WEBVTT 00:00:04.864 --> 00:00:06.424 Hi, I'm Paul Verschoor and today 00:00:06.424 --> 00:00:09.824 I'm speaking with Martin McKee about collaboration and global health. 00:00:10.544 --> 00:00:14.744 Martin is a medical doctor and a professor of European public health at the 00:00:14.744 --> 00:00:19.244 London School of Hygiene and Tropical Medicine, former chair of the UK Society 00:00:19.244 --> 00:00:24.164 for Social Medicine and past president of the European Public Health Association. 00:00:24.604 --> 00:00:29.024 So I'm here with Professor Martin McKee, professor of European public health 00:00:29.024 --> 00:00:34.184 at London School of Hygiene and Tropical Medicine And also, you have a very 00:00:34.184 --> 00:00:36.804 illustrious and extensive CV. 00:00:37.904 --> 00:00:43.184 So why don't you start to give me a short summary in your trajectory, 00:00:43.444 --> 00:00:48.704 your professional trajectory, that brought you where you are today? 00:00:49.644 --> 00:00:53.984 Okay, well, it is rather complicated, I guess. Whenever I was at school, 00:00:54.004 --> 00:00:58.164 I wanted to study politics, philosophy, economics. I came from a medical family, 00:00:58.244 --> 00:01:02.624 and my parents persuaded me correctly that there was more job security in medicine. 00:01:02.824 --> 00:01:06.344 So I trained in internal medicine. I worked in laboratory medicine. 00:01:06.464 --> 00:01:10.844 I'm afraid I got a little bit disillusioned because it wasn't clear how relevant 00:01:10.844 --> 00:01:15.864 the work I was doing, peptide biochemistry, was to the patients that I was seeing 00:01:15.864 --> 00:01:18.524 in the outpatient clinics and in the wards. 00:01:18.764 --> 00:01:23.804 So I moved into public health. I'd always had an interest in the broader policy 00:01:23.804 --> 00:01:29.044 arena and in politics, not from a party political point of view, 00:01:29.104 --> 00:01:32.564 but from looking at politics as a subject of research. 00:01:33.144 --> 00:01:40.104 And I was appointed at the London School of Hygiene and Tropical Medicine as 00:01:40.104 --> 00:01:44.404 a senior lecturer to a new post to develop links with Europe in 1989. 00:01:45.224 --> 00:01:49.804 In November 1989, just as a wolf, Kim was brought down in Berlin. 00:01:50.064 --> 00:01:53.944 And I had the task of building connections across the continent. 00:01:54.324 --> 00:01:59.784 So I worked for a number of years building up collaborative links. 00:01:59.904 --> 00:02:05.824 And then in 1997, I was invited to work with the World Health Organization at 00:02:05.824 --> 00:02:09.304 what was the Ljubljana Conference on Health System Strengthening. 00:02:10.364 --> 00:02:15.664 And out of that, I and three other colleagues developed something that we called 00:02:15.664 --> 00:02:18.344 the European Observatory on Health Systems and Policies. 00:02:18.564 --> 00:02:22.424 So this was a partnership of universities, the London School of Hygiene, 00:02:22.504 --> 00:02:25.664 the London School of Economics, and a number of European governments, 00:02:26.004 --> 00:02:32.344 initially the Norwegians, the Swedes, the Finns, and then subsequently many 00:02:32.344 --> 00:02:36.964 more, and the World Health Organization subsequently joined by the World Bank 00:02:36.964 --> 00:02:38.084 and the European Commission. 00:02:39.145 --> 00:02:44.265 And what that was all about was I was continuing to do my research, 00:02:44.505 --> 00:02:48.525 which is broadly based in public health, population health, 00:02:48.845 --> 00:02:54.485 but this was a mechanism by which we could take our work and the work of colleagues 00:02:54.485 --> 00:02:59.105 and translate it into policy, working with policymakers. makers. 00:02:59.345 --> 00:03:04.205 So over the more than 20 years that we've been working, we've provided the background 00:03:04.205 --> 00:03:08.525 material for most of the rotating presidencies of the European Union. 00:03:08.685 --> 00:03:14.225 We're fed into work by the G20 and we've done a lot of work with national governments, 00:03:14.445 --> 00:03:19.205 helping to evaluate their reforms, making proposals about what they might do. 00:03:19.565 --> 00:03:23.245 And really, we've continued ever since to do that. 00:03:24.185 --> 00:03:29.425 So that's a complex, a very complex multi-scale process, right? 00:03:29.485 --> 00:03:32.725 If you set up such an advisory body. 00:03:33.125 --> 00:03:41.205 But now, given that broad experience, how would you define collaboration? 00:03:41.445 --> 00:03:42.585 What is it exactly? 00:03:43.345 --> 00:03:48.925 Well, it's a two-way process, and we have thought a great deal about this. 00:03:49.465 --> 00:03:54.065 There is a real problem in academia in that we are often providing information 00:03:54.065 --> 00:03:59.785 that is not what politicians, policymakers need to know, and we're providing it too late. 00:04:00.005 --> 00:04:05.925 Or, and I think it was one of the American presidents who said he needed more 00:04:05.925 --> 00:04:09.945 one-handed economists because they were always saying, on the one hand this, 00:04:10.085 --> 00:04:14.225 on the other hand that. And often the advice is not contextualized. 00:04:14.245 --> 00:04:20.165 It doesn't really relate to the situation that the policymaker finds themselves in. 00:04:20.305 --> 00:04:25.105 On the other hand, as a scientist, we get very frustrated with policymakers 00:04:25.105 --> 00:04:31.025 who ask us for simple answers to complex problems and don't realize that, 00:04:31.085 --> 00:04:33.585 in fact, things do take time to change. 00:04:33.945 --> 00:04:37.425 Often trying to change a policy is like steering an oil tanker. 00:04:37.625 --> 00:04:42.225 So I think the key point here is that we see ourselves in the observatory as 00:04:42.225 --> 00:04:44.105 sitting between the researchers. 00:04:44.485 --> 00:04:49.305 Within the observatory, of course, we have our partners who are the policymakers. 00:04:49.805 --> 00:04:53.825 They're often senior officials in their governments or in the international agencies. 00:04:54.085 --> 00:04:57.925 And I and others are primarily researchers. 00:04:58.645 --> 00:05:03.225 You referred to my CV. I've published quite a bit of work over the years. 00:05:03.585 --> 00:05:10.585 But we are occupying that middle space of trying to bridge the gap and communicate one to the other. 00:05:10.745 --> 00:05:15.725 Now, as a researcher, this is a benefit to me because then I get ideas for research. 00:05:15.905 --> 00:05:19.985 And hopefully it's a benefit to our policymaker colleagues because we do the 00:05:19.985 --> 00:05:24.565 research that they want rather than things that we might otherwise do that will not be relevant. 00:05:24.945 --> 00:05:29.105 But what you emphasize now is very much a communication function, 00:05:29.205 --> 00:05:34.225 a translation function between two worlds. But both worlds are, 00:05:34.325 --> 00:05:36.385 again, complex collaborative systems. 00:05:37.254 --> 00:05:42.914 If we first would go to this world of medicine that you would represent towards 00:05:42.914 --> 00:05:48.794 the policymakers, how would you define collaboration in that world? 00:05:49.194 --> 00:05:50.654 What are its key features? 00:05:51.094 --> 00:05:53.274 Why does it work? What is it about? 00:05:54.554 --> 00:05:57.754 I think almost the same as there are for collaboration anywhere else. 00:05:57.834 --> 00:06:03.074 There was a systematic review by Inver about 20 years ago, and that highlighted 00:06:03.074 --> 00:06:05.334 the importance of trusted relationships. 00:06:05.334 --> 00:06:08.834 Relationships it's really important that you 00:06:08.834 --> 00:06:11.874 and your colleagues whether they're other researchers or policy makers 00:06:11.874 --> 00:06:15.534 have each other's mobile phone numbers or whatsapp nowadays 00:06:15.534 --> 00:06:18.374 so you're communicating now i will 00:06:18.374 --> 00:06:23.974 be called by a minister on a sunday evening asking for an answer to a question 00:06:23.974 --> 00:06:28.114 because they've got my mobile phone number and you know that's actually very 00:06:28.114 --> 00:06:34.854 important i think uh it's um important that you always spell out the limitations 00:06:34.854 --> 00:06:37.354 to your work, the limits to generalizability. 00:06:37.674 --> 00:06:42.314 You don't make grandiose claims. I think listening is incredibly important. 