Interview with Dr. Bernhard Schwartländer, WHO World Representative to China: Part I

Interview[1] by April Xiaoyi Xu (PO ‘18), Editor-in-Chief

Transcribed by Lathan Liou (PO ‘19), Kaela Cote-Stemmermann (SCR ‘18), and Annie Wan (PO ‘20), Staff Writers

Dr. Bernhard Schwartländer took up his position as WHO Representative in China in September 2013. Before joining WHO in China, he served as Director for Evidence, Policy and Innovation at the UNAIDS headquarters in Geneva, Switzerland and as the United Nations Country Coordinator on AIDS in Beijing, China.

Prior to these assignments, Schwartländer held a number of senior international positions including Director for Performance Evaluation and Policy at the Global Fund to Fight AIDS, Tuberculosis and Malaria, Director of the World Health Organization’s HIV Department, and as Director of Evaluation and Strategic Information at UNAIDS.

Schwartländer is a medical doctor and holds a doctorate in medical epidemiology. His work is published in many scientific journals and books. He brings extensive experience in development policies as well as infectious disease epidemiology and programming at global and country levels, and holds appointments as adjunct professor with Peking and Tsinghua Universities in Beijing.[2]

 

CJLPP: Dr. Schwartländer, next month marks the start of your fifth year as WHO World Representative (WR) to China. Reflecting on your role so far as WR, what are some of the highlights of WHO China and for you personally over the past four years?

Schwartländer: The journey of the office in China has been quite amazing. There is so much knowledge in China. It’s not really our role to come to China and to tell them what to do. There are some of the smartest people globally in all of the areas that we work in. So it’s really much more about practical solutions to solve some of the significant problems that we have in China when it comes to delivering health. It’s more like putting the best minds of the world together with the best minds of China, to analyze the situation and find solutions with the experience that we have access to around the world, and I think that has been amazingly successful.

China is a whole continent. It’s not just one country like any other. It has the largest population in the world. There are a huge differences between the east, west, south and north. We have to focus our work on a number of areas because otherwise we couldn’t make much difference in anything. If you dilute too much, you don’t get any results.

It’s very clear that one of the major areas to focus on was supporting the largest health reform project in the world. Not only because of the size of the issue, but also because of the amazing move China is making from a largely dysfunctional health system to a very modern, 21st century health system from which the world can also learn from. There is massive work that has been going on, so obviously that was one of the areas that we decide we need to put some of our strongest capacities on in order to help support this reform effort.

We also looked into some of the most pressing health challenges in China beyond the system’s development. We’re looking particularly in the areas where we can have a big difference. Whenever there is something linked to behavior, that is something you can influence, and something you can change. That’s always a very important entry point. Smoking tobacco was one of the areas that we felt needed to be tackled and could certainly be changed. So that was the second top priority.

We also worked in regulatory strengthening, another area China has recognized that they are lacking behind. There’s a clear ambition to develop a system—a modern, world-class system—that makes sure that the quality of all drugs, health items, foods and cosmetics meet the highest quality standards. This is another top priority that we focus a large part of our time on. However, many requests come in other areas as well, but 80% of our time is focused on these big priorities.

CJLPP: Early on this year, Chinese President Xi Jinping met with WHO’s then Director-General (DG) Margaret Chan in Geneva to sign an agreement to radically improve access to healthcare beyond China, through the One Belt One Road initiative. From the 17th to 19th of August this year[3], current DG Dr. Tedros Ghebreyesus attended a series of high profile events, including one on One Belt One Road[4]. Could you please share with us some of the key takeaways and areas in which the WHO will be continuing to contribute to President Xi’s ambitious project and vision?

Schwartländer: I would like to start with answering the question by mentioning that the One Belt One Road initiative is not just a project. What probably better describes it is a commitment and style of working together built on the thousands of years experience gained through cultural exchange.

It’s really less about the concrete things like projects. As you mentioned, it’s really about how can we use cooperation between societies. I say that it is about more than just countries because it is ultimately about people who exchange goods, who exchange ideas, who exchange cultures and language. On a personal level, they are building friendships and even families across cultures and nations. I think that’s fundamentally at the heart of this initiative, and it’s fundamentally also the vision that China has for a much more global world. President Xi has spoken impressively about globalization and cooperation several times this year. First in the World Economic Forum in Davos, before he came to Geneva to visit WHO, President Xi also spoke to the UN in Geneva where he reiterated his vision of a world that actually comes together rather than being divided. This is, therefore, a fundamental vision much beyond health.

Now, we are of course very happy that the current Chinese government recognizes how important health is in everything related to development. Fundamentally, One Belt One Road is about joint sustainable development. Health must be the centerpiece, because ultimately everything goes back to health. If you’re not healthy, there cannot be economic development, there cannot be peaceful and happy development; and there cannot be equity unless there’s health for all people. So it’s really a centerpiece of the sustainable development agenda and the Belt and Road initiative. I think that under this strong commitment to and recognition of the role of health was the basis for this Belt and Road health summit.

