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 and recently became Chef de Cabinet of the World Health Organization. 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]
For Part I of the interview, please visit https://5clpp.com/2017/10/17/interview-with-dr-bernhard-schwartlander-world-health-organization-who-world-representative-to-the-peoples-republic-of-china/.
CJLPP: In our conversation just now, we have mentioned some cultural dimensions to consider. The next question is actually from a colleague of mine at the journal: how do you think AIDS is stigmatized in China and is that different than how it is stigmatized in western countries such as Germany, the US, and the UK? If so, why?
Schwartländer: This is a very good question, and stigma is indeed one of the major factors that influences the epidemic of HIV worldwide. One thing that is quite different in China is that China never had a law that made homosexual behavior illegal. Many other societies actually had legal regulations that made homosexual behaviors illegal and therefore poses challenges, even legal challenges, to people who feel they have a preference to the same sex. This makes it extremely difficult to deal with the stigma because they know whatever they do has to happen secretly and silently. That is, of course, a recipe that makes it difficult to engage these populations in health promotion programs. There are still societies where there is a death penalty for homosexual behavior.
Now in China, such laws did not exist. But what did exist were extremely strong social norms, which is something that also can create enormous stigma. People are expected by their families to get married and have families of their own. If that does not happen, there are parents that won’t talk to their children anymore, creating enormous pressures on those that have different desires or plans in life.
This goes through all parts of society. In the healthcare sector, people cannot talk about it because it’s not accepted, and people also fundamentally don’t understand and cannot talk about it. That goes back to one of the specific things that I see in China more than other countries. The sex education and reproductive health education is very weak in China. Sex is not talked about at schools and it is very difficult to talk about it in families. I, personally, know so many people and colleagues whom I really like and are personal friends, but when it comes to sexual education, they don’t believe their children need it, because their girls don’t have boyfriends or their boys don’t have girlfriends, or because their child is busy at school and doesn’t need it. Of course, those are such silly statements, because they all have friends and have sex, we know that. There is a huge number of pregnancies and abortions, which is a consequence of people not having the right sexual education.
I think that is a prominent feature in China that we have to address. Young people, in particular, need to have access to the right information. Young people also need to be given information on homosexuality because that is also a component of moving into a healthier future. It is difficult to change the beliefs of older people because they are not so flexible in their thinking and find it more difficult to accept. However, the younger generation must be provided with the right information and the right mindset so that they can actually take health education forward in a new way, one that does of course include homosexuality which is so often a component of HIV epidemics.
CJLPP: Having just now discussed about young people in China, let’s now move on to the topic of China’s significant aging population. How do you think the Chinese government will address the healthcare concerns that accompany China’s large aging population, and how will China change its healthcare policy to accommodate this rising need?
Schwartländer: Aging is a phenomenon that is very interesting. In many ways it is a good thing. The fact that life expectancy has increased is a fundamental reflection that we have been living in a healthier way. We have access to better food and better services, especially at birth. Many children don’t die, and more and more mothers are healthier. So many measures have been taken so that people live longer and healthier lives. What is happening at the same time is that we have a lower number of births and smaller families, which means that the proportion of the society who are elderly is increasing around the globe. It is very rapidly increasing in China, the numbers are just staggering and there is a number of ways we have to think about this. One, we have to realize that healthy aging starts at birth, so this is not just about looking into what happens when old people get sick. Second, we have also to look at how we can make sure that people, when they grow older, are healthy and stay healthy. If elderly people are healthy, we don’t need to look into what are the special needs of old people when they come to the hospital. So looking at how we keep them healthy, and keeping them away from hospitals as long and as effectively as possible is important.
There are many things around healthy lifestyles that have to start early in life and have to continue when people grow older. But there is also a new dimension that we haven’t thought about: what do we do with a population, which is up to one third of the total population, who are basically out of a job because they are retired? But they are there, they are healthy, they are productive, and they want to participate in society, so how can we include them? How can we keep them as active members of our society? Because if they are part of something, feel useful, are not excluded from the process of society and can feel part of it, it can have a massive impact on their mental health. It keeps them younger, and it also keeps them healthy. There are many examples of that. So there is a whole new dimension that we need to look at when we talk about aging, which is much more than the traditional care and medical sector in order to really create societies with healthy aging.
