficult, estimation of cost seems to be reasonable. The overall pressure change between the surface of the water and the final location of the pipe at 800 ft. should be about 352.8 psi, which is not so excessive that a special material will be required. However, it may be necessary to include some form of filter on the receiving end of the tube to prevent certain lifeforms from clogging the tube and/or killing those lifeforms. As previously mentioned, the release end of the tube would probably have some form of spray attachment to break the water stream up into droplets. The solar cell/photovoltaic system only has to power a single pump plus any other necessary electronics to draw up the water, so it would probably be smaller than the ‘for home use’ systems that are currently available. Finally the battery is probably the most expensive addition to the standard buoy, but one could state that with the coming popularization of electrical vehicles, battery prices should drop slightly reducing the overall cost of lithium-ion batteries for other devices such as this one.

In closing whether or not the above system is effective at reducing local water temperatures to theoretically increase coral survival time is not the main issue. Although it would be excellent if it did, the overall point is the realization that human effort to curtail carbon emissions is not progressing faster enough to have any real level of confidence that a vast majority of coral will survive the coming decades. To save the coral it is becoming more probable that humans will have to deploy a non-emission reduction strategy. While it is not guaranteed, such a strategy will probably involve some form of technological intervention, so it is important to begin with both the research and the testing as soon as possible.