And of course within that we had a number of discussions–what does this mean concretely? It’s not a very narrowly defined area of work because health should be in all policies. Health should be thought about when countries agree to build roads between them. There are different ways of building roads and cities—investing in infrastructure that is healthier or less healthy—that supports people to thrive in healthy ways. That’s what’s at the core of this thinking.

There’s one area which really stands out though, and that is what the incoming WHO Director-General is saying: we need to keep the world safe. There are many places where outbreaks are happening, where diseases are suddenly spreading, and it’s been recognized by the world over the last years more than ever. Whenever something happens in one place—like Ebola, SARS, Zika, and many other attacks—these viruses don’t need a visa, they cross borders in minutes. An outbreak or a disease is only one flight away from anywhere else in the world nowadays. We need to recognize that we can only make sure that everybody in the world is safe if we jointly build systems that make societies resilient against disease. We are only as strong as the weakest among us.

One of the key themes cast under this Belt and Road initiative is how we can work together to strengthen these systems, with a focus on health emergencies. In the longer-term we can work together to build health systems that make societies resilient to health problems, and make sure that anybody along the Belt and Road initiative has full access to all the health services that they need.

CJLPP: Shifting our focus to domestic issues now, one of Dr. Ghebreyesus’ top priorities as Director-General is further promoting universal health coverage (UHC), which is arguably a broad and perhaps abstract concept to some people partly because of the technical language. Given that, how can ordinary people, especially youth, contribute directly to WHO campaigns and help in reaching its goals in China and around the world?

Schwartländer: I think it’s really important to reflect a little bit about what “universal health coverage” means. It does mean that every person, no matter where they live, who they are, and what they do, has access to the services they need to stay healthy without getting into financial hardship. I think that that’s critical, all these components are very critical.

It is also very important that we do not limit this thinking to hospitals and places where medical care is delivered; that should be the last resort. The world has recognized that prevention and keeping people healthy is one of the most important pieces of universal health coverage. There is no system in the world that can cope with the tsunami of non-communicable diseases that is rolling over all of our societies. And we can’t cope with that in our systems if we only focus on doctors and hospitals. Universal health coverage is prevention, treatment, and care of people in all aspects of health. It helps keep people healthy and makes sure that they don’t suffer drastic economic losses when they get sick.

There are so many actions that young people can take to help societies and themselves. I very often say that healthy aging starts at birth. What we’re talking about is that we want to make sure that people stay healthy throughout their lives. We are all getting older. It’s healthy aging that you’re looking for so that you can enjoy life rather than just counting years. Now, that does start at birth, it is about how we feed our children, how they can develop their health and whether they have enough exercise. We have to make sure that young adolescents, for example, don’t start smoking. The majority of smokers today started in their youth. So of course we’ve been looking to young people to take charge of their own health and not follow extremely unhealthy trends that industries try to sell them because they will make money from it.

CJLPP: Let’s discuss more about inequity. Despite China’s remarkable progress in healthcare reform, inequity remains a crucial challenge to China. What are some of your thoughts here, especially given that China will be introducing a new Essential Health Law later this year?

Schwartländer: I think that’s a very important question. In China in the past the healthcare system has basically broken down. It has mainly broken down because there was no good primary healthcare system. 80% of the things that do happen to people when it comes to health should be best taken care of in a primary care setting where people can receive the care, the treatment and the prevention work that they need to become healthy and stay healthy. For many reasons which we could discuss, that system has broken apart.

Now, what has happened in China is that there is extremely sophisticated healthcare in many places, like Shanghai and Beijing. There, you get world-class medical care. There are world-class treatment sites and some of the best operation rooms. But these excellent facilities are only available to a small number of the population. Some wealthy people can afford a type of healthcare that is completely unthinkable to people in a less-wealthy province. It’s a real challenge to develop a country like China in a way that there’s equity, where not only the rich in a fancy city get all the healthcare, but the poor also get the basic care that they need.

Now, you mentioned the health law and I think that’s critically important. Because what we have also seen is that there are real challenges, not only in China but for health systems around the world, in finding efficient ways of having universal health coverage. Some of the very best models have a mix of private and public partnership here. There are many models, including in my own country, Germany, where many previously public hospitals are now under private management. If you are in the private sector delivering healthcare, it has to happen in a way that not only the richest of the rich can pay for it. If you want to build a hospital and make money you have to do it in a way that benefits everybody and not just those who have the big money. That’s a very simple way of saying it, but unless you have such a policy framework and standards developed that can be looked at and enforced, you may very quickly aggravate the inequities that I’ve already describes between the west, east and also the south, but also inequity within places where the richest people are able to buy the best and the finest. If you don’t have a strong regulatory framework, all the good doctors will to migrate into those places where they can make money. This not only makes it impossible for others to buy similar services because they don’t have the money, but it also may weaken the public sector because there’s a strong migration away from the public side. So, you need to be very thoughtful of these matters. You have a responsibility for a whole society, and while this public-private mix is very important, you need to make sure that it does happen within the framework that takes into account the potential outfalls.

