Interview

“It is morally questionable to let people get sick in the first place”

Living conditions, health threats and healthcare vary greatly around the world. What do you focus on when you deal with “Digital Global Public Health” in your professorship?

Lothar Wieler: The term “global public health” was chosen deliberately because I am primarily concerned with public health systems and less with the specific healthcare of individual patients. “Global” because in our department, which we have been building since April 2023 at the Hasso Plattner Institute of the University of Potsdam, we learn a lot from comparing different countries. Currently, we are mainly looking at countries in Africa, particularly South Africa. But we are also looking east, for example to Romania. In doing so, we focus on prevention. After all, with our work, we want to help reduce the burden of disease by enabling people to protect themselves from disease through preventive measures.

One of the difficulties with prevention is that even if people have the right information – for example, knowing which foods are healthy and that exercise is good – that doesn't necessarily mean that they will live more healthily.

Yes, health education, or so-called “health literacy”, is an important starting point for changing behavior, but it is not enough on its own. Changing the environment is just as important. One goal here would be for food from large corporations – so-called “convenient food” – to be of higher quality and, above all, to be processed less. Another sensible approach would be, for example, to ban advertising for unhealthy food for children, as the current German Minister of Agriculture has proposed. Unfortunately, he failed with this.

One country that is very successful with prevention is Singapore. The city state is organized in a very paternalistic way, which is only partially transferable to our culture, but prevention is indeed given a high priority there. People are living healthier, longer lives and the prevalence of certain diseases, such as type 2 diabetes, is falling dramatically. Of course, the scientific findings are also known in our part of the world, but we still have to manage the “mind shift” from focusing on treating the sick to preventing disease. This can only be achieved through lobbying and a change in the healthcare system. The Scania network is developing many innovative concepts in this area.

And what is your focus in health education?

We focus on identifying misinformation and providing specific population groups with targeted information. We focus on infectious diseases, mental illness and obesity, as the latter is often associated with type 2 diabetes. The proportion of the world's population that is overweight will increase dramatically - this will become one of the biggest health burdens of this century. Thanks to digital tools and generative artificial intelligence, we can reach specific target groups in the right language and tone of voice. GPT, as a large language model, has recently illustrated the extraordinary possibilities of these tools.

How can digitalization also help advance healthcare?

These include tools for evaluating health data. These enable us to better classify complex clinical pictures. Take the COVID-19 pandemic as an example: one of the challenges was to communicate to people what risk they have of becoming seriously ill or even dying. We were able to quickly identify the major risks, which are age and certain underlying health conditions. This individual information is available to health insurance companies for their policyholders, along with the tools to evaluate it. Each health insurance company could have sent its patients a letter with the respective risk and behavioral suggestions. We call this “precision public health”. People could have been given a much clearer idea of their personal risk and how they should behave in their personal environment. This kind of empowerment would certainly have been a great help for many people.

However, we need to be aware of a global problem here: the use of digital tools can increase inequality. This is also due to the fact that the tools of artificial intelligence are currently in the hands of a few large tech companies. We are therefore particularly keen to ensure that as many population groups as possible benefit from digitalization and that the digital divide does not widen further.

What other advantages of digitalization do you see for the healthcare system?

One major advantage is disruption: it allows information to be exchanged between areas that we refer to as “silos” – such as inpatient and outpatient care in Germany. It is still often the case that patient information is not automatically sent to general practitioners when patients are discharged from hospital. A complete, machine-readable electronic patient file would also help to improve care. When you go to a doctor for the first time, you still usually get a piece of paper and write down your remembered previous illnesses, whether you have had an operation before, and so on. This is incredible, because, firstly, you don't necessarily have it all in your head and, secondly, you can't necessarily assess what is important at the moment. If doctors had a complete and analyzable electronic patient record, they would be able to classify illnesses much better, treat them more specifically, and analyze the interaction of certain medications much more easily.

Another advantage is automation: there are many daily processes that computers can do better or faster. This starts with making appointments and also applies to the evaluation of certain MRI or X-ray images. But it also affects the work of nursing staff: They spend a lot of time logging their activities – the documentation requirement. However, they could also use voice recognition tools to speak the information into a smartphone; speech would be converted directly into analyzable logs. Or you could use smartwatches or smart rings to record movements and determine the activity. This would give nurses and doctors significantly more time for their patients, and it would be possible to close gaps in times of a shortage of skilled workers.

Of course, you have to be aware of the risks and explain them to people. If digital applications are seen as a black box, that's not a good motivator. And of course data protection is a high priority. Here it is important to find a balance: if I demand 100 percent security – which never exists anyway – then in many cases innovation is inhibited, which can ultimately mean greater harm for people.

In Germany, healthcare is comparatively good. However, we have very high costs, while life expectancy, according to the OECD, is below the EU average for the first time. What needs to change?

This is definitely shameful for such a prosperous country, which also has such a pleasant climate. However, life expectancy is not only related to healthcare, which is only about a quarter of it. The main reason, to put it simply, is an unhealthy lifestyle: smoking, drinking alcohol, unhealthy eating, and not enough exercise. Most people want to live healthier for longer, which means we need to change from a system of caring for the sick to one of maintaining health. In fact, it is also morally questionable to let people get sick in the first place and then treat them, instead of directly giving them the opportunity to live healthier lives.

And while the German healthcare system is powerful, it is not effective – the treatment outcomes are below average in certain areas – and it is also not efficient, which means it costs too much. The problem is that services are financed regardless of whether the outcome is good or bad. For example, there are certified cancer centers for certain types of cancer. But patients are still treated by doctors who are not part of such a center. I am sure that people would travel 50 kilometers if they knew that it would significantly increase their chances of survival. Here, more transparency regarding the quality of care will lead to greater awareness among patients.

Your expertise ranges from microbiology to the macro level of public health. What research or practical project would you implement if you had unlimited resources?

In the course of my life, I have moved more and more into the field of public health, starting with molecular bacteriology and infectious diseases, in other words from basic molecular research to applied population research. And I have come to the realization that the basis of every commenwealth is a healthy community – and this social environment depends directly on political action. In Berlin, you would say “Kiez”. That is the level at which everyday problems are solved, not at the national level. That means I would spend the most resources on making communities more resilient so that they can solve problems better themselves – flanked by good governance. You can be very specific in the communities and answer questions such as: Which digital solutions are best for this or that case? So it's applied implementation research – but with the most innovative technical solutions.

How political can or should science be when it comes to health issues?

A science like biomedicine, or science in general, that deals with measurable parameters should remain as objective as possible and publish on the basis of the results obtained in well-founded studies. And that should be as apolitical as possible. I also say this because during the coronavirus pandemic, it was the only way to maintain trust. That is one of the lessons I have learned from the pandemic: trust is the most important currency. If you interpret or attempt to reinterpret data that is available in an objective form, then people will justifiably lose trust.

At the Sciana network meetings, fellows reflect on their own leadership role. In your opinion, what does a leader need to do a good job in these turbulent times?

Generally speaking, good leaders should be as authentic as possible. They should know what they can and can't do. A healthy sense of self-assessment and critical faculties are perhaps the most important qualities, because only then you can act convincingly. Secondly, managers should have people around them who can compensate for their weaknesses. And, of course, they need to be empathetic to their employees and place a strong emphasis on their professional skills. Another important quality is resilience. This is one of the most important things in a crisis. Because if you are not resilient and then have to make difficult decisions under pressure, you can no longer evaluate with objective criteria. You also need to have a clear moral compass.