Turkmenistan ranks among the mostrepressive and closed societies in theworld. The Internet is heavily regu-lated and available only to a smallfraction of the population. Amongthe countries of the CIS, it has thelowest penetration rate of Internet ac-cess and the highest degree of first-generation
lance is significant, and the few citizens who benefit from access to the Internetare closely monitored by state agencies.
A Central Asian republic with a population of around 5 million and land area of488,100 square kilometers,1 Turkmenistan is a country rich in natural gas and oilresources.2 The government has undertaken efforts to develop the gas and cotton in-dustry but has failed to encourage development in other economic sectors.
Turkmenistan was a closed society under the proclaimed ‘‘President for Life,’’ Sapar-
murat Niyazov.3 To nourish his personality cult, Niyazov—in power for 15 years—frequently rotated, dismissed, or brought charges against government officials and
GDP per capita, PPP (constant 2005 international dollars)
Literacy rate (percent of people age 15þ)
Source by indicator: World Bank 2009a, World Bank 2009a, World Bank 2009a, UNDP 2008, World
Bank 2009b, World Bank 2009b, Economist Intelligence Unit 2008, ITU 2007, Miniwatts Marketing
judicial representatives to create a situation of permanent instability in the society.4The death of Niyazov in December 2006 brought about a glimmer of hope for thosepining for reform.5 In February 2007, Gurbanguly Berdymukhamedov won the coun-try’s largely symbolic presidential elections. The post-Niyazov transition was surpris-ingly smooth, with Berdymukhamedov promptly securing support from the mostimportant behind-the-scenes players, whom he then removed once becoming presi-dent. During the time of Niyazov, the president headed both the legislative and judi-cial branches of the state. Berdymukhamedov pledged to introduce democraticreforms and separation of powers. In September 2008, a new constitution entered intoforce that dissolved the People’s Council (the highest representative body, whichincluded parliament and cabinet members) and divided its powers between the presi-dent and the new 125-member parliament.
During Niyazov’s rule, all opposition parties were banned. Dissenters were harassed
or exiled, and a small and weakened opposition existed either underground or abroad.6By contrast, the new constitution promotes multiparty politics, thus formally legaliz-ing opposition. However, in the 2008 parliamentary elections, the Democratic Party—the current ruling party—was the only one registered to participate. The leaders of themain political opposition parties—the Social and Political Movement of Watan andthe Turkmenistan Republican Party—continue to reside abroad to avoid potentialrepression.
The people of Turkmenistan were positive about some of the reforms promised by
Berdymukhamedov, including reinstating the recently abolished ten-year mandatoryperiod of education, reversing measures aimed at denying pensions for the elderly,and guaranteeing Internet access to all.7
The ethnic composition of the population is Turkmen (85 percent), Russian (7 per-
cent), Uzbek (5 percent), and other minorities (3 percent).8 The largest percentage of
the population shares orthodox Turkmen and Islamic values (89 percent), althoughMuslim traditions have been, to some extent, modulated by local customs and thecountry’s Soviet past. Important factors in determining one’s position in the Turkmensociety remain kinship, regional links, and tribal affiliation. The state traditionally mar-ginalizes ethnic and religious groups. Except for officially recognized Sunni Muslimand Russian Orthodox denominations, religious activities are severely limited. Religiouscongregations are required to register with the government to gain legal status.9
The telecommunications sector in Turkmenistan is developing slowly, encumbered byheavy government subsidies of basic services, contradictory procedures for obtaininglicenses, and low levels of foreign investment.10 In the late 1990s, two German compa-nies, Siemens and Alcatel, were approved by the government to develop the telecom-munications system. In addition, the TurkmenTelecom Company and the U.S.-basedVerizon have agreed to provide Turkmenistan with direct access to the Internet.11 Chi-nese telecommunication companies, financially supported by the Chinese govern-ment, have also entered the market. According to the U.S. Embassy in Turkmenistan,prior to 2004 there were no broadband fixed wireless service providers in the country,and the difficulties involved in obtaining operating licenses from the Ministry of Com-munications made the involvement of foreign companies impossible.12
Since the emergence of the Internet, the government has sought to establish com-
plete control of the Internet to avoid any potential threat that unmonitored accessmay pose to the regime. In 2001, the largest ISP, Ariana, struggled to survive formonths while appealing the revocation of its license. It continued to provide free Inter-net access to NGOs until the government finally closed it down. Thereafter, only thestate-run provider, TurkmenTelecom, continued operations. Under the former admin-istration, there was very little public Internet access. It was available only to those whocould afford to pay USD 8 per hour at the few hotels catering to foreigners and lessthan ten public access points in the country, all sponsored by foreign aid programs. Private use was restricted to a few foreign-owned businesses that could acquire two-way satellites or the few USD 1,000 a month DSL lines, a few dozen universities andinstitutions connected through the NATO-established Virtual Silk Highway project,and a small number of local individuals and businesses that managed to acquiredial-up access accounts.13
There is only one legal provider of Internet in Turkmenistan, the official government
body, TurkmenTelecom. All channels pass through TurkmenTelecom’s central hub, andall are thoroughly monitored by the security services. TurkmenTelecom offers a smallrange of service connections for individuals and organizations, all of which are offi-cially limited to the holder of the account. It remains illegal for a private organization,
for-profit or otherwise, to open an Internet cafe´. Should an organization manage toacquire a dial-up account, it would be presented with a contract obligating it to usethe account solely for private personal use and not to share it with anyone. Those inbreach of the rules are sanctioned.
