In June 2008, ICANN began the creation of a new program of expanding naming of the Internet from the original two limited rounds of applications for new top-level-domain (TLD) names conducted in 2000 (proof-of-concept round) and 2004. This new program opened up in 2011, allowing for the creation of numerous specific new gTLDs, expanding from the original list of 22 TLDs then in existence and aimed at vastly expanding the Internet name space. This expansion specifically included new unsponsored gTLDs (ie, operated under standard policies of ICANN’s processes) that generally consist of three or more characters and are open for any purpose or use.

ICANN’s new naming program allowed proposals for virtually any new domain name suggested by applicants, including those in different languages/characters, comprising numbers, and even using company brand names [10]. Acceptance of applications for new gTLDs began in January 2012 and has led to submission of nearly 2000 applications for a wide variety of gTLD strings [1]. Included were gTLDs that are geographic (eg, .paris, .Africa), general term domains (eg, .law, .money, .science, .sex), and those for specific entities (eg, .mit for Massachusetts Institute of Technology, .apple for Apple Inc, .bbc for the British Broadcasting Corporation, .McDonalds for McDonald’s Corporation). ICANN anticipated the first group of new gTLDs passing through the application process to be operational in late 2013 [11]. However, final award of new gTLDs will undergo a complex evaluation process that could include considerable costly delays and also potentially end in award of gTLDs through an auction process (with the highest bidder being awarded a gTLD) when there are several contending applicants. This procedural complexity has led to intense lobbying pressure on ICANN to allow applications to proceed despite documented objections from countries, international organizations, consumer advocacy groups, independent watchdogs, and the broader public community. Further, this process would ostensibly favor richer and more well-connected applicants—a system that many observers find questionable and lacking credibility.

Importantly, included in this new program were a number of proposals by various entities for a new .health domain and other health-related gTLDs. Applications are predominantly from private corporate entities with most having little or no history in medicine nor public health, include large pharmaceutical manufacturers applying for gTLD proprietary/trademark names, and comprise only a handful from health organizations and associations. This uneven mix of applicants creates uncertainty for the future prospects of a trusted space for online health content, which we describe below.

The domain central in the current debate is the proposed “.health” gTLD [1]. Yet recognition of a need to create a dedicated Internet space for health is not new. More than a decade ago, the need for a trusted .health TLD with collaboration and oversight by the international community was explored [3,12]. In 2000, shortly after the creation of ICANN, the World Health Organization (WHO) and other stakeholders proposed formation of a .health TLD, but ultimately its proposal was not chosen as one of the seven proof-of-concept names for new TLDs during that round [12,13]. Subsequently, the new ICANN naming program announced in 2008 provided another opportunity to revisit the creation of .health (including possible resubmission of the original WHO proposal). Yet since this time, WHO and other public health-related stakeholders have been conspicuously absent in actively seeking the domain.

Instead, the current round of .health applicants consists exclusively of for-profit, private sector entities, all of which passed ICANN’s initial assessment and remain unopposed (Table 1), meaning they have the potential to be awarded the gTLD through ICANN’s evaluation process that will most likely end in an auction to the highest bidder. All are in single legal jurisdictions (eg, not represented by nor coordinating with any international/global health organization) and hence lack global geographic scope and representation. Indeed, simply on the basis of corporate law, none of the for-profit applicants are even publicly traded companies. This brings into question levels of transparency/disclosure, sufficiency of corporate governance (eg, those required under the US Sarbanes-Oxley Act and similar iterations in Australia, Canada, France, Germany, India, Japan, The Netherlands, South Africa, and other countries), ongoing financial viability, and accountability to the public.

Further, no applicants are familiar to the health field, but rather include companies such as various affiliates of Donuts Inc, which is attempting to obtain not just .health but has applied for more than 300 gTLDs under a number of different subsidiaries, most removed from health (eg, .apartments, .beauty, .casino, .dating, and even .wtf), suggesting the company is not focused on the prudent stewardship of patient-centered health information. Indeed, Donuts Inc is primarily backed by private equity/venture capital funds that has invested some $57 million in an attempt to secure gTLDs—a move that has raised concern among industry and Internet watchdogs [14]. Alarmingly, it has also been reported as being connected with other Internet companies that have provided services to spammers and cybersquatters, raising concerns about potential Internet fraud and abuse if Donuts is awarded its applied-for gTLDs [14].

Furthermore, of the current .health applicants, there are no developing countries, international/intergovernmental organizations, nonprofits, foundations, nor civil society groups as primary applicants. Only one applicant, DotHealth LLC, provides any support letters or specific inclusion from health-related stakeholders. However, DotHealth LLC supporters clearly do not constitute an adequate representation of the global health community. Indeed, all DotHealth LLC (only recently formed in 2011 based on its incorporation documents) supporters are US-focused, several are recently formed entities, one supporter’s website is non-functional, and many have close ties to industry.

Absence of active participation by public health stakeholders may point to a lack of attention and priority setting in recognizing the potential importance of a .health domain. Further, public health actors may lack technical expertise and financial resources to submit a viable application, similar to concerns raised in the original WHO ICANN proposal [3,12]. ICANN’s listed high entry and maintenance cost of gTLDs (including initial application fee of US $185,000 and annual fee of US $25,000) are not prohibitive for businesses generating profits but may be difficult to afford for the vast majority of global health organizations relying on unstable funding [1,3,10].