00:06:43.254 --> 00:06:48.754 And I think also perhaps a dose of what's called imposter syndrome is probably 00:06:48.754 --> 00:06:54.334 quite helpful, because I think one sees in science that there are some giant egos. 00:06:54.614 --> 00:06:59.274 And sadly, during the COVID pandemic, we have seen a number of people with giant 00:06:59.274 --> 00:07:03.714 egos, some of whom have got Nobel Prizes, who have got things terribly, 00:07:03.714 --> 00:07:09.494 terribly wrong because they never seem to doubt themselves. 00:07:09.994 --> 00:07:13.294 Whereas I think it helps if you're constantly doubting yourself. 00:07:13.514 --> 00:07:18.054 That may be a bit easier for someone like me who is working across a wide range 00:07:18.054 --> 00:07:23.114 of fields and is drawing on a range of disciplines and therefore is dependent on other people. 00:07:23.234 --> 00:07:25.354 And so you're constantly checking. 00:07:25.494 --> 00:07:29.654 But I think not having a giant ego, having a lot of self-doubt, 00:07:29.734 --> 00:07:35.854 but also having that confidence, which is crucial to be able to say something and engage with others. 00:07:36.014 --> 00:07:40.374 Because often you do find that there are researchers, I'm talking more about 00:07:40.374 --> 00:07:43.974 the collaboration with policymakers here, I guess, where they go to a meeting 00:07:43.974 --> 00:07:48.354 and they basically say, well, I can't make any comment on that because I don't 00:07:48.354 --> 00:07:50.554 have the precise answer, which may be true, 00:07:50.774 --> 00:07:55.334 but they may be able to draw on analogies, or they may be able to explain mechanisms 00:07:55.334 --> 00:07:59.634 or they may be able to point to theories that would help, but they may feel 00:07:59.634 --> 00:08:01.734 that they are unable to do so. 00:08:01.794 --> 00:08:04.454 And there's a gendered element to this as well, it has to be said. 00:08:04.754 --> 00:08:09.214 Men tend to be more confident than women, unfortunately, for lots of reasons 00:08:09.214 --> 00:08:10.554 that we're familiar with. 00:08:10.934 --> 00:08:16.314 Right. But this is now circling around the issue of trust, basically, right? Trust. 00:08:16.654 --> 00:08:22.514 Your point would be to establish and maintain trust, you have to find this fine 00:08:22.514 --> 00:08:25.274 balance between confidence and self-doubt. 00:08:26.173 --> 00:08:31.393 I think you do. I think you do. You need to be constantly questioning yourself because things change. 00:08:32.153 --> 00:08:37.893 You know, lots of things that I thought were true at the beginning of the pandemic are now known or not. 00:08:38.333 --> 00:08:42.773 You know, I was with those people who said, well, face masks are probably not 00:08:42.773 --> 00:08:43.873 going to be very effective. 00:08:44.013 --> 00:08:48.013 I was clearly wrong, but I think I realized that relatively early. 00:08:48.153 --> 00:08:51.653 Other people still haven't fully accepted that. uh you 00:08:51.653 --> 00:08:54.433 know so all of these are you know 00:08:54.433 --> 00:08:57.473 you're on you're on a journey and uh it was 00:08:57.473 --> 00:09:00.873 Maynard Keynes in the UK who said when the facts change 00:09:00.873 --> 00:09:05.773 I change my mind what do you do sir and I think I think you need to have that 00:09:05.773 --> 00:09:11.793 but listening is terribly terribly important and understanding and and I think 00:09:11.793 --> 00:09:17.273 also listening not just to learn from other people but listening to recognize 00:09:17.273 --> 00:09:19.453 when they don't understand something, 00:09:19.613 --> 00:09:22.553 because they say something and there is a clue, 00:09:22.833 --> 00:09:28.273 verbal or nonverbal, that means that they have, we say, got the wrong end of the stick. 00:09:28.353 --> 00:09:32.073 Now I'm doing what I shouldn't be doing because you shouldn't be speaking in 00:09:32.073 --> 00:09:35.673 idioms and things like that, particularly where you're working across languages. 00:09:36.473 --> 00:09:44.313 But then I think making sure that even though you're both speaking English, 00:09:44.433 --> 00:09:46.453 you both understand it in the same way. 00:09:46.513 --> 00:09:50.273 And that's often not the case because the framing 00:09:50.273 --> 00:09:53.333 of the problem can be different and that influences 00:09:53.333 --> 00:09:58.913 how the words are meant but now when you say um you might you might detect that 00:09:58.913 --> 00:10:02.793 someone has the wrong end of the stick right in some sense that that is also 00:10:02.793 --> 00:10:07.573 a conclusion you get from updating your model about the other and understanding 00:10:07.573 --> 00:10:11.173 okay a bunch of their premises are actually Unfortunately, they've still found it. 00:10:11.253 --> 00:10:17.593 But now if that is, let's say, a peer from the medical community or it's a policymaker, 00:10:17.873 --> 00:10:22.533 how do you respond to that conflict now between world models? 00:10:23.753 --> 00:10:26.573 Well, it depends very much that it is a partnership. 00:10:27.524 --> 00:10:31.544 And everybody involved has to be willing to change their views. 00:10:32.484 --> 00:10:38.324 I've written elsewhere about denialism, which is, and also about cognitive biases. 00:10:39.084 --> 00:10:42.944 So we do know in the literature, we do a lot of work in the observatory on cognitive 00:10:42.944 --> 00:10:47.684 biases, because we're well aware that the things we say can easily be misinterpreted. 00:10:47.684 --> 00:10:53.204 So we want to understand how we can use language in a way that reduces the possibility 00:10:53.204 --> 00:10:54.964 of it being misinterpreted. 00:10:54.964 --> 00:10:59.464 And the difficulty is that we do know that when people have strongly held views 00:10:59.464 --> 00:11:04.324 about something, correcting them will actually reinforce that strongly held view. 00:11:04.424 --> 00:11:09.644 And there is good experimental evidence of this studies looking at weapons of 00:11:09.644 --> 00:11:13.724 mass destruction and gun control and things where subjects are asked their views 00:11:13.724 --> 00:11:17.124 beginning at the beginning and then given an authoritative correction. 00:11:17.124 --> 00:11:22.624 We also know that people's political framing may influence how they interpret evidence. 00:11:22.684 --> 00:11:28.564 A classic study, a randomized trial, in which people were given different explanations 00:11:28.564 --> 00:11:30.444 for the etiology of diabetes. 00:11:30.824 --> 00:11:35.584 But before, at the beginning, they were asked if they were registered Democrats 00:11:35.584 --> 00:11:37.904 or Republicans, a study in the United States. 00:11:37.904 --> 00:11:43.224 And those people who were given the explanation relating to the social determinants 00:11:43.224 --> 00:11:45.484 of health, the built environment, the obesogenic environment, 00:11:45.884 --> 00:11:50.804 if they were registered Democrats, they were more likely to support population 00:11:50.804 --> 00:11:54.764 level community interventions than the ones told we don't know what it is. 00:11:54.764 --> 00:11:57.484 Whereas the registered Republicans were less likely. 00:11:58.164 --> 00:12:02.624 So we need to understand all of these things, and everybody needs to be willing 00:12:02.624 --> 00:12:05.664 to reflect on their own biases. 00:12:05.924 --> 00:12:09.784 And that often requires a bit of work to make sure they understand the role of biases. 00:12:10.064 --> 00:12:16.564 Yeah, but Martin, what I was really asking is that, take the COVID situation also in the UK. 00:12:16.644 --> 00:12:21.544 We've seen pretty intense debate about should we open up early or late, 00:12:21.664 --> 00:12:24.844 and then you have, let's say, people speaking for the economy, Thank you. 00:12:25.192 --> 00:12:28.492 Pushing for opening up early, while the medical experts would say, 00:12:28.532 --> 00:12:32.412 look, that's a road to disaster, and we should postpone it. 00:12:32.512 --> 00:12:35.832 So now we have two opposing worldviews based on different premises, 00:12:35.952 --> 00:12:41.352 where I would be confident you would feel very strongly about the more medical position. 00:12:41.632 --> 00:12:46.972 But then how do you bridge that gap in terms of the communication and issues 00:12:46.972 --> 00:12:49.352 and also the bias issues that you just sketched out? 00:12:49.672 --> 00:12:53.672 That is extremely difficult. So at the very beginning of the pandemic, 00:12:53.772 --> 00:12:59.072 we wrote a paper in Nature Medicine, which made the case that it is not health versus the economy. 00:12:59.332 --> 00:13:01.352 We looked at what had happened in 1918. 00:13:01.852 --> 00:13:06.552 We showed that in a study of 43 American cities, those that closed down first 00:13:06.552 --> 00:13:11.112 and remained closed longer bounced back more rapidly by 1925. 