In order to receive Internet access, users must register with TurkmenTelecom by sub-
mitting a declaration and their passport. In addition, TurkmenTelecom warns users onits Web site that the Internet is not a ‘‘place for unconsidered behavior.’’ Accordingly,users have to refrain from undertaking a wide array of broadly defined activities whenthey are online—for example, posting materials containing foul language, showing‘‘inappropriate behavior’’ online, posting information that conflicts with the standardnorms of behavior and legislation, and uploading pornographic materials.14 The con-tract signed by the operator and user contains even more restrictions, such as a banon accessing Web sites that contain violent content and Web sites that disseminate‘‘untruthful and defamatory information’’ (a definition that includes opposition Websites). If, after a warning, a user insists on accessing forbidden Web sites, the operatorshuts down his or her Internet service. Users are liable for any actions that might causedamage to the government or ‘‘anyone else.’’
Foreign aid organizations and expensive hotels continue to provide Internet access,
though there is consensus among users that the speed of connections provided byTurkmenTelecom has declined over the last two years. These organizations and hotels,as a self-imposed measure, filter some opposition and freedom-of-expression Web sites. They defend such policies as necessary in order for them to continue providing Inter-net services. Their activities, as well as those of their patrons, continue to be monitoredby the authorities.
Similar self-censorship behavior has been observed in schools. After Niyazov’s death,
the new president promised to install Internet access in every school and demandedthat no new school or kindergarten be opened without Internet access.15 This massivestate computerization program led to the purchase of thousands of computers for thecountry’s schools. However, lack of training in ICT among teachers and remainingfears among administrators that access to the Internet may lead to repression have leftmany of the computer rooms locked.
The results of the computerization program have been far more modest than the
rhetoric behind it, and the country has largely failed to implement policies guarantee-ing free and accessible Internet. The president legalized Internet cafe´s in 2007, but theycontinue to number only a few, are not advanced technologically, and are closelymonitored by the state security service.16 Since February 2007, 15 TurkmenTelecom-operated Internet cafe´s have been opened in the country’s six largest cities.17 Theirhours of operation were limited to normal government business hours, and theprice in 2007 was set at about USD 4 per hour (at this time the average salary inTurkmenistan was less than USD 100 a month).18 All Internet cafe´ users are required
to present a passport, and their activities are recorded and logs are sent to a govern-ment server.
Nearly two years after the transition several of the 15 official access points were
closed, and all have suffered repeated service outages and closures. In 2007, PresidentBerdymukhamedov reprimanded the minister of communications for the high pricesat Internet cafe´s.19 As a consequence, access prices dropped by more than 60 percent,and Internet access at Internet cafe´s now costs around USD 2. Aside from the obvioussubmission to monitoring inherent in presenting one’s passport, Internet cafe´s arestaffed mostly by youth; furthermore, anyone who uses an Internet cafe´ is mindful ofwhat he or she accesses. Nevertheless, administrators report that most Internet cafe´s re-ceive only up to ten visitors a day.