CLPP: We have covered a lot of content on China so far. We will now address aspects of your career as well as the UN as a whole. You have highlighted the importance of cooperation—which for various stakeholders means learning from each other. Based on your first hand experience working and leading various international organizations, what would you say are some of the ways that different UN agencies can learn from each other internally?
Schwartländer: Now, we have a large number of United Nations agencies today, and when you go back to the idea of the United Nations, it was an extremely noble idea which came up in the last century. It actually came up after the world went through a number of real crises including the terrible second World War, which included nations from across the world being drawn into a violent war. They realized—the world realized—that this could not go on forever. We have to collectively carry a responsibility for mankind. We have to collectively take responsibility for the globe. It cannot be that certain places just don’t care about what they are doing in a way that has a massive impact on others when it comes to, for example, pollution and climate change. There is a recognition that we live in not only a social ecosystem, but also an environmental one, in which everybody around the globe, wherever people live, are connected. We need to find political solutions that not only allow friendly countries to have such exchanges, but also big countries that are not so closely connected. They need a platform where such exchanges can happen, and that’s the basic idea behind United Nations system.
Over the years, quite a number of specialized agencies or programs have developed from specific issues, like the World Health Organization. Health is a topic that requires people with specific expertise to come together in an agency, in an organization that really focuses on that area. It’s the same with many others .As you already pointed out, many of these special interests or foci, are actually connected. Let’s take UNICEF. They look into the wellbeing of children as their main objective, but how can that happen without looking at their health, and how can the World Health Organization work together with UNICEF to make sure that those interconnections are effectively identified and addressed with different organizations, different units, different departments taking their responsibilities but working closely together across the silos to deliver services to the people. When it comes to people, there’s one child, there’s one health, there’s one wellbeing and there’s one education. Unless we bring these things together, people won’t understand us.
So, what I think is important is what organizations can learn from each other, beyond the technical issues—I’m always fascinated talking to my fellow United Nations colleagues because there’s so much to learn. I mean, all of these sectors have very specific aspects that relate to the life of people in other countries, so it’s good to discuss. But I think what is really important, and I think it’s fundamentally also on the sustainable development agenda is that we have to get away from thinking about our specific objective—“I’m only dealing with health, you’re only dealing with education.” We have to recognize that ultimately it is about people, wherever they live. For one person getting up in the morning, they don’t have to think about a specific disease; they think “How can I be healthy? How can I be productive? How can I make sure that I can get food and water to my family”. Unless we go back to that and say “What’s the need of the people and how can we collectively deliver what these people need in a given place?”, we will not be successful in our drive for a better humanity. So, number one is tear down the silos, talk to each other with the people at the center. Number two: a message for my United Nations colleagues is to stop thinking too much at headquarters. So much discussion goes on in the headquarters. Go out into the countries and look into what the people need and how we can actually collectively help them. And that will get us a long way in overcoming these different silos, overcoming competition for resources or whatsoever. At the end of the day, for those people whom we serve, none of this matters. They have a very clear desire to have a good life, and we have to collectively deliver this.
CJLPP: Has working for the UN been a long-term aspiration for you?
Schwartländer: When I went to medical school, I wasn’t even thinking that I would end up in public health, and certainly not thinking about working for the United Nations. So I must admit that the jobs that I first took when I joined the World Health Organization, and later UNAIDS in the United Nations system developed because of the work that I did in my own country. They developed out of the cooperations that we have, for example, within Europe, recognizing that when it comes to public health, you have to think beyond the borders, living in a globalized world. I had more and more contact with people in the United Nations, and there came a point in time when I felt that my expertise and aspirations to work in public health would actually really mesh well with the work of the United Nations, and it just happened. I was really happy and got great opportunities to work on a global agenda. Along the way, in several ways I was very happy. I was offered the opportunity to work not only for one organization, UNAIDS, but also for the World Health Organization. I’ve worked for the World Bank for some time, and I’ve worked with the Global Fund to fight AIDS, tuberculosis and malaria, and all of these gave me incredible insights into the different aspects of development cooperation and how to most efficiently work with partners in countries to support them to build systems. So, this is essentially never about our own organizations. The work we’re doing is fundamentally to make sure that we can help national governments, national counterparts, NGOs and others to build better systems in their own countries. And I have learned so many aspects of that and how to do that better. So, I really feel very, very privileged with my career and the opportunities that I got, but for most of these jobs, I didn’t plan them ahead. They came along, and I jumped on them because it was a huge opportunity and I was very, very happy with the many different positions I was able to carry throughout my career.