00:13:11.692 --> 00:13:16.432 And we have made the case repeatedly. But there is a problem here. 00:13:16.532 --> 00:13:20.312 Many Many people, I think, are persuaded by the arguments, but there are those. 00:13:20.832 --> 00:13:23.972 This is where the politics really does come in. 00:13:24.012 --> 00:13:27.452 It's really fascinating the way in the United Kingdom there's a very, 00:13:27.512 --> 00:13:33.132 very clear overlap between people who supported Brexit and those people who 00:13:33.132 --> 00:13:37.492 reject restrictions with COVID. 00:13:37.632 --> 00:13:40.772 Part of this is because both come from a libertarian perspective, 00:13:40.872 --> 00:13:44.872 but there are people that you just have to accept you will never convince. 00:13:45.692 --> 00:13:48.412 And so that's just impossible you have 00:13:48.412 --> 00:13:51.312 to work on the people who are in the middle ground 00:13:51.312 --> 00:13:54.772 and I think there we have seen a movement in 00:13:54.772 --> 00:13:59.692 fact on this particular issue I'm quoted in the main article in one of the Sunday 00:13:59.692 --> 00:14:04.052 papers today the Observer newspaper where I've been making the case that we 00:14:04.052 --> 00:14:08.772 should be reopening on Monday with considerable caution and that is a view held 00:14:08.772 --> 00:14:12.472 by And I think most people from public health, not everybody, 00:14:12.612 --> 00:14:16.172 but most people, given the emergence of a new variant. 00:14:16.512 --> 00:14:20.472 But I think we're also hearing that now echoed by, and I was just listening 00:14:20.472 --> 00:14:22.552 to the radio, a man who owns a pub. 00:14:23.230 --> 00:14:27.570 Who was also expressing caution and saying that, yes, he wants to open, 00:14:27.710 --> 00:14:30.930 but he will be taking lots of precautions and so on. 00:14:31.030 --> 00:14:36.190 So I think people are recognizing the argument that it's very well to open up, 00:14:36.210 --> 00:14:39.710 but if you're going to have to close down again, and we're now coming into potentially 00:14:39.710 --> 00:14:43.570 a third wave, they can see the economic arguments. 00:14:43.770 --> 00:14:49.150 And also, people are now becoming more familiar, particularly in big business. 00:14:49.310 --> 00:14:53.670 They're reading the very good work in the Financial Times, making the clear 00:14:53.670 --> 00:14:58.290 point that the countries that have had the least amount of COVID public health 00:14:58.290 --> 00:15:00.970 damage have also done best in terms of the economy. 00:15:01.330 --> 00:15:07.550 Evidence in Sweden, in the Nordic countries, for example, that Sweden decided 00:15:07.550 --> 00:15:09.890 that it would not impose restrictions elsewhere. 00:15:10.030 --> 00:15:14.130 It's had a far higher death toll than Finland or Norway, and it's actually had 00:15:14.130 --> 00:15:16.690 a larger negative impact on its economy. 00:15:17.370 --> 00:15:20.670 But we're getting there. But there's an interesting consequence of this, right? 00:15:20.750 --> 00:15:25.190 Because in some sense, if we frame it again around the question of how do we 00:15:25.190 --> 00:15:30.990 collaborate, in some sense you're saying, well, collaboration is possible among like-minded people. 00:15:31.210 --> 00:15:37.030 But if there's too much divergence in the premises people make about the world, 00:15:37.170 --> 00:15:41.730 in this case about COVID-19, there is no way to close that gap. 00:15:43.035 --> 00:15:46.735 Yeah, I think you're right there. I don't think there is. And you see this with 00:15:46.735 --> 00:15:51.175 AIDS denial, Holocaust denial, climate change denial, and so on. 00:15:51.295 --> 00:15:57.315 And that's something that you've got to understand why people are holding those firm views. 00:15:57.875 --> 00:16:02.735 If I was a psychiatrist, I would say this is a delusion. It's a firmly held 00:16:02.735 --> 00:16:04.135 view, unshakable by reason. 00:16:04.795 --> 00:16:09.055 But there are many reasons why people do it. Now, there was an American author 00:16:09.055 --> 00:16:13.715 who famously said, it's very difficult to get a man to change his mind. 00:16:14.435 --> 00:16:22.495 It's very difficult to get a man to know something if his income depends on him not knowing it. 00:16:22.495 --> 00:16:28.675 And we see this very much with disinformation and fake news because there are 00:16:28.675 --> 00:16:29.555 different motivations. 00:16:29.915 --> 00:16:34.595 There are some people who are just stubborn. There are some people who have 00:16:34.595 --> 00:16:40.215 a particular worldview which is based on individualism and libertarianism and so on. 00:16:41.295 --> 00:16:45.515 Captured, if you drive between the border of Vermont and New Hampshire, 00:16:46.115 --> 00:16:48.335 Vermont with a socialist senator, 00:16:48.615 --> 00:16:53.255 and in New Hampshire, the bumper plates all say, live free or die. 00:16:54.035 --> 00:16:57.875 So you can see the culture that influences that. Then, of course, 00:16:57.955 --> 00:17:01.635 you often in science have to be aware that there are powerful vested interests. 00:17:01.895 --> 00:17:06.015 We know most about this from the tobacco industry and the way in which they 00:17:06.015 --> 00:17:09.815 have sought to cast doubt on secondhand smoke. 00:17:09.995 --> 00:17:14.155 We published a paper in The Lancet many years ago showing how they had a secret 00:17:14.155 --> 00:17:19.075 testing plant that was doing experiments but not publishing until it worked 00:17:19.075 --> 00:17:22.375 out the conditions that would give the results it wanted, 00:17:22.515 --> 00:17:26.115 and would then commission independent researchers to do that experiment, 00:17:26.335 --> 00:17:27.895 having tried all the other ones. 00:17:28.195 --> 00:17:30.855 And it explicitly said, we are about to do it. 00:17:31.233 --> 00:17:35.073 Creating doubt. There's a book called Merchants of Doubt, which is about that. 00:17:35.253 --> 00:17:39.693 And then the other thing we're facing in science at the minute is state actors 00:17:39.693 --> 00:17:45.993 that are seeking to undermine science as a means of undermining trust in democratic institutions. 00:17:46.433 --> 00:17:51.133 So we're seeing some of the anti-vaccine movement and pro-vaccine movement coming 00:17:51.133 --> 00:17:55.513 from the same country in the same way that this particular country, 00:17:55.713 --> 00:17:58.473 your listeners will be aware of which one I'm talking about, 00:17:58.473 --> 00:18:03.513 are supporting both the Black Lives Matter and the Ku Klux Klan in the United States, 00:18:03.733 --> 00:18:07.093 because it is about creating, it is about undermining trust. 00:18:07.273 --> 00:18:12.333 And in some areas of science, like vaccines in particular, they know that certain 00:18:12.333 --> 00:18:15.393 messages will be communicated very rapidly. 00:18:16.033 --> 00:18:21.433 By the online anti-vaccine community and will get much greater spread than if 00:18:21.433 --> 00:18:24.793 they were creating disinformation about something that nobody cared about. 00:18:25.013 --> 00:18:28.913 Right. But Martin, what's interesting now is that on the one hand, 00:18:28.933 --> 00:18:33.753 you put your finger on the issue of incentives, right? And incentives pertain to goals. 00:18:34.053 --> 00:18:40.453 And often the idea is we can overcome many of our conflicts and disagreements 00:18:40.453 --> 00:18:42.113 because we share common goals. 00:18:43.333 --> 00:18:50.113 But then do you think that's still the case in this confines of the COVID crisis 00:18:50.113 --> 00:18:56.593 where you would say, well, human life, quality of life should be our largest common goal? 00:18:57.273 --> 00:18:59.393 But we could start to doubt that 00:18:59.393 --> 00:19:03.493 now, given the divergence we see in the approaches that people propose. 00:19:04.173 --> 00:19:08.033 I think we see that much more in the United States than we do in Europe. 00:19:08.373 --> 00:19:11.613 You know, the anti-lockdown movement in Europe is still relatively small. 00:19:12.213 --> 00:19:16.133 Of course, some of it is being funded from the United States. We know that. 00:19:16.713 --> 00:19:21.613 We've already seen with the Great Barrington Declaration the links to some of 00:19:21.613 --> 00:19:25.253 the people who fund climate change denial and so on. 00:19:25.833 --> 00:19:29.513 But I think you do see that much more there than you do here. 00:19:30.293 --> 00:19:36.413 And that, you know, I think when you are, this is where I think there is a view 00:19:36.413 --> 00:19:42.333 in science, which some people will say, well, you should look at each paper in its own rights. 