It is also unclear how current .health applicants would manage potential registrant quality and trustworthiness for .health use, or, in a related issue, possible categorization of restricted/reserved .health domain names. Since the applicants themselves are commercial, their ICANN .health applications indicate few if any restrictions on future .health registrants and would mostly offer registration and sale of .health use broadly. Only one of the applicants, Afilias Limited, indicates that under its revised criteria in response to public interest concerns, .health registrants would have to at least hold a health care provider license. Yet, it should be noted that requirement for licensure verification does not guarantee any level of protection for consumers, does not guarantee appropriate oversight, and is not sufficient in itself to safeguard the public interest.

Some hypothetical examples of .health gTLD second-level domain names that could be misused are provided in Table 2 and illustrate the immediate risk of unrestricted use proposed by the majority of current .health applicants. Indeed, in certain circumstances where there are multiple .health second-level domain registrants, award may be conducted by a third-party auction/broker system to the highest bidder, which would ostensibly favor for-profit or wealthier entities/individuals.

Reflecting some of the above concerns, in January 2013, the International Medical Informatics Association (IMIA) filed an objection based on community opposition to the four .health gTLD applicants [15]. IMIA stated that all failed to demonstrate how their use of .health would be in the public interest, none had adequate consumer protections, and all were solely commercial in nature without any representation from the health community. Other stakeholders, including France, Mali, WHO, Save the Children, the HealthOntheNetFoundation, other nongovernmental organizations (NGOs), as well as the European Commission, voiced similar concerns [16,17].

In March 2013, following these objections, ICANN’s Independent Objector (IO), an impartial party acting in the public interest, lodged formal objections to all four .health applicants [18]. Additionally, ICANN’s At-Large Advisory Committee, which vets objections to gTLD applications, similarly voted to support an objection for three of the four applicants (except Afilias; the provider licensure provision may have been a differentiating factor) [19]. However, in a subsequent decision, the International Chamber of Commerce (ICC), an entity reviewing disputes filed by the IO, denied all limited public interest objections filed against current active .health applicants (ie, Donuts Inc, Affilias, DotHealth LLC) effectively clearing the way for future procedural decisions, favoring award of .health most likely through a bidding system [20,21]. Interestingly, objections filed by the IO for other health-related gTLDs (eg, .hospital, .med) described below and in Table 3 have been upheld. Yet ICANN has not explained how these gTLDs are more important than .health, thus creating a great deal of inconsistency in the objection process.

Another concerning development occurred in October 2013, when ICANN’s New gTLD Program Committee issued a separate decision to re-categorize .health as being appropriate for open entry, effectively exempting it from certain “Safeguard Advice” (including requiring regulatory body oversight/licensure) that would limit its use [19]. In this decision, ICANN prioritized implementation of safeguards for “highly-regulated” gTLDs such as .sucks, .wtf, .poker, .lawyer, and .bank, over its limited safeguards proposed for .health [19].

Controversy regarding the three remaining applicants for .health has sparked global debate on eHealth governance and concerns from various public health stakeholders [1]. However, other important health-related gTLDs have not been adequately analyzed nor discussed that face similar concerns. In addition to reviewing current applicants for .health, other health-related gTLDs with key terms including .care, .clinic, .dental, .dentist, .diet, .doctor, .healthcare, .hospital, .medical, and .surgery are in play (Table 3). Alarmingly, Donuts Inc-related subsidiaries are named as applicants for all of the above health-related gTLD strings, and similarly will not require tangible restrictions or verification of licensure/credentials for future registrants. Only two other applicants for the .doctor gTLD have any verification systems, such as mandated medical licensure, prior to .doctor domain use.

Large multinational pharmaceutical companies are also active in gTLD applications. This includes applications by 6 pharmaceutical manufacturers including Pfizer, Eli Lilly and Company, Merck, Sanofi, Hisamitsu Pharmaceutical, and Teva Pharmaceutical Industries. Largely these corporations are registering for brand and trademark protection purposes and generally limit registrants to company affiliates or licensees/authorized partners, which may represent a legitimate use of a gTLD. One application for the proprietary name of erectile dysfunction drug Cialis by Eli Lilly was pursued but is no longer active. However, direct-to-consumer advertising of prescription products is not allowed in the vast majority of countries other than the United States and New Zealand, and it may be unlawful for pharmaceutical manufacturers to engage in multijurisdictional online advertising that could occur through future gTLDs [7,22].

In contrast to the .health gTLD applicants, the .med gTLD (abbreviation for medical) have included partnership with more reputable health care stakeholders and information technology providers and have processes for restricting future registrants. This included the Cleveland Clinic’s engagement with Medistry LLC for its .med application requiring a request for proposal to vet qualifications of future registrants and Google Inc’s own application (Charleston Road Registry Inc). However, despite the Cleveland Clinic affiliation representing a higher level of legitimacy compared to .health applicant counterparts, community objections to its .med applications were upheld by the ICC (along with objections to Google Inc’s application), whereas similar objections raised by the IO for .health have been denied.

Similar to health care licensure verification requirements, the Australian Cancer Research Foundation (.cancerresearch) has policies requiring future registrants to be entities affiliated with the Foundation. The American Heart Association filed for two gTLDs (.heart and .stroke) but has subsequently withdrawn these applications (Table 4). In addition, the nonprofit German entity, dotHIV gemeinnuetziger e.V., applied for a .hiv gTLD to specifically leverage health communication and fund raising [23]. It has no restrictions on use and claims it will distribute at least 50% of future registration fees towards fundraising for the disease.

Some gTLD professional medical organization applicants have also initiated safeguards to protect public health, including the US National Association of Boards of Pharmacy (NABP) who is the sole applicant for .pharmacy and is currently in the award/contracting process. NABP’s application includes the stated goal of addressing the growing problem of illicit online pharmacies. In its application, it commits to establishing a safe and reliable international online space for online pharmacies requiring vetting of applicants for applicable regulatory standards, licensure, drug authenticity, and valid prescription requirements.