CJLPP: What kinds of suggestions do you have for students who are interested in working for law and policy in the public health sector?
Schwartländer: One thing I would like to tell students is that it’s a very privileged type of work to work in public health. Medical students especially take the job and take the studies because they are eager to bring health interventions to people. We all start to work with patients. We learn how the body works, how health works, how bugs work, and how we can protect people from illness. Most of us, with very few exceptions, realize how important it is to work in the right policy environments so that the right decisions are being taken and the frameworks exist to really make sure that everybody has access to the right interventions from prevention to treatment to care. And that often works through policy and law development. It’s incredibly important that we get the systems right, that nobody suffers financial hardship when they have to go to the hospital or have an accident, and all of those are legal frameworks that you have to put in place. There are financial frameworks that you have to put in place, so it cuts across all kinds of sectors and departments. It’s the social security aspects of health; it’s the development aspects of health; it’s the financial aspects of health, which are enormous.
Today, in China, there are still about 50 to 70 million people in poverty. Almost half of those people are in poverty because of health, so how can you even think about bringing people out of poverty if you don’t look into health? All of that relates to policy development. In a larger sense, it’s a very noble area of work, and it can be an extremely satisfying area of work because you’re dealing with large populations much beyond an individual patient. It can be very rewarding to see how your work contributes to the health of many people, to give them access to health. For me, it’s the best thing I can do. ,.
CJLPP: As an epidemiologist, you love numbers, and as a people leader, you love to share the stories and meanings behind all of those numbers. What is your take on the future of public health in relation to big data analysis?
Schwartländer: I think dealing with big data offers enormous opportunities to improve health for people, and it’s very interesting what many people don’t quite understand. We do differentiate between what we call large data and big data. The difference is that we say large data is sharing larger data sets, which is possible today because we have better tools, better computers and better software that allows us to manage large data sets. For example, by combining health information and patient information of many large hospitals around the country we understand better how treatment works or what type of diseases people come to the hospital with. But in a sense, it’s still the traditional thinking in medicine but just applying it to bigger data sets.
Now, for, big data the way we describe it is actually to look into information that is available beyond the health sector and seeing how that can actually help us to understand health better, and to predict, for example, health problems earlier. Based on the fact that there are lots of things happening every day—like what people are buying on the Internet or elsewhere—that could give us incredible insights into the health of the people and the health risks of the people. It’s the type of food they buy, the type of devices they buy, the toys they buy, the decisions that they take which give us hints on how people think, their objectives in life, for example, and all of that can help us understand how that links to health. Some of the main research companies have access to huge amounts of data, and it can allow us to recognize very early whether there is an outbreak-type situation, be it influenza or be it other things, because when people do not feel they may start to buy medicines. If you only look at the individuals you don’t recognize those trends. They don’t show up to hospitals, but if you look at huge population numbers across the board, look at financial transactions with credit cards, you can very early on pick up that people buy certain medicines, buy certain things that are linked, or very likely linked, to health situations, or just look for health conditions on search engines.
So, there are many aspects of data and information that are available, but that are not directly connected to health. If you put that together in a creative way, you can actually get incredibly useful information about public health, public health policy, and how to also help influence this in a healthier way. That’s when I see the strength of big data, and in many ways, we are only at the beginning of this discussion. It is happening. There are approaches, for example, to build smarter and healthier cities, including regulation of traffic which can increase road safety and decrease pollution. All of these things are happening. It is the beginning of something that really I think is big.
CJLPP: That concludes our interview, Dr. Schwartländer. Thank you so much again. It’s been such a pleasure talking to you.
[1] The interview was conducted on August 22nd, 2017
[2] Source: http://www.wpro.who.int/china/about/representative/en/
