# Space and Global Health/Blockchain and Global Health
## Introduction

In global health, multiple actors (stakeholders) and technologies come together to enable a trustworthy, secure and credible eco-system. To ensure risk mitigation and credible information exchanges, it is necessary to have a secure and trustworthy interaction of associated stakeholders from the Global Health or Public Health domains and also Technologies Domain, including space technologies. The intersection of Space and Global Health is primarily in using spatial and remote sensing technologies that can inform policies to support public health on earth. (See also Working Group on Space and Global Health. Open community approaches for interfacing space and global health have also been initiated.
In this context, Distributed Ledger Technologies (D2L), particularly, Blockchain may act as an enabler in a distributed environment where the control is with the associated actors / stakeholders and not with any central authority to run the infrastructure. For example, provisioning of data from space technology domain to inform global public health domain for making informed decisions in real time, may be regarded as an information exchange, securely. These exchanges are simultaneously secured and trustworthy with the use of cryptographic principles, so that decision makers can rely on those transactions in the operational workflows. The key element is trust in sharing relevant information from space technologies to health domains and vice versa.
On the other hand, in the healthcare eco-system, user data has a significant impact on prevention and treatment methods. A health professional has to trust the digital information available to make an informed decision. Cryptographic methods (including blockchain), ensures that information in an electronic health record is immutable (unchangeable) and are still valid in the processing chain towards the end-point as decision maker, whether it is the health consumer or worker. With the interconnection of disparate systems, the interoperability in terms of validation of transaction has the objective to increase the accuracy of records (EHRs) when then space technology domain and health domains are connected in a decentralized network.
As the pandemic accelerated digital methods in information exchange, blockchain with its unique characteristics (eg, immutability, decentralisation, and transparency) can be useful in bringing together multiple domains. Many countries had begun trialing blockhchain in health for knowledge transfer. For example, Australian Department of Health is using blockchain for medical research activities. Conversely, recommendations for the structure of Open Educational Resources for Space and Global Health were derived from capacity building programs published by the World Health Organisation and an Australian perspective on the Open Community Approach. Australia was chosen as an example of a country with diverse demographic multi-ethnic, multi-lingual, and multicultural communities, distanced from each other due to the unique geo-location. The ability of health domain being informed by space technologies have also been discussed for Canada.
When the discussion centers around global health, while the World Health Organisation is considered a central authority, every country has its own public health context. In countries where Universal Health Care systems exist, public health is a government handled domain may it be federal, provincial or local levels. In other countries, public health may be privatized. Depending on these systems, knowledge exchanges methods may have restrictions. When these countries propose to share data globally for informing their own policies, the process would need to rethink governance models. Nonetheless, blockchain or D2L technologies may become an enabler for these cross border exchanges with an overarching layer of security and trust.
The levels of trust in using blockchain and distributed technologies in health domain can be used as a reference point for enabling information exchanges seamlessly between Space and Health domains.

# Learning Activity
### Identify and discuss use cases in the global public health and/or space technologies domain that have used blockchain.

There are many use cases for blockchain in public health in today’s healthcare systems as well as in future healthcare systems. With today’s current technology the most obvious use for blockchain technology is in managing electronic medical records, handling claims, facilitating research, sharing health data and supply chain management.
Electronic Health Records (EHRs) are not currently suited to handle a lifetime of records from various institutions, and patients lack control of their data. Utilizing blockchain technology frameworks such as a permissioned blockchain to access and store encrypted patient data may be a solution to better managing EHRs. This would create an immutable record of the patient’s history to reduce medical fraud, as well as reducing the risk of errors made in the storage or sharing of clinical data which can pose severe threats to patient safety and level of care. The use of blockchain technology will improve access to medical care, streamline record management, enhance clinical information accuracy, and expand security of patient data. So far, the architecture and usability of blockchain-based EHR are being actively experimented with and tested. For example, Mayo Clinic partnered with Medicalchain on a pilot project where Hyperledger is adopted for physician identity registration while Ethereum used for data transaction. The University Health Network worked with IBM, eHealth Ontario and the Blockchain Research Institute to develop a proof of concept for PHR on a private-permissioned blockchain. Dubovitskaya et al. (2020) proposed a complete architecture of blockchain-based data management where data storage, the link between user interface and the application layer, and communication channels between nodes are all specified. Notably, in their proposed architecture, health data will be stored off chain and membership service organizations certify the access to the blockchain.
Similar to the management of EHRs, healthcare claims, billing and payments are an obvious area for blockchain integration within healthcare. Blockchain technologies have quickly gained popularity in managing and tracking financial records, and a permanent ledger could be developed to track patient claims, hospital billing and payments made. This would improve security and reduce fraud within these areas, while also providing a more secure method of payment.