Contact with the outside world is still difficult in Turkmenistan. Prices for home
access to the Internet are steep, creating an additional economic barrier to widespreadInternet use. Thus, the Internet largely remains a privilege to those working for foreigncompanies, the government, and, in a small number of cases, those studying or work-ing at universities. International organizations are trying to improve the local climateby providing regional centers and administrations with modern computer equipmentand Internet access, as well as establishing satellite connections of Turkmen sciencecenters to the worldwide network.20
In March 2008, the official government Web site Turkmenistan.ru announced that
TurkmenTelecom was finally offering dial-up home Internet connection to the public. The rates were set at USD 42 to open an account, a flat USD 5 per month fee, and USD4 per hour for browsing, with speeds of 45 Kbps.21 These rates are unaffordable for thevast majority of the population and more than six times higher than in neighboringUzbekistan. New leased lines were also to be connected starting immediately, at highmonthly rates of USD 1,000–USD 2,000.
Internet use in the CIS region has increased significantly in the last several years in
all countries except for Turkmenistan. Various attempts at measuring Internet penetra-tion have posited that between 0.17 and 4 percent of the population use the Internet,with ITU estimates being 1.4 percent.22 Notwithstanding the low level of penetration,the number of users has increased significantly since the offer of home Internet access. Fixed-line penetration is less than 10 percent, with negligible broadband. Permissionhas now been given for broadband national WiMAX frequencies. There are fewer than500 Web sites hosted in the country under the top-level domain ‘‘.tm,’’ more than halfby a foreign-funded development project. The rest consist almost entirely of officialWeb sites of government entities. Nearly 95 percent of regular Internet users are inthe capital, Ashgabat.
There are two mobile operators in the country. Atlyn Asyr is wholly controlled by
the state, with roughly 160,000 subscribers. In November 2007, MTS, a Russian mobileservice provider (100 percent privately owned), began offering GPRS/EDGE service to
its corporate clients in Turkmenistan. In May 2008, the same service was offered toindividual users for USD 50/Mbit plus a one-time fee of USD 5. As of 2008, MTS hadaround 500,000 users in Turkmenistan.23 The service provided by MTS is considerablycheaper than TurkmenTelecom’s: it costs USD 5 to connect (one-time fee); 1 MB is 58cents (day) and 29 cents (night). For users who live in rural areas where fixed lines arenot modernized, MTS remains the only option to connect to the Internet. Interest-ingly, MTS’s introduction of GPRS Internet seems not to have been supported by thegovernment, and the service was never announced in official media. The price isstill quite high for most users, the service slow and unreliable, and Internet traffic stillmonitored and filtered through TurkmenTelecom. Focusing on GPRS, however, wouldherald a leap forward in public access to the Internet, bypassing the high-cost infra-structure of land and telephone lines. If the state does not encourage the establishmentof independent networks, however, the service could remain slow, expensive, andunreliable, and will most likely remain filtered.24
Turkmenistan recently sold the rights of administration of top-level ‘‘.tm’’ domains
to a U.S.-based contractor. Foreign companies are willing to pay high prices for ‘‘.tm’’domain names because the abbreviation evokes the term ‘‘trademark.’’ The vast major-ity of Turkmenistan-based Web sites are within second-level domains of internationalor official government bureaus, such as ‘‘.gov.tm’’ or ‘‘.edu.tm.’’
The president and the Cabinet of Ministers are the policymakers in the communi-cations sector. The Ministry of Communications implements policy; it is the sector’sregulator, issuing licenses to operators, approving tariffs, and carrying out investiga-tions to ensure that operators conform to all laws and regulations. The ministry super-vises eight bodies in the post and telecommunications sectors: TurkmenTelecom (fixedoperator), Ashgabat City Network, Altyn Asyr (GSM), TV Radio/TV Broadcasting, Spec-trum Administration, Turkmenistan Post, Special Delivery service (Postal), and Train-ing Center. The deputy chairman of the Cabinet of Ministers oversees the work of theministry and the minister of communications reports directly to him.25
The role of the sector minister in controlling the state operator is de facto marginal
as the general director of TurkmenTelecom reports directly to the Cabinet of Ministerswithout referring to the minister. The Internet market is strictly controlled by theCabinet of Ministers, and receiving an Internet license entails close monitoring of allproviders’ commercial activities. Each license is for a period of three years, and thereare more than 30 different license types in the communications sector. It is anticipatedthat revisions will be introduced to the Law on Communications (2000), which wouldprovide easier conditions for new technologies to enter the market. President Berdymu-
khamedov has encouraged some liberalization in the market by allowing alternativeInternet operators to apply for licenses. In fact, by law, the state operator does not en-joy exclusive rights. Nonetheless, TurkmenTelecom remains the only ISP in the marketwith a valid license to operate. The tariffs are set by the operators themselves, while theministry reviews the tariff proposals when granting the license.