00:19:42.653 --> 00:19:46.433 You should look purely at the methodology and you should say, 00:19:46.493 --> 00:19:48.393 you know, you should ignore who funds it. 00:19:48.493 --> 00:19:52.153 You should ignore any of these influences is because you should be able to judge 00:19:52.153 --> 00:19:55.393 the paper in and of itself. 00:19:55.753 --> 00:19:58.853 I think we now have a lot of evidence that that is not the case. 00:19:58.973 --> 00:20:04.613 For example, the work I mentioned on the smoking bans, the second-hand smoke, 00:20:04.753 --> 00:20:08.413 because there was nothing wrong with the studies that were being done, 00:20:09.061 --> 00:20:13.141 It was just that there were lots of other studies that had been done that were not being published, 00:20:13.221 --> 00:20:17.461 or there was a lot of work that was done at that time, 00:20:17.521 --> 00:20:23.081 which was looking at essentially because the early work on secondhand smoke 00:20:23.081 --> 00:20:32.421 had been looking at the lung cancer or heart disease in the wives of men who 00:20:32.421 --> 00:20:34.241 either smoked or didn't smoke. 00:20:34.341 --> 00:20:38.241 So the exposure was to secondhand smoke was that their husband smoked. 00:20:39.061 --> 00:20:42.701 And the control was women who lived with a husband who didn't smoke. 00:20:43.241 --> 00:20:47.981 Then there was a wealth of research that was undertaken to try to demonstrate 00:20:47.981 --> 00:20:52.801 that those women or those families were in some way different in other ways, 00:20:52.921 --> 00:20:58.601 like their consumption of certain fruit or certain vegetable or something like that. 00:20:58.681 --> 00:21:03.941 And by trawling through the data or by having pet birds in the house, 00:21:04.081 --> 00:21:06.041 you know, completely ludicrous ideas. is. 00:21:06.401 --> 00:21:11.681 And so there was nothing actually wrong with the study. It was just that there 00:21:11.681 --> 00:21:14.201 were all sorts of other studies that had not been done. 00:21:14.681 --> 00:21:20.981 And so therefore, I think that is why in public health, we do pay probably more 00:21:20.981 --> 00:21:26.181 attention than elsewhere to why studies, to who funded studies and where they 00:21:26.181 --> 00:21:29.021 came from, because we do know that that can influence them. 00:21:29.101 --> 00:21:34.201 Studies that show, for example, economic analyses of the impact of smoking bans 00:21:34.201 --> 00:21:40.181 on bar and restaurant takings in a systematic review done by Stan Glantz at UCSF. 00:21:40.321 --> 00:21:44.901 The only factor that was related to whether the study would find an adverse 00:21:44.901 --> 00:21:46.941 effect or not was who funded it. 00:21:48.161 --> 00:21:54.681 What I'm interested in is this goal setting in the collaborations that you're 00:21:54.681 --> 00:21:57.281 familiar with in this domain of public health. 00:21:57.541 --> 00:22:02.981 Because so So far, you have not really brought that to the foreground as a structuring element. 00:22:03.241 --> 00:22:08.181 Well, often we assume it's that by sharing common goals, we can actually work together. 00:22:08.944 --> 00:22:16.364 So how strong is actually the role of then the common goals in the processes 00:22:16.364 --> 00:22:17.524 that you are involved in? 00:22:18.164 --> 00:22:23.324 No, you don't. And I think you do need to understand what the goals are. 00:22:23.444 --> 00:22:26.984 In general, the collaborations that I tend to be involved in, 00:22:27.044 --> 00:22:29.324 we may not share the same goals exactly. 00:22:29.324 --> 00:22:33.684 So, you know, I will work with politicians of a very wide range of political 00:22:33.684 --> 00:22:40.824 complexions within the broad democratic process, but from centre right to centre left. 00:22:41.004 --> 00:22:44.244 And we may, I mean, I'm very cautious, 00:22:44.244 --> 00:22:48.764 very careful not to say what my own personal political views are. 00:22:48.824 --> 00:22:53.564 I think people would be, they may make assumptions, but often I think they might be wrong. 00:22:54.444 --> 00:22:58.204 But I think that what you try to do is it's a bit like a Venn diagram. 00:22:58.204 --> 00:23:02.664 You're trying to find that bit of overlap where your values and their values 00:23:02.664 --> 00:23:08.624 coincide, recognizing that particularly for policymakers, there will always be two sets of goals. 00:23:09.004 --> 00:23:14.264 One is making the world a better place, hopefully, and the other is progressing 00:23:14.264 --> 00:23:15.384 their own careers. years. 00:23:15.744 --> 00:23:20.924 As Benjamin Disraeli, a British prime minister, said, now I have ascended the greasy pole. 00:23:21.384 --> 00:23:26.384 And that's always the case. And I think that's why those of us who are involved 00:23:26.384 --> 00:23:34.404 in this arena need to spend time reading political biographies, political diaries. 00:23:35.484 --> 00:23:39.644 One I've just finished reading is by a junior foreign office minister in the 00:23:39.644 --> 00:23:45.664 United Kingdom, Alan Duncan, Lincoln, which is a very irreverent 00:23:46.088 --> 00:23:49.108 and disparaging commentary on his colleagues. 00:23:49.448 --> 00:23:53.228 And each page, you're quite shocked at the language he uses. 00:23:53.328 --> 00:23:58.408 He talks about one very clearly not very bright MP who had gone to a book festival 00:23:58.408 --> 00:24:01.548 and asked, why did he go there? Can he even read a book? 00:24:02.188 --> 00:24:07.348 I mean, many of us would have doubted that, to be honest, but in his own party. 00:24:07.588 --> 00:24:14.068 And so I think that helps a lot to understand these influences. 00:24:14.068 --> 00:24:17.608 But, you know, it also sheds light on their values. 00:24:17.808 --> 00:24:23.448 So, for example, in health systems research, we look at Charles de Gaulle, 00:24:23.588 --> 00:24:24.868 a right-wing politician. 00:24:25.068 --> 00:24:29.748 But when de Gaulle came back after the Second World War and wanted to expand 00:24:29.748 --> 00:24:35.268 health insurance, there was a lot of pressure from the big French captains of 00:24:35.268 --> 00:24:37.228 industry saying we can't afford it. 00:24:37.228 --> 00:24:43.808 And he said, even though he was a right-wing politician, don't tell me what we cannot do. 00:24:43.968 --> 00:24:51.128 When I was in London organising the Free French, you were here collaborating with the Nazis. 00:24:51.628 --> 00:24:56.448 And he talked about La France Profonde and he talked about engagement with the 00:24:56.448 --> 00:24:58.268 people and all the rest of it. 00:24:58.328 --> 00:25:01.628 So you get an understanding of the values of people, I think, 00:25:01.648 --> 00:25:07.308 by reading around and understanding. People have many complex multirations. 00:25:08.348 --> 00:25:12.768 Isn't this something that actually the current period puts in evidence? 00:25:12.928 --> 00:25:17.188 For instance, a few decades ago, we could even go back to the Second World War, 00:25:17.668 --> 00:25:23.868 there were implicit objectives and values in society that were just shared almost automatically. 00:25:24.928 --> 00:25:30.148 Well, right now, maybe we live in a society that's in that sense much more fragmented 00:25:30.148 --> 00:25:34.248 with respect to its objectives and values. You bring up issues like ego, 00:25:34.568 --> 00:25:36.888 where you bring up issues like short-term gain, 00:25:37.752 --> 00:25:41.892 may be trumping long-term objectives. 00:25:42.312 --> 00:25:46.552 So is that something that you would also see in your environment, 00:25:46.692 --> 00:25:48.612 that we have sort of a fragmentation of objectives? 00:25:49.132 --> 00:25:52.392 I think you do, but I think there are a couple of problems here. 00:25:52.492 --> 00:25:55.312 One is that in some countries you're seeing a massive polarization. 00:25:55.972 --> 00:26:00.712 The United States at the minute, we've just seen Liz Cheney ejected from the 00:26:00.712 --> 00:26:01.552 Republican leadership. 00:26:01.872 --> 00:26:08.212 The Republican Party in the United States has almost nothing in common with the party of Lincoln. 00:26:09.612 --> 00:26:15.872 And that was the case, a paper a number of years ago when the Tea Party movement 00:26:15.872 --> 00:26:21.572 was coming out and it looked at the values and the surveys of legislatures from 00:26:21.572 --> 00:26:23.432 the Republican Party in Congress, 00:26:23.592 --> 00:26:26.532 splitting them by Tea Party or not, and the Democrats. 