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In 2012, the Internet Corporation for Assigned Names and Numbers (ICANN) opened a new round of applications for generic top-level domain (gTLD) names, receiving 1930 applications, of which at least 18 were related to health (eg, “.doctor”, “.health”, “.med”). The entry of new, commercial players applying to create health-related names reopens the debate on the role of international organizations, governments, non-governmental organizations, and other stakeholders regarding the safeguards and policies needed to protect consumers.
In 2012, the Internet Corporation for Assigned Names and Numbers (ICANN) opened a new round of applications for generic top-level domain (gTLD) names, receiving 1930 applications, of which at least 18 were related to health (eg, “.doctor”, “.health”, “.med”; see
As the paper by Mackey and colleagues in this issue of Journal of Medical Internet Research (JMIR) shows [
.health (4, one of which is withdrawn)
.med (4, one of which is withdrawn)
.doctor (3)
.fit (2)
.healthy (Chinese variant)
.healthcare
.medical
.hospital
.pharmacy
.skin
.surgery
.heart (withdrawn)
.hiv
.clinic
.dental
.dentist
.cialis (withdrawn)
.fitness
Some potential operators of health-related gTLDs already promote their namespace as “trusted” (see
Screenshot of DotHealth LLC.
Source credibility can be achieved in two ways: (1) an “upstream” evaluation by the registrar requiring certain credentials or criteria for the prospective second-level domain owner (for example ISO certification, professional licenses, educational degrees or other credentials), and/or (2) by a workflow where registrars take additional steps to ensure that site owners declare their financial interests and disclose their credentials and privacy protection mechanisms, making this information transparent (and machine-readable) so that users can judge for themselves if the source is trustworthy, and software can assist users in finding relevant and trustworthy information for their specific purpose. One approach to achieve this is through a simple but mandatory questionnaire to site owners when they apply for a second-level domain name. This metainformation should be viewable and searchable by consumers, and perhaps be mandated to be provided on the sites themselves as machine-processable meta-tags (metadata), which would make it possible for the site owner to change the metadata, or to have different metadata for different sections of the site, as suggested in the MedCERTAIN/MedCIRCLE projects [
Such considerations are currently not included in any of the applicants’ documents. While DotHealth LLC is planning a “Request for Information” (RFI) process for selected second-level domain names which include, for example, disease names [
Are the proposed public interest commitments of the current applicants for health-related domains enough? Many in the global health community do not think so. The WHO received a mandate at the 9th plenary meeting of the World Health Assembly on May 27th, 2013, to “convey to the appropriate bodies, including the ICANN GAC and ICANN constituencies, the need for health-related global top-level domain names in all languages, including “.health”, to be consistent with global public health objectives”[
Where does the public stand on this issue and where are the voices of patient and consumer organizations? As the debate has not entered mainstream media, there has not been much (if any) debate. According to a poll conducted by JMIR Publications in February 2014 among Internet users from the US, over 80% of consumers have not heard about the new health-related gTLDs, and most are indifferent about the question who should administer health-related gTLDs (60.2% said they “don’t care”), but among those who cared, a clear majority is against the idea that they should be managed by a private for-profit company (only 10.7% were comfortable with this idea), while most favored a non-profit organization to be in charge (20.2%) (
Another poll conducted by JMIR Publications reveals that 43% of respondents are unsure if .health should be better regulated than .com or .org domains, but among those who have an opinion on this question, a slight majority thinks that this should be the case, with 33.3% of all respondents favoring more regulation and only 23.2% saying that this should not be the case (
A fourth JMIR poll confirms that gTLDs enjoy different levels of “credibility” among users (
JMIR polling results among the US population regarding health-related top-level domains.
Health related information and data occupy a crucial and unique status on the Internet. A domain name is associated with a site’s brand, origin, content or quality. The sites that fall under .health are likely to be considered as the ultimate online source of information and advice on health, in particular by populations with less ehealth literacy. The marketing of .health as a trusted name, when it is not warranted, creates the likelihood of material detriment. The .health gTLD has been the 8th most contested name of the over 1900 gTLDs proposed—for good reason. It is time for ICANN to listen to the health community. The issue of how to define “quality health information” has been subject of much research and debate over the past decade, and contrary to what some applicants have implied, there is more consensus than disagreement over the criteria that should be taken into account when assessing health information quality and credibility [
However, given how readily the ICANN committees and their legal experts have brushed aside concerns from the health community, the most likely outcome is that a flood of new health-related gTLDs will enter the market late 2014 or 2015, marketing their gTLD as trustworthy to consumers. In this case, we urge any successful gTLD registries to seek collaboration with the health community and to reach out to individuals and organizations (including patient organizations) who have spent decades in conducting research on what quality health information means and how source credibility and technical criteria can be monitored. In the absence of that, perhaps it is time for the trusted players in the health community to apply for gTLD programs in a forthcoming round (for example, .who, .medcertain) that implement some of the suggestions related to transparency above, or to even go further by forming a large collaborative non-profit consortium which awards domain names under a new gTLDs based on the second-level domain applicants proposals and expertise, as opposed to their ability to pay. For consumers and patients, the adage “caveat lector” [
generic top-level domain
Internet Corporation for Assigned Names and Numbers
Journal of Medical Internet Research
Request for Information
World Health Organization
The author wishes to thank the participants of the Consultation On Maintaining Trust And Confidence in the Health Internet at the World Health Organization, 16-17 December 2013, Geneva, Switzerland, for the formative discussions that led to this editorial.
The author was involved in many health information quality initiatives, including the EU-funded MedCircle/MedCertain projects for trustworthy health information on the Web (as Principal Investigator), the e-Health code of ethics (e-Health Ethics Summit), and European Commission Quality Criteria for Health Websites. He is the editor of JMIR (and some of its sister journals like JMIR mHealth) and publisher at JMIR Publications, which assesses the quality of health information and Web-tools on a daily basis, and which may play a future role in assessing applicants for second-level domains under health-related top-level domains. The World Health Organization partially reimbursed travel costs for a trip to Geneva for a consultation about health-related top-level domains.