According to existing rules, when an alternative ISP or broadband provider expresses
an interest in using an incumbent operator’s network, an inspection commission isformed to investigate the operator’s proposal. However, as yet, no alternative provideris known to have applied to provide such services.26
Although both the old and the new constitutions guarantee freedom of expression
and free dissemination of information, the government largely controls all media out-lets (television, press, and radio). The Turkmen television is state-owned and providesfour channels. Channel One, or ORT, broadcasts of Russian television are restricted toonly two hours per day and rarely broadcast live. Any reference related to the Sovietpast, erotic topics, prostitution, alcoholism, or drug addiction is removed from moviesand soap operas.27 Foreign television stations and radio are accessible only to the hand-ful of people who have satellite dishes or shortwave radios. The press is controlledby the government, and even the nominally independent newspapers Adalat andGalkynysh were created by decrees of the former president. Other government-approved newspapers are Turkmenistan (published in Turkmen) and Neutral Turkmeni-stan (in Russian).
Publishing houses and photocopying establishments have to receive registration
licenses from the government before starting their operations.28 State media employeescannot establish contacts freely with foreign media.
The lack of mechanisms guaranteeing media freedom, the extensive provisions sanc-
tioning libel and defamation in the Criminal Code, and the broad provisions related toterrorist activities in the Law on Terrorism29 have imposed total self-censorship onTurkmen society under the former and current governments. Article 132 of the Crimi-nal Code makes libel by way of channels of mass information punishable by fines, upto two years of forced labor, or up to one year in prison. Article 133 of the CriminalCode provides for similar sanctions for certain insults against government agents(who are defined as anyone who permanently or temporarily represents a branchof the government). Article 176 of the Criminal Code seeks to protect the president. Under part 1, any attempts on the life or health of the president are punishable byimprisonment for life or death. Part 2 of this article provides for a prison term of upto five years for libel directed against the president. No specific mention is made ofmass media—libel in any form can lead to charges.30 Libel charges are usually used toarrest journalists, and there is always a danger of false charges being laid for crimessuch as embezzlement.
As reported by Radio Free Europe, during the previous regime most of the trials
of journalists, government opponents, or any person who was considered a ‘‘threat’’to the regime were held in secrecy.31 Under Niyazov, repression of dissenters in Turk-menistan often involved beatings, threats, and arrests.32 The current president hasgranted amnesty to many dissidents and journalists who were jailed by the Niyazovregime.33 However, in spite of the few positive steps taken by President Berdymukha-medov, media groups continue to place Turkmenistan among the ‘‘ten worst countriesto be a blogger’’ because of the lack of guarantees for freedom of expression.34
In Turkmenistan, few users with access to the Internet are able to read English. Accord-ingly, only information in Russian disseminated on the Internet might raise seriousconcerns for the regime. Nonetheless, the preferred method of limiting informationon the Internet is simply blocking undesirable content. Such a policy, documentedduring Niyazov’s reign, is still in place.
Reporters Without Borders has declared Turkmenistan, along with Belarus and Uzbe-
kistan, an ‘‘Enemy of the Internet,’’ because of a combination of monitoring Internetbrowsing, filtering Web content, imprisonment, harassment, and the prevention of theposting of political materials.35
The Turkmen government maintains tight control on the flow of information
through the official mass media. Any dissident criticizing the lack of expression andtight censorship is likely to be included in the government-held blacklist, which canrestrict the right to travel abroad.36 Authorities remain hostile to religious sects, andunregistered religious groups are still not allowed to perform religious activities. Thegovernment is also engaged in a long-standing practice of deporting citizens belongingto different religious sects.37 There has been no stark change in the monitoring andinterception of communications over the last two years. Sensitive issues such as dis-crimination against women, terrorism, religious extremism, and separatism are stillcensored by the government. Because of the overall restrictive climate, people committhemselves to broad self-censorship.