Another area in which blockchain technology can be effectively implemented in healthcare systems is in management of clinical, biomedical, and pharmaceutical research. Blockchain can introduce a decentralized framework for collaborations and data sharing among researchers, while also better tracking records, patient enrollment, and consent. In addition to this, it can help in the evaluation of drugs by keeping detailed records of the research and development activities, results, and production of the drugs. Patients can also manage their consent better with blockchain technology and can have control f their data and who has access to it. By utilizing smart contracts and blockchain technologies in parallel, data can be more efficiently shared, stored, and audited in research applications, and a digital ledger will provide the most efficient method of doing so. Importantly, smart contracts can be combined with tokenization of health data, such that health data is transformed through cryptography into discrete objects and transferred over a blockchain, while the transfer is rewarded either by a cryptocurrency outside of the native blockchain or a utility or value token native to the blockchain. This not only ensures the security and privacy of health data sharing, but also incentivizes patients to share health data with those who are in need, for example, research organizations and pharmaceutical companies, addressing the economic injustice currently perceived by patients regarding health data sharing and increasing the volume of high-quality real-life data that health researchers can access.
An apparent use case in today’s public health systems is in supply chain management. From manufacturing to patient use, the supply chain has many different stages, all of which are vulnerable to human error or malicious behavior. These various supple chain records can be easily entered in a blockchain ledger that becomes permanent and decentralized to reduced fraudulent or erroneous activity in the supply chain. This can lead to more efficient processes, safer supplies, and lower costs for healthcare systems.
In addition to these use cases in public healthcare systems, there are many applications for blockchain in the health systems of the future. For example, neuroscience research into reading and interpreting brain activity and identifying patterns could benefit from using blockchain technology. Similarly, with the increased use of wearable devices and remote patient monitors in telehealth services, lots of health data will need to be stored and shared in the future. These wearables are one member of the much larger Internet of Things (IoT) that is currently being built and will be extremely useful in hospitals. All of these IoT devices in a hospital, from a sensor to security systems, even to lights, will all need to be securely controlled and will have to store and share data. Blockchain can help solve these future issues of storing and sharing data in a secure manor using either private, public or some sort of hybrid ledger. It can also decentralize the storage necessary for the large amounts of data being collected and create an unchangeable ledger to ensure security and accountability.
These applications of blockchain technology within healthcare systems are not without their challenges though. First and foremost, one of the most difficult challenges to overcome are the technology requirements of blockchain and connected devices. Many hospitals are still working on digitizing records, so introducing smart IoT technology or new methods of record management may be difficult. Somewhat related is the challenge of culture shift within healthcare systems. Blockchain is a new technology, and some people are weary of using it for such critical systems, so to implement blockchain technology the capabilities, weaknesses, and misconceptions surrounding it must be addressed within public healthcare. These may include addressing concerns about safety and security of data, such as a 51% attack, or concerns about the storage needed to keep a ledger of all healthcare activities. Finally, the largest difficulty is not unique to blockchain technology within healthcare but is a common theme in any technology in public health, which is interoperability and standardization. It is extremely important for various health agencies to be able to communicate and share data with each other, and for that to happen there needs to be a standard blockchain technology or communication protocol adopted to streamline the process.
As the pandemic continues, the healthcare and life sciences industries face new challenges, including adapting their supply chains to provide protective equipment and rapidly developing treatment options, testing tools and vaccines. In addition, there has been a general shift towards more patient-centric healthcare. Patients desire more control and involvement in their care. Healthcare providers see value in creating greater patient engagement because it can promote higher treatment adherence, free up clinicians’ time and achieve better health outcomes. At the same time, there has been rapid medical science advancement, decreased cost of genome sequencing, digitization of healthcare data and advancements in artificial intelligence. These advancements have all converged to create opportunities to capitalize on precision preventative care and new biomarker-based therapies. As an example, new biomarker guided research in the development of drug therapies is gaining traction.
Advances in molecular biology and immune system research change the paradigm, and now tissue agnostic, biomarker-based drug development and theory is becoming more widespread. Adaptive clinical trial designs now target biomarkers across all tumor types in cancer research. As a result, there is greater demand for ‘real word’ data At the same time, healthcare professionals want to know how to manage consent and secure personal health data so they can use health data to drive new diagnoses and therapies in a way that complies with health information regulations. the digital health sector, personal health information is sometimes being captured, shared, and utilized by third parties without their knowledge or agreement, which can have harmful consequences on individuals. As a result, people are becoming hesitant to use services that collect their sensitive data. Personal health data, such as the genome, encodes a sensitive yet heritable profile of an individual, marked by genetic diversity reflecting one's history and disclosing one's vulnerability to health and diseases, which is a major concern for participants in research and therapeutic applications. The current practice of locking health data away is flawed as sharing genetic data is critical for advancing biomedical discoveries and leveraging promises of the digital health revolution. In other words, if health research has to be optimized, measures must be discovered to safeguard privacy while allowing data sharing and consumption.
With its inherent characteristics of decentralization, transparency, and anonymization, blockchain technology has sparked discussions and proposals that it could be beneficial in healthcare. These distinguishing characteristics provide a foundation for asserting claims without challenge (e.g., ’I created this artwork’) or preventing bad actors from retracting their actions (e.g., for fraudulent purposes or to avoid accountability). In renowned blockchain systems including Bitcoin and Ethereum, the transfer transaction is recorded on the chain via ledger records. Meanwhile, another type of blockchain system has emerged: identity-based distributed ledger systems, with Self-Sovereign Identity (SSI) systems being a new and rapidly growing variant of this class.