00:26:26.772 --> 00:26:30.052 Now, the non-Tea Party ones and the Democrats overlapped a lot. 00:26:30.172 --> 00:26:32.012 The Tea Party were out in the extreme. 00:26:32.692 --> 00:26:37.212 You've seen this, particularly the rise of identity politics Again, 00:26:37.572 --> 00:26:42.892 we're now seeing in the United Kingdom a complete realignment of politics in 00:26:42.892 --> 00:26:49.052 that the Conservative Party, which was once seen as the sort of party of the 00:26:49.052 --> 00:26:51.052 landowners and of capital, 00:26:51.292 --> 00:26:55.272 is now shifting to identity politics and social conservatism. 00:26:55.272 --> 00:27:01.212 And in that way is actually increasing support in traditional Labour or socialist 00:27:01.212 --> 00:27:04.072 areas, while the Socialist Party, 00:27:04.192 --> 00:27:07.492 the Labour Party, is making gains in traditional conservative areas. 00:27:07.732 --> 00:27:09.812 So there's a sort of turning round. 00:27:10.152 --> 00:27:13.232 And I think the identity politics is changing things. 00:27:13.372 --> 00:27:18.712 And of course, with identity politics, you do actually go back to, 00:27:18.812 --> 00:27:20.712 in many ways, pre-Enlightenment values. 00:27:20.712 --> 00:27:25.932 So in my own part, where I was born in Northern Ireland, the leading unionist 00:27:25.932 --> 00:27:30.352 party there has just elected as a leader, someone who believes that the earth 00:27:30.352 --> 00:27:34.452 was created 6,000 years ago and rejects evolution. 00:27:34.852 --> 00:27:38.752 I have no idea how he explains the emergence of new variants of COVID, 00:27:38.992 --> 00:27:45.132 but we have a geological feature there, the Giant's Causeway. 00:27:45.132 --> 00:27:51.792 And his party insisted on having a plaque in the visitor center there saying 00:27:51.792 --> 00:27:55.592 that there is also a view that this was created by God so many years ago. 00:27:56.452 --> 00:28:00.972 So, you know, that's what you're saying. And in a way, that takes us back to 00:28:00.972 --> 00:28:02.752 the days before Galileo. 00:28:03.472 --> 00:28:07.852 And so that makes it challenging. But the other thing is the constant quest 00:28:07.852 --> 00:28:11.212 to be visible on a 24-hour news cycle. 00:28:11.212 --> 00:28:17.092 And therefore, there is what a former Lord Chief Justice in the United Kingdom 00:28:17.092 --> 00:28:21.592 called binge lawmaking, you know, putting out initiatives, making announcements, 00:28:21.892 --> 00:28:23.112 never following them up. 00:28:23.632 --> 00:28:29.552 And that, of course, becomes problematic because that is almost putting this 00:28:29.552 --> 00:28:35.132 sort of drive to advance the ego of the politicians on speed. Right. 00:28:35.484 --> 00:28:40.564 And it makes it very difficult because it erodes trust in politics. 00:28:41.404 --> 00:28:45.344 There is a, you know, it really does undermine trust. 00:28:45.524 --> 00:28:49.784 And I think it was Metternich who said, after getting news of Talleyrand having 00:28:49.784 --> 00:28:52.824 died, I wonder what he meant by that. 00:28:53.384 --> 00:28:58.544 And this is where you're constantly trying to interpret what a politician says. 00:28:58.884 --> 00:29:04.444 There's a famous quotation in the United Kingdom on September the 11th, 2001. 00:29:05.484 --> 00:29:10.324 Where a minister sent out a memo saying, today is a good day to bury bad news. 00:29:10.964 --> 00:29:16.444 And so you're often asking, why are they making this announcement on this day? 00:29:16.684 --> 00:29:21.344 What are they diverting from? Here in the United Kingdom, whenever they need to bury something, 00:29:21.604 --> 00:29:25.304 they announce that they will have a new royal yacht, for example, 00:29:25.544 --> 00:29:32.544 or somebody has been in touch through the spiritual world with Princess Diana or something. 00:29:33.004 --> 00:29:38.084 So stories come out and you think, Well, this is the dead cat and bones as we talk about it. 00:29:38.384 --> 00:29:41.484 But now this is, in some sense, of course, not a very optimistic outlook. 00:29:41.744 --> 00:29:46.284 So if you now bring that just to the domain of medicine, where you have also 00:29:46.284 --> 00:29:50.764 your professional track record, there you could argue, well, 00:29:50.844 --> 00:29:56.584 there's always a shared underlying value, which is to protect human life. 00:29:56.864 --> 00:30:03.364 On the other hand, is that value actually really so systematically adhered to 00:30:03.364 --> 00:30:06.244 by all the members of that profession? 00:30:06.544 --> 00:30:11.344 And how is it then balanced against the short-term interests that people have? 00:30:12.144 --> 00:30:16.564 So are you optimistic about that? Or what's your view? 00:30:16.864 --> 00:30:24.084 I think it is sometimes problematic whenever people still stay very tightly 00:30:24.084 --> 00:30:29.044 within their own discipline or within their own area, because I think that there 00:30:29.044 --> 00:30:30.944 can very easily become a groupthink. 00:30:31.784 --> 00:30:35.784 I remember this from my days many, many years ago in peptide biochemistry, 00:30:35.904 --> 00:30:40.084 whenever one of my colleagues had all of these bizarre ideas about what this 00:30:40.084 --> 00:30:41.664 particular peptide would do, 00:30:41.824 --> 00:30:45.704 never actually did the studies, but having talked about them for a while, 00:30:45.764 --> 00:30:46.964 that became the new position. 00:30:47.284 --> 00:30:50.584 And then they would leap on from that. And it was a bit like, 00:30:50.584 --> 00:30:55.064 you know, the knight's move thinking, two to the forward and one to the left, 00:30:55.104 --> 00:30:58.084 but it was sequential so that after a few of these studies, 00:30:58.431 --> 00:31:04.071 you were off in a complete fantasy world and never having done the empirical work to develop it. 00:31:04.271 --> 00:31:08.931 So I think there is a case for moving outside one's disciplinary silos. 00:31:09.551 --> 00:31:14.291 I think there are also many examples of where, I mean, we've seen this with 00:31:14.291 --> 00:31:18.511 face coverings, actually, where the aerosol scientists and the epidemiologists 00:31:18.511 --> 00:31:20.331 and so on, we're not talking together. 00:31:20.591 --> 00:31:24.831 And so I think that there can be a problem in that there are different paradigms. 00:31:24.831 --> 00:31:28.871 We see it in medicine very much with the rise of evidence-based medicine. 00:31:28.991 --> 00:31:35.111 Now, we all absolutely agree that where possible, we should be doing randomized controlled trials. 00:31:35.291 --> 00:31:39.351 I've done randomized controlled trials. We recently did a very complex cluster 00:31:39.351 --> 00:31:43.731 randomized controlled trial of an intervention for hypertension management in 00:31:43.731 --> 00:31:47.291 deprived areas of Colombia and Malaysia published in The Lancet. 00:31:47.291 --> 00:31:50.591 So, you know, I'm fully bought into randomized controlled trials, 00:31:50.731 --> 00:31:54.891 but there are many things that cannot be evaluated by randomized controlled trials. 00:31:55.011 --> 00:31:59.451 And then there are people who will say, unless we have not only a randomized 00:31:59.451 --> 00:32:04.291 controlled trial, but a meta-analysis, we have no evidence, and therefore we should do nothing. 00:32:04.291 --> 00:32:10.351 And that was the problem with face coverings, whereas there are other designs and those. 00:32:11.691 --> 00:32:17.591 Designs like natural experiments may give you insights in situations where you 00:32:17.591 --> 00:32:19.911 cannot do randomized controlled trials. 00:32:20.071 --> 00:32:25.711 I think that also takes us back to the very early work on causality by Bradford Hill. 00:32:26.011 --> 00:32:30.271 People often forget that within the nine criteria of causality, 00:32:30.471 --> 00:32:33.031 there were some that were purely empiricist. 00:32:33.431 --> 00:32:38.711 So they were about the sequencing of events and whether or not, 00:32:38.751 --> 00:32:41.951 you know, essentially a physical, you know, was there a clear cause and effect? 00:32:42.151 --> 00:32:46.751 If I keep dropping this pen to the desk, will it always fall? Yes, it always will. 00:32:46.931 --> 00:32:51.191 But there was also some ideas that were taken from Kant, Immanuel Kant, 00:32:51.411 --> 00:32:54.871 which was looking at the rationale, the mechanisms, the. 00:32:59.187 --> 00:33:04.027 So I think that sometimes in science, we are trapped within our paradigms. 