There are reports that Turkmenistan’s security services have put into place a system for
Internet surveillance of all ISPs throughout the country.38 The OpenNet Initiative sus-pects that an automatic Internet surveillance and filtering system based on deep-packet-inspection technology has been installed on TurkmenTelecom routers. Since allincoming and outgoing information passes through TurkmenTelecom systems, Internettraffic can easily be intercepted. Any traffic can be monitored by authorities, and cer-tain preselected Web sites containing information that could be harmful to the regimeare filtered. Other reports confirm that users can be identified if they send encryptedmessages and materials containing certain keywords, such as the president’s name.39
In 2008, OpenNet Initiative testing was conducted in Turkmenistan on a direct land-line connection to TurkmenTelecom. The tests detected substantial filtering of localand regional media and freedom-of-expression Web sites. Significantly, Azeri mediasites, including a popular multimedia site with an ‘‘.az’’ extension and an Azeri Website targeting corrupt officials, were blocked. The ONI revealed targeted filtering on anumber of other Web sites including those covering local and international women’srights, human rights, and narcotics, and one Web site containing information aboutreligious beliefs. An environmental site and a P2P site were also blocked. In addition,a number of pornographic and gambling sites were blocked. The ONI also observedreverse filtering of U.S. military domains.40
The former Turkmen president exercised strict control over Turkmen society andmedia, and restricted any information inconsistent with his widely propagandizedpolicies. The current president has pledged to seek a more lenient approach to leadingthe country, but much still remains to be done. The scope of sensitive issues in Turk-menistan continues to be broad and may involve any criticism of the regime or inde-pendent opinion. Few citizens have access to the Internet, and most continue to fearcensorship and other unpredictable centralized methods of control. Until liberalizationof the Internet market occurs, such measures will continue to be a concern for mostInternet users in the country. The few international organizations providing Internetaccess practice self-censorship in order to protect their staff and their diplomatic posi-tion. With so few users of the Internet and the massive risks facing any advocates offreedom of speech, the government continues to hold the future of the Internet inTurkmenistan entirely in its hands.
1. World Bank, World Development Indicators 2007,
2. Turkmenistan holds one of the world’s largest gas fields. See Energy Information Adminis-
tration, ‘‘Turkmenistan Energy Profile,’’ September 16, 2009,
3. BBC News, ‘‘Turkmen Go Back to Old Calendar,’’ April 24, 2008,
4. Bruce Pannier, ‘‘Turkmenistan: President Reshuffles Government Once Again,’’ Radio Free
Europe /Radio Liberty, January 27, 2006,
5. BBC News, ‘‘Turkmen Go Back to Old Calendar,’’ April 24, 2008,
6. The BBC concluded that during the last elections no opposition party participated. See Monica
Whitlock, ‘‘Turkmenistan Poll Turnout ‘Low,’ ’’ BBC News, December 20, 2004,
7. BBC News, ‘‘New Turkmen Leader Is Inaugurated,’’ February 14, 2007,
2/hi/asia-pacific/6359569.stm; BBC News ‘‘Turkmenistan Takes Reformist Step,’’ September 26,
8. Embassy of Turkmenistan, Washington, DC, ‘‘Government and Politics,’’
.turkmenistanembassy.org/turkmen/gov/gov.html. The official data differ from outside estima-
9. Amnesty International, ‘‘Turkmenistan: The Clampdown on Dissent and Religious Freedom
10. The Trans-Asia-Europe fiber-optic line connects Turkmenistan with Uzbekistan and Iran, but
the Turkmen-Azerbaijan segment has not yet been constructed. See Business Intelligence Service
for the Newly Independent States (BISNIS), ‘‘Turkmenistan, Overview of Fiber Optic Telecom-
munications Network Development,’’ May 22, 2003,
11. U.S. Commercial Service, ‘‘Country Commercial Guide,’’ 2000,