 

CJLPP: Earlier, you referred to the new health law in China. What do you see as the essential ingredients to effective law and policy in the realm of public health in China and across the world?

Schwartländer: There are a number of extremely powerful examples in many countries, including China. Many examples are related to child care, where societies have realized that making sure mothers do not fall sick, or even die when they give birth is important. Giving birth was a high cause of mortality in all of our societies over the centuries. This is where protection is the most important; it’s the young mothers and the babies that carry the future of our societies. And still today, some of the most effective measures here are the vaccine programs, to make sure that children are covered effectively by some of the best things that we have in medicine. Effective vaccines can protect children for life and protect them from diseases, which can cause enormous suffering with long term effects for children. So these are clearly huge success stories.

Now, I will focus my other success stories more on the preventative side, because there are enormous things that have happened in science development and research. All of these things are just stunning successes that have kept many of us alive, including myself. I may not be alive and talking to you without some of these progresses in medicine, I know that. All of these things are just enormous. But I think medicine also has to be measured by the way we can keep people healthy so that they don’t fall sick.

There are, of course, incredible success stories, and I have to come back to smoking, because it is just one of those things that are just so ridiculous. How can you sell products to people which basically kill them, and make a huge amount of money with it? This is really something that I cannot possibly accept. But we have seen many societies that have changed the the influence of the tobacco industry. For example, places, like New York, that are under strong leadership are now smoke free cities. Beijing and Shanghai are really now following suit with those models. I think the prevention of diseases is incredibly important and one of the largest success in medicine, which is often forgotten about because we tend to look at the science and the research, the machines and the pills. But in terms of the number of people that it can save, these prevention approaches can add up to even larger numbers.

CJLPP: You mentioned in a previous interview that everything that happens in China is huge due to the country’s size and huge population. China is the “smoking dragon,” with a significant population of smokers and consequently second hand smokers as well. One of the challenges that China is still facing, despite the law that was passed in recent years, is tobacco usage and related policies. You wrote an op-ed last year that highlighted several inadequacies in the enforcement of this new law, specifically the section that attempted to make all indoor spaces in the city 100 % smoke-free. Speaking one year later, now in 2017, what are some of the apparent positive aspects that have happened in accordance to this law in the past year, and what are some areas that require more work on China’s part?

Schwartländer: You’re right, one of my personal success stories that I see from my work, and my team in China, is the introduction of the smoke free laws in three of the major megacities. Our work has contributed [to this positive result], but we are clearly not the only ones. It was a partnership between many like-minded people working together. But I think our contribution has helped to protect many Chinese people from the deadly outcomes of smoking. We’re talking about primarily protecting non-smokers from being routinely exposed to the unhealthy fumes of cigarettes. But by doing this, we have seen that even the smokers themselves realize more and more that what they’re doing is unhealthy for their families and also for themselves. The number of smokers that actually appreciate the non-smoking laws in cities is enormously high.

The state regulates certain drugs because those substances can be unhealthy. But when it comes to smoking, it seems very difficult to say that you are not allowed to smoke in a public indoor space, when, obviously, your individual behavior creates a large health risks to others, rather than stepping outside and smoking somewhere where you don’t expose others to your smoke and the deadly fumes that you produce. It seems to be so difficult to get to this recognition, which should be an extremely simple step.

We were very frustrated that these laws didn’t move faster and that it was such a huge struggle, even after the three major cities had passed these laws successfully and seen really good results. There is still a struggle to have this law implemented nationwide. You still hear all of these silly arguments and they are all arguments placed by the tobacco industry. We hear the argument that “it is such a cultural thing for the Chinese to smoke.” But this is just garbage, in every society tobacco companies have managed to lead us to smoke. Seeing chairman Mao with a cigarette cannot be interpreted as a Chinese cultural thing. This has happened everywhere. Churchill was smoking cigars, it has been happening because the tobacco industry has been very successful in selling these products and making people addicted. We have seen in many societies all around the world, how societies have changed, and how they are recognizing that smoking really has a massively negative impact and how it has to change. I have already spoken about New York and the leadership of Mayor Bloomberg and how the whole place turned around and is now a model city of smoking. Italy, which is not known for being the most strict of societies, people there are creative and I love the place, but there, overnight, people were happy to stop smoking inside, in bars, with no problem at all. So why couldn’t that happen in a place like China?

One thing that really frustrates me is the production of cigarettes in China. China has the largest number of cigarettes produced worldwide and the largest number of smokers in one country worldwide. All of these cigarettes are produced by state owned companies. So the state actually produces something, which if used as intended, kills a large part of the users. Now how can that be? How can the state make something that kills people? This is something that really frustrates me and something that I think needs to be changed. So there is still a lot of work that we have to do in China.

[1] The interview was conducted on August 22nd, 2017

[2] Source: http://www.wpro.who.int/china/about/representative/en/

[3] one week before this interview took place

[4] Editor’s note: The terms “One Belt One Road” and “Belt and Road Initiative” are used interchangeably.

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