00:33:04.067 --> 00:33:09.767 And unless somebody has done the experiment of the type that we do, we reject it. 00:33:10.027 --> 00:33:13.607 And this is, of course, the longstanding 00:33:13.607 --> 00:33:17.227 dichotomy between science and the arts that we have often seen. 00:33:17.527 --> 00:33:24.267 Right. But what I'm worried about is whether enough people in medicine actually 00:33:24.267 --> 00:33:27.007 know what they mean when they speak of evidence-based. 00:33:27.007 --> 00:33:32.567 Because the real understanding of what evidence means seems very limited, 00:33:32.627 --> 00:33:38.747 restricted to a more dogmatic belief in a simple algorithm that things have to go through, 00:33:38.927 --> 00:33:45.767 which is then used to, in some sense, obstruct any kind of change of the existing paradigm. that. 00:33:47.187 --> 00:33:52.487 Yeah, I totally agree. The example I use in all of this is, in reality, 00:33:52.707 --> 00:33:57.367 we're looking at very complex causal relationships. 00:33:57.627 --> 00:34:01.867 And they're often complex, by which I mean from the mathematics of complexity, 00:34:02.207 --> 00:34:06.187 the relationship is determined by the starting conditions, the associations 00:34:06.187 --> 00:34:09.447 are often nonlinear, and there are positive and negative feedback loops, 00:34:09.607 --> 00:34:12.687 which means that you You can explain why something happened, 00:34:12.767 --> 00:34:14.347 but it's very difficult to predict it. 00:34:15.207 --> 00:34:19.427 And you see that in a way, there are methods that can be used, 00:34:19.567 --> 00:34:24.627 comparative qualitative analysis, which is basically a sort of Boolean algebraic approach. 00:34:24.847 --> 00:34:27.607 You know, what are the conditions that are necessary? What are the conditions 00:34:27.607 --> 00:34:29.787 that are sufficient using case studies? 00:34:30.027 --> 00:34:36.067 So these can help you a little bit. The example I often use is what explains 00:34:36.067 --> 00:34:41.047 the suffering of people living in the eastern part of the Democratic Republic of the Congo? 00:34:41.227 --> 00:34:44.787 And the answer is the growth of mobile phones. 00:34:45.333 --> 00:34:50.253 Because the growth of mobile phones, they use chips that contain tantalum. 00:34:50.333 --> 00:34:54.293 These people live over mines where coltan ore is mined. 00:34:54.693 --> 00:35:00.373 Nobody, no warlord, none of the greater powers would have any interest whatsoever 00:35:00.373 --> 00:35:04.913 in the bit of forest that they live in, was it not for the tantalum below their feet. 00:35:04.913 --> 00:35:10.573 So their suffering, their villages being burnt, are ultimately linked to the 00:35:10.573 --> 00:35:12.253 growth of mobile phones. 00:35:12.673 --> 00:35:15.153 That is a complex causal link. 00:35:15.993 --> 00:35:20.773 Similarly, staying in the Democratic Republic of the Congo, the civil war, 00:35:20.873 --> 00:35:25.233 the breakaway of Katanga, that was largely driven by the fact that they were 00:35:25.233 --> 00:35:27.453 sitting on top of deposits of uranium. 00:35:27.453 --> 00:35:31.873 And in the 1960s, the West and Russia needed uranium. 00:35:32.013 --> 00:35:37.813 So the death of Patrice Lumbumba and others, you know, that was ultimately related 00:35:37.813 --> 00:35:39.913 to the work being done in the Manhattan Project. 00:35:40.313 --> 00:35:45.713 Now, these are very tenuous, very tortuous, very complex causal pathways. ways. 00:35:45.813 --> 00:35:50.893 But if we're looking at a global policy level in the G20 or something like that, 00:35:51.013 --> 00:35:53.273 there are things that we need to understand. 00:35:53.573 --> 00:35:55.873 Blood diamonds would be another example. 00:35:56.613 --> 00:36:00.093 These are not amenable to clinical trials. Right. 00:36:00.193 --> 00:36:05.813 But what I also get from the way that you talk about collaboration is also as such, 00:36:05.953 --> 00:36:08.673 collaboration is not necessarily something we really 00:36:08.673 --> 00:36:11.933 fully understand so but if we now go back to 00:36:11.933 --> 00:36:18.213 the observatory and your current activities also around policy making in the 00:36:18.213 --> 00:36:25.233 uk what what do you see as your successes in in collaborating across these domains 00:36:25.233 --> 00:36:28.773 what has been the success story for the observatory. 00:36:29.723 --> 00:36:35.523 To really show, look, we did manage by very specific interventions to raise 00:36:35.523 --> 00:36:38.503 awareness and make important things change. 00:36:38.943 --> 00:36:43.643 I think probably more at a European level. So I think you can see that we fed 00:36:43.643 --> 00:36:50.583 very much into the directive on cross-border care, looking at what the issues were there. 00:36:50.703 --> 00:36:54.283 We did a lot of case studies. We looked at existing cross-border collaborations. 00:36:54.283 --> 00:36:58.663 For example, in that triangle between Achenliege and Maastricht, 00:36:58.783 --> 00:37:03.883 for example, across the French-Spanish border and the Pyrenees across the Northern Irish border. 00:37:04.063 --> 00:37:06.903 So that was in particular, that was important. 00:37:06.903 --> 00:37:11.103 We've done a lot of work looking at the contribution of health to the economy, 00:37:11.303 --> 00:37:16.543 demonstrating how better health feeds into economic growth through people being 00:37:16.543 --> 00:37:21.043 more productive and participating more in the labour force, by which I mean 00:37:21.043 --> 00:37:24.463 healthy people work more hours per week and they don't retire early. 00:37:24.623 --> 00:37:28.423 Their investment in their own education if they have an expectation of the future 00:37:28.423 --> 00:37:33.843 takes us into issues of time preference and discounting and issues of how people 00:37:33.843 --> 00:37:38.023 who are healthy will invest in small and medium enterprises into their own business. 00:37:38.223 --> 00:37:39.583 So we've done a lot of work on that. 00:37:39.903 --> 00:37:44.963 We've shaped the health and all policies agenda feeding into the 2006 Finnish 00:37:44.963 --> 00:37:50.103 presidency, and which then became mainstreamed in European health policy. 00:37:51.183 --> 00:37:54.963 A lot of work in individual countries and primary care, for example, 00:37:54.963 --> 00:37:58.183 the role of primary care and strengthening that. 00:37:58.363 --> 00:38:04.283 We've been involved in individual level analysis. I was on a review of the recent Finnish reforms. 00:38:04.703 --> 00:38:11.063 For example, chronic disease management, I think our work on looking at the 00:38:11.063 --> 00:38:18.703 challenges of getting integrated chronic disease management and taking us away from it. 00:38:18.963 --> 00:38:25.783 But Martin, is there the route always to transform the argument into an economic one? 00:38:26.447 --> 00:38:35.567 No, it's not. It is often about finding a solution for a minister who is faced with a problem. 00:38:36.267 --> 00:38:40.947 But that is usually also a problem of cost and controllability. 00:38:41.167 --> 00:38:43.587 Sometimes, but many of these things are cheaper. 00:38:44.247 --> 00:38:49.947 High-quality primary care actually saves money. Not doing things that are ineffective save money. 00:38:51.527 --> 00:38:56.647 Is that the route? Is that the way to the politician's heart to make an economic argument? 00:38:57.047 --> 00:39:03.047 It often is because the health minister often has to make the argument to the finance minister. 00:39:03.227 --> 00:39:07.227 And that's the key. You're not trying to convince the health minister often. 00:39:07.507 --> 00:39:11.367 You're helping the health minister to convince the minister of the treasury 00:39:11.367 --> 00:39:15.407 or the finance minister. So you're helping them to make those cases. 00:39:15.927 --> 00:39:20.847 Now, often there are, but not always, I mean, some of the things may be, 00:39:20.887 --> 00:39:23.907 you just actually want, you know, in the Eastern European countries, 00:39:24.007 --> 00:39:27.947 there was a clear case for arguing for better health, just simply because that, 00:39:28.007 --> 00:39:29.907 like education and physical infrastructure, 00:39:30.227 --> 00:39:35.707 the internet, and so on, these were contributors to economic growth in their own right. 00:39:36.087 --> 00:39:40.747 Looking at that symbiotic relationship between health, health systems, 00:39:40.787 --> 00:39:46.667 and economic growth, which include looking at the contribution of health to 00:39:46.667 --> 00:39:50.767 the medical industrial complex, to regional development, 00:39:51.087 --> 00:39:56.407 to hospitals and universities working with small and medium enterprises that 00:39:56.407 --> 00:39:59.367 they do in some of the Italian regions, for example. 