12. Foreign companies such as Siemens and Alcatel (Germany), NEC ( Japan), and Huawei
(China) usually work as subcontractors on government-sponsored projects. See Business Intel-
ligence Service for the Newly Independent States (BISNIS), ‘‘Turkmenistan: Overview of the
Wireless Communctions Network,’’ March, 2004,
13. Ron Synowitz, ‘‘World: Rights Group Lists ‘Enemies of the Internet’ at UN Summit,’’ Radio
Free Europe /Radio Liberty, November 15, 2005,
15. Newsru, ‘‘President Turkmenii Reshil Otkyt Dustup k Internetu v Kazhdom Detskom Sadu’’
[The President of Turkmenistan Decided to Provide Every Kindergarten with Internet Access],
16. Chrono-tm, ‘‘Paradoksy Razvitiya Interneta v Turkmenistane’’ [Paradoxical Internet Development
17. Chrono-tm, ‘‘Internet ne Proshel’’ [Internet Did Not Come Through], May 11, 2008,
18. USA Today, ‘‘A Crack in the Isolation of Turkmenistan: Internet Cafe´s,’’ February 16, 2007,
19. Reuters India ‘‘Turkmen Leader Sacks Official over Bad Internet,’’ May 20, 2008,
20. The organizations promoting these projects are the Organization for Security and Coopera-
21. Farangis Najibullah, ‘‘Turkmenistan: Wireless Internet Hints at End to State Monopoly,’’
22. International Telecommunication Union (ITU), ‘‘Internet Indicators: Subscribers, Users, and
23. Turkmenistan.ru, ‘‘MTS Podlklychila Turkmenov k Internetu’’ [MTS Connected Turkmens to
24. Abdulmugamid, ‘‘Internet Metamorphoses in Turkmenistan,’’ NewEurasia, May 2, 2008,
25. European Bank for Reconstruction and Development, Comparative Assessment of the Tele-
communications Sector in the Transition Countries: Assessment Report Turkmenistan, December 2008,
27. Ferghana.Ru Information Agency, ‘‘Censorship in Turkmenistan: Outright Lunacy,’’ May 18,
28. U.S. Department of State, ‘‘Turkmenistan,’’
29. Unofficial English translation of the Law at
31. Gulnoza Saidazimova, ‘‘Central Asia: Rights Group Says Region Suffering after Andijon,’’
Radio Free Europe /Radio Liberty, May 23, 2006,
32. Turkmen dissident writer Rahim Esenov was put in jail in 2004 after refusing to edit his book
to Niyazov’s liking. Radio Free Europe /Radio Liberty, ‘‘RSF: Turkmenistan Should Release RFE/RL
33. Radio Free Europe /Radio Liberty, ‘‘Turkmen President Signs Decree on Amnesty,’’ May 25,
34. Radio Free Europe /Radio Liberty, ‘‘Groups Says Iran, Turkmenistan among ‘10 Worst Coun-
tries to Be a Blogger,’ ’’ May 1, 2009,
35. Reporters Without Borders, ‘‘First Online Free Expression Day Launched on Reporters With-
out Borders Website,’’ December 3, 2008,
36. UNIAN News Agency, ‘‘Press Freedom Deteriorated in Europe,’’ May 3, 2006,
38. Turkmenistan Helsinki Foundation for Human Rights,
40. Reverse filtering occurs on the Web server hosting the content, as opposed to at a point along
the way of the traffic flow, and is based on restricting requests based on geographical location of
the originating Internet Protocol address. Copyright holders who want to restrict access to their
content in certain markets often use reverse filtering. Examples include hulu.com, BBC.com, and
other sites that syndicate commercial video and audio content that is subject to licensing. The
ONI has detected that many U.S. military sites are inaccessible outside the United States. We
strongly suspect that this may be as a result of reverse filtering.
Publications classées par ordre alphabétique du premier auteur. AAbdelkrim,J., Pascal,M., and Samadi,S. (2007): Establishing causes of eradication failure based on genetics: Case study of ship rat eradication in Ste. Anne archipelago. Conserv.Biol. , 21:719-730. Adamski,H., Pessel,S., Ferraro,V., Arvieux,C., Chevrier,S., Le Gall,F., Gangneux,J.P., and Chevrant-Breton,J. (2007): Chronic ulcerat
2006 IC & PBS On-Line Patient Conference Transcript An Evening with Dr. Robert Moldwin New, Emerging Therapies for Interstitial Cystitis Featuring Dr. Robert Moldwin, Associate Professor of Clinical Urology Director, Author of Moderated by Jill Osborne, Presid Date: July 11, 2006 Jill Osborne - Good evening and welcome to the 2006 IC & PBS Online Patient