Christoper Allen proposed the concept of SSI in 2016, which allows people to maintain have complete control, custody and access (i.e., through as portability and interoperability) r over their digital identities. Compliance: SSI systems tackle blockchain-based e a difficulty with recordkeeping that affects other types of distributed ledgers (i.e., personal information leakage from recording transactions on ledger) . When clinical trial consent transactions are maintained on a blockchain, these records frequently contain personally identifiable information or metadata that could lead to re-identification of an individual, putting compliance with privacy and data protection laws at risk. Thus, SSI systems that do not record peer transactions on a ledger are designed to be extremely privacy-preserving and comply with the General Data Protection Regulations (GDPR) and comparable data protection legislation in other jurisdictions since they do not require the deletion of data from a ledger. Recently, solutions based on SSI blockchains have received the attention of some researchers. Belchior et al [3], proposed a SSI based access control solution, which shows how Decentralized Identifiers (DIDs) and VCs (Verifiable Credentials) can be integrated with attribute-based access control in a federated setting, minimizing data disclosure and data redundancy. Liu et al proposed a SSI based solution for multimedia data management. Papadopoulos et alpresented a privacy-preserving decentralized workflow that facilitates trusted federated learning among participants. Leux et al [6] proposed a self-sovereign health data management solution, where VCs were used to enable privacy preserving sharing of personally identifiable health data. However, the existing solutions do not address the problem of preventing the unauthorized usage of the data (e.g. personal health data) after the identity or other data has been shared. As a result, it is critical to have a system that protects individuals’ privacy when personal health data are being shared, that permits limited access to third parties under particular conditions, and prevents unauthorized secondary usage.
Kang et al. pioneered the design and implementation of such a system by integrating multiple technology stacks from the fields of SSI blockchain, data usage control, and confidential computing. The solution brings together advances from the fields of identity management, confidential computing, and advanced data usage control. In the area of identity management, the solution is aligned with emerging SSI standards. In respect to confidential computing, the Cheon-Kim-Kim-Song (CKKS) fully homomorphic encryption (FHE) scheme is incorporated with the system to protect the privacy of the individual’s data and prevent unauthorized secondary use when being shared with potential users. In the area of advanced data usage control, the solution leverages the typical digital rights management (DRM) solution architecture to derive a novel approach to licensing of data usage to prevent unauthorized secondary usage of data held by individuals. Specifically, the design covers necessary roles in the data-sharing ecosystem: the issuer of personal data, the holder of personal data (i.e., the data subject), a trusted data storage manager, a trusted license distributor, and the data consumer. A genomic data licensing use case was evaluated, which shows the feasibility and scalability of the solution. On today's digital health platforms, there is a lack of control and privacy over individual-owned data. Without their permission, secondary use is a violation of privacy and data protection laws. In response, the design of Kang et. alprovides people more control over a much broader range of personal data. Besides, in comparison to the commonly used scenario of SSI for authentication and proof verification, Kang et. al’s design broadens the scope of blockchain-based decentralized identity.
Conversely, major space-faring nations such as Canada recognizes the urgent need for astronaut healthcare in deep-space exploration class missions to Mars and beyond. This will require new methods of delivering virtual health care, such as linking Personal Health Records (PHRs) to EHR systems. A centralized EHR system creates a central point of failure during cybersecurity attacks, limits the control of data by the users, lacks guaranteed traceability and accountability, and greatly slows down the growth of IoT in virtual health care. Blockchain technology can introduce several benefits to healthcare data management such as,
* Healthcare data stored with blockchain technology are immutable, transparent, traceable, and secure from mishandling, theft, and disasters.
* EHRs stored using blockchain ensures data interoperability through standardized structures, thus ensuring the ability to share health data globally.
* Blockchain technology eliminates the need of third parties to govern patient data, thus reducing data handling costs of current healthcare systems.
The benefits of blockchain/D2L approaches have prompted countries like Estonia, UAE, and Switzerland to trust and implement the technology in their EHR systems with success. In the context of space, blockchain can support the collaborative processes of the space industry, such as communicating with geosynchronous satellites, securing satellite swarms communications, tracking and sharing space debris location and so on. With its standardized data structure, blockchain allows to bring space technologies to advance earth’s healthcare, while also enabling rapid astronaut support from ground stations. Astronauts in deep space exploration class missions do not have fundamental healthcare due to lack of real-time consultation with ground-based flight surgeons, and the lack of an onboard medical expert. As a result, Canadian Space Agency (CSA) identified that medical operations in space must become more autonomous, incorporating crew-worn sensors and AI assisted clinical decision-support systems. Using blockchain technology as a communication and security layer in this system will enable transparent and secure handling of astronaut health data and easier linking with earth based EHRs.