00:39:59.607 --> 00:40:04.987 So you're making a lot of arguments, but fundamentally, you're listening to their concerns. 00:40:05.207 --> 00:40:10.867 And some of the concerns may not be economical. They may be simply that there 00:40:10.867 --> 00:40:15.507 is a political agenda behind this because they're getting attacked because there 00:40:15.507 --> 00:40:16.987 are failures in the health system. 00:40:17.047 --> 00:40:20.387 In Hungary, many years ago, there was a fire in Hungary. 00:40:21.162 --> 00:40:24.522 A fire that burnt out of control and the family were killed. 00:40:24.702 --> 00:40:30.562 And that was a stimulus to do something about emergency services because of the politics of it. 00:40:31.362 --> 00:40:36.462 When I chaired a midterm review for the State Council in China of their health 00:40:36.462 --> 00:40:41.222 systems, part of it was because there was widespread popular discontent with 00:40:41.222 --> 00:40:44.542 the health system and they wanted to find ways of reducing that. 00:40:44.802 --> 00:40:49.422 So there are a There are a number of motivations, but they fundamentally come 00:40:49.422 --> 00:40:51.422 back to that a politician has a problem. 00:40:51.842 --> 00:40:55.762 Okay, but then now there are two ways to interpret that, right? 00:40:55.822 --> 00:40:58.802 Because on the one hand, here I have a politician with a problem within their 00:40:58.802 --> 00:41:00.842 own complex collaborative system. 00:41:01.602 --> 00:41:05.062 They bring in the experts to advise on that problem. 00:41:05.382 --> 00:41:08.382 And this now could have two possible effects, right? 00:41:08.442 --> 00:41:11.342 One could be that the politician in case can just say, okay, 00:41:11.402 --> 00:41:13.682 I asked for advice and we're going to do X. 00:41:14.062 --> 00:41:18.162 And X might be unrelated to the advice. Or they could actually follow up the 00:41:18.162 --> 00:41:21.182 advice, which might, of course, disrupt the system they're in. 00:41:22.182 --> 00:41:26.362 So what's the common pattern here? Well, it varies, actually. 00:41:26.502 --> 00:41:31.602 And the thing is that it's hugely important if you are giving advice to understand the system. 00:41:31.822 --> 00:41:35.222 There are far too many consultants, which we are not. 00:41:35.382 --> 00:41:39.122 I mean, we're absolutely not. We're not the big consultancy companies. 00:41:39.122 --> 00:41:41.982 And these are people where we know the countries. 00:41:42.062 --> 00:41:46.102 In the observatory, we publish very detailed what we call health system and 00:41:46.102 --> 00:41:51.662 transition profiles, 150 up to 300 page analyses of each health system, 00:41:51.722 --> 00:41:56.802 working with our colleagues in the country. you absolutely have to understand it. 00:41:56.882 --> 00:42:03.282 You cannot go to Hungary without understanding the history of the early 20th century. 00:42:03.542 --> 00:42:08.642 You cannot go to Austria without understanding the federalized or Germany, 00:42:08.842 --> 00:42:12.542 the decentralized system, to Finland without understanding the nature of the. 00:42:16.760 --> 00:42:21.440 How the country works. You need to understand the politics, because often in 00:42:21.440 --> 00:42:22.920 coalition governments, the health 00:42:22.920 --> 00:42:26.920 minister is frequently a member of the minority party in the coalition. 00:42:27.960 --> 00:42:33.240 And so therefore, there are other things other than the relative power of the minister. 00:42:33.380 --> 00:42:38.820 But the minister of health may not just be junior in terms of the hierarchy, 00:42:39.080 --> 00:42:41.520 but may be coming from a different political perspective. 00:42:41.760 --> 00:42:44.440 And you need to understand that too. Right. 00:42:45.220 --> 00:42:51.260 Go ahead, Martin. Sorry. But that means you might, from a medical perspective, 00:42:51.520 --> 00:42:56.960 have the same message that you ever present in different forms dependent on the recipient. 00:42:57.660 --> 00:43:02.860 Yeah, absolutely. Yeah. Because you're working with them to try and find a solution. 00:43:03.380 --> 00:43:09.860 You can just say, go and read my paper. And a lot of the time we do. Many simple questions. 00:43:10.120 --> 00:43:12.220 So we also do rapid reviews. 00:43:12.540 --> 00:43:16.160 We have a network. We have a COVID response monitor on the internet. 00:43:16.420 --> 00:43:20.100 We have a financial crisis monitor, which we ran during the financial crisis. 00:43:20.400 --> 00:43:23.680 And there's a load of information. They'll say, how do they do this in Sweden? 00:43:23.720 --> 00:43:27.380 We say, go and look at our webpage because our Swedish colleagues have written it down. 00:43:28.040 --> 00:43:32.100 Or they'll say, what do you know about such and such? And we'll give them a 00:43:32.100 --> 00:43:35.180 paper. And we may have written the paper. Somebody else may have written the paper. 00:43:35.380 --> 00:43:41.360 So there's part of that. And probably 80% of our work with our partners is that, 00:43:41.500 --> 00:43:44.200 just saying, look, it's all been written here, just go and read it. 00:43:44.400 --> 00:43:48.760 But the more difficult ones are the ones where you're working carefully with them. 00:43:49.020 --> 00:43:52.860 You're trying to understand what the nature of the problem really is. 00:43:52.900 --> 00:43:56.460 And the nature of the problem may not be the one that they say it is. 00:43:56.560 --> 00:43:58.620 There may be something else that's there. 00:43:58.800 --> 00:44:01.960 And what they're trying to fix is not the issue. 00:44:02.860 --> 00:44:07.000 So that requires quite a lot of work. But then there are two elements to this 00:44:07.000 --> 00:44:11.840 because on the one hand, how you describe it, the observatory then is also likely 00:44:11.840 --> 00:44:14.820 proactive because people have questions, you already answer it. 00:44:15.519 --> 00:44:21.499 So that work has already been done. Yeah. So if you have this proactive perspective, 00:44:21.999 --> 00:44:25.179 that means you're predicting the future in these different health, 00:44:25.219 --> 00:44:26.499 broader healthcare systems. 00:44:27.859 --> 00:44:34.479 Yeah, sort of. It was famously said, I think Bevan, who created the National 00:44:34.479 --> 00:44:38.459 Health Service in England, said, why do I need a crystal ball when I can read the book? 00:44:38.559 --> 00:44:41.759 Because he referred to New Zealand doing the same 10 years earlier. 00:44:41.759 --> 00:44:47.059 So from that point of view, the problems that we face are generally ones that 00:44:47.059 --> 00:44:48.519 somebody else has faced already. 00:44:48.699 --> 00:44:53.359 Or the things that we know about primary care, mental health, hospitals. 00:44:53.599 --> 00:44:58.059 I've got this particular thing about hospitals, having spent a lot of my time 00:44:58.059 --> 00:45:05.699 working in them. and hospital design, what the hospital of the future will be like, things like that. 00:45:05.759 --> 00:45:12.119 I have to say the Netherlands does this particularly well, but not many other countries do. 00:45:12.339 --> 00:45:15.739 So we sort of know the things that are likely to come up. Now, 00:45:15.779 --> 00:45:18.699 obviously, with COVID, it was different in many ways. 00:45:19.259 --> 00:45:24.559 And I'm the rapporteur for a pan-European commission on health and sustainable development. 00:45:24.719 --> 00:45:29.519 I'm one of a handful of medics on it. I've got two former prime ministers and 00:45:29.519 --> 00:45:36.659 three former presidents and a lot of people from central banks and so on. 00:45:36.899 --> 00:45:43.019 And so there we're getting into new areas, more challenging areas, 00:45:43.219 --> 00:45:46.039 and particularly our involvement with the G20 and so on. 00:45:46.099 --> 00:45:51.679 So that's taking us into a slightly new area, but global financial instruments and so on. 00:45:51.799 --> 00:45:55.599 But this does mean that as an organization, the 00:45:55.599 --> 00:45:58.639 observatory has its own internal goals it 00:45:58.639 --> 00:46:01.319 tries to realize so what's that goal is a 00:46:01.319 --> 00:46:04.299 goal let's say uh quality of life uh 00:46:04.299 --> 00:46:10.419 life expectancy um how would you no no no it's not no because it is a partnership 00:46:10.419 --> 00:46:15.239 and it's not it's not like a research grant where we go to the governments and 00:46:15.239 --> 00:46:16.539 the european commission and the 00:46:16.539 --> 00:46:22.919 who and say we want money um the universities put my time into the pot. 00:46:23.139 --> 00:46:27.619 Other people put time or the Belgian government provide the offices, 00:46:27.799 --> 00:46:30.959 for example, or, you know, different things. 00:46:31.079 --> 00:46:38.879 A lot of it is money being put into it. WHO put staff as well into it. So it is a partnership. 00:46:39.039 --> 00:46:43.219 And as such, the partnership is governed by our board. 00:46:43.419 --> 00:46:47.239 And the board has representatives from all the parties, and they decide what 00:46:47.239 --> 00:46:52.659 the priorities are, which have shifted over time, but they're broadly... How have they shifted? 00:46:53.544 --> 00:46:58.484 Well, just, I suppose, in terms of content, we've moved away, 00:46:58.524 --> 00:47:00.004 I suppose, from an initial more 00:47:00.004 --> 00:47:06.244 descriptive approach to a more analytic approach, more rapid responses. 00:47:06.404 --> 00:47:10.084 But this is more about the detail, I suppose, more than anything else. 00:47:13.264 --> 00:47:19.164 So the objective must be defined. Is your objective to just provide proper advice 00:47:19.164 --> 00:47:24.724 to whatever any government asks, or is your objective internally defined like, 00:47:24.804 --> 00:47:27.884 we want to improve Factor X for society? 00:47:28.464 --> 00:47:32.864 No, it's not. We want to improve the quality of evidence being used in policy 00:47:32.864 --> 00:47:34.984 and health in Europe. That's fundamentally it. 00:47:35.064 --> 00:47:39.384 That involves working on both sides of the equation. So that involves running 00:47:39.384 --> 00:47:43.104 a summer school, for example, in Venice every year, virtually last year and 00:47:43.104 --> 00:47:47.004 this year, but normally supported by the Veneto region, which is a partner. 00:47:47.224 --> 00:47:51.764 And that brings together senior policymakers with academics and practitioners. 00:47:52.524 --> 00:47:56.884 We do the same at the European Health Forum at Gastein. We have a session for 00:47:56.884 --> 00:47:59.884 permanent secretaries and people like that working, 00:48:00.104 --> 00:48:06.784 bringing, convening people to help to support them to understand what questions 00:48:06.784 --> 00:48:10.604 they can ask and what are answerable, and then to make sure that our staff are 00:48:10.604 --> 00:48:12.724 listening and understand what the questions are. 00:48:12.904 --> 00:48:16.984 So it is really about improving the quality of evidence in policymaking, 00:48:17.124 --> 00:48:20.764 working on both the quality of the evidence and working on the policymaking. 00:48:20.764 --> 00:48:25.124 But that's, of course, not always unambiguous, right? 00:48:25.204 --> 00:48:30.624 Because also the evidence might not always be complete, while the person asking for the advice, 00:48:30.784 --> 00:48:35.744 the government asking for the advice, might actually utilize the evidence in 00:48:35.744 --> 00:48:41.024 a global policy intervention that might go against some basic values of the observatory. 00:48:41.104 --> 00:48:43.084 So how do you balance that? 00:48:43.669 --> 00:48:46.709 Well, I don't think we've ever had that problem, to be perfectly honest. 00:48:46.889 --> 00:48:50.189 I mean, I can see your point. I can understand that there could be theoretical 00:48:50.189 --> 00:48:52.489 ways in which this would be done. 00:48:52.729 --> 00:48:56.889 And, you know, we have endless examples of how Alfred, I mean, 00:48:56.909 --> 00:49:01.929 Alfred Nobel's discovery of dynamite was, of course, incredibly useful for mining 00:49:01.929 --> 00:49:03.629 and for construction and so on. 00:49:03.629 --> 00:49:08.029 But one of the reasons he gave his prices was a feeling of guilt about the use of it in wartime. 00:49:09.069 --> 00:49:15.929 Nuclear power is the same. But I think we're probably less worried about that 00:49:15.929 --> 00:49:21.469 in the area of health policy. you know, I think there is definitely a shared 00:49:21.469 --> 00:49:23.109 value about inclusive societies. 00:49:23.449 --> 00:49:29.769 In our work with, you know, we've been talking more recently about how, 00:49:29.869 --> 00:49:34.649 you know, in health, we need to be moving to including investing and innovating. 00:49:35.149 --> 00:49:42.029 So there is a sense that we would not be comfortable with a health policy that 00:49:42.029 --> 00:49:46.509 said, this is only providing healthcare for a a particular racial group. 00:49:46.709 --> 00:49:50.269 I mean, that clearly would not be something we would have anything to do with. 00:49:50.349 --> 00:49:53.729 But then if you look at our partners, I can't imagine that they would do that either. 00:49:55.269 --> 00:50:03.409 Okay. But that also means that you will not proactively pursue a controversial policy issue. 00:50:03.729 --> 00:50:07.309 For instance, in my own case, very active in neurorehabilitation, 00:50:07.769 --> 00:50:11.409 chronic stroke patients are often told, well, you have to learn to cope with 00:50:11.409 --> 00:50:16.069 it because we cannot do anything for you, even though this is factually untrue. 00:50:16.329 --> 00:50:22.089 It has become a policy guideline because it saves a lot of money that way. 00:50:23.169 --> 00:50:28.869 We have to act here, right? Yeah, and I think if you look at a recent policy 00:50:28.869 --> 00:50:32.429 brief we did on long COVID, for example, a condition that is relatively neglected. 00:50:33.349 --> 00:50:38.109 We actually initiated that, led that, we published a policy brief jointly with 00:50:38.109 --> 00:50:40.829 WHO, but that was an initiative that came from us. 00:50:40.969 --> 00:50:43.829 And it came from us because I'm working with colleagues who 00:50:43.829 --> 00:50:46.729 are concerned about that particularly patient groups so we're 00:50:46.729 --> 00:50:50.289 bringing the work we're doing in academia into our 00:50:50.289 --> 00:50:53.269 work where we're hearing about these issues you know 00:50:53.269 --> 00:50:58.309 wearing my university hat not my observatory hat we did an early paper on how 00:50:58.309 --> 00:51:02.909 covid was a complex multi-system disease right and we're team working now we 00:51:02.909 --> 00:51:08.129 tried very hard to bring clinicians of different types neurologists cardiologists 00:51:08.129 --> 00:51:12.229 and respiratory physicians and others across europe together and we failed. 00:51:13.349 --> 00:51:17.829 One of the things where I will say we have had real problems in doing, 00:51:17.929 --> 00:51:21.189 and we have not succeeded in everything we've done. 00:51:21.749 --> 00:51:25.209 I recently edited a book on the future of the hospital. 00:51:25.569 --> 00:51:30.769 I've been very anxious for many years as a physician myself that we should get 00:51:30.769 --> 00:51:37.329 the clinicians to engage much more with policymakers because they often quite rightly complain. 00:51:38.538 --> 00:51:43.058 Into the vacuum and to the ether in some way. And I've been working very hard 00:51:43.058 --> 00:51:48.198 to try to bring sort of the representatives of medicine to come and say, well, what is it? 00:51:48.218 --> 00:51:50.438 Let's have a positive vision going forward. 00:51:50.738 --> 00:51:53.778 Now, this book on the hospital did that a bit. 00:51:54.338 --> 00:51:59.578 So for example, we had, I think, some good material on frailty and older people. 00:52:00.218 --> 00:52:03.398 We've talked about stroke services, integrated stroke services, 00:52:03.658 --> 00:52:07.698 integrated management of respiratory disease and things like that. 00:52:07.698 --> 00:52:09.858 By some very engaged clinical champions. 00:52:10.298 --> 00:52:13.298 But it's been very, very hard work. 00:52:14.138 --> 00:52:20.398 Right. So, you know, if we could get that, that's a challenge which we haven't solved yet. 00:52:21.458 --> 00:52:24.538 Well, but this is actually the big challenge we're facing, right? 00:52:24.598 --> 00:52:28.738 Because we also know the current healthcare systems are not sustainable unless 00:52:28.738 --> 00:52:33.658 really we think very fundamentally how we approach that and also definitely 00:52:33.658 --> 00:52:35.498 bring in, let's say, more technology. 00:52:35.498 --> 00:52:42.358 So the question then becomes, can we accomplish this transition through a collaborative 00:52:42.358 --> 00:52:48.098 continuous process or does it really require some resolution where just a new 00:52:48.098 --> 00:52:53.318 generation of physicians has to take over? So which of these trajectories will it be? 00:52:54.076 --> 00:52:57.716 I wish I knew, but we've certainly been making that point. And this is our include, 00:52:57.836 --> 00:53:03.296 invest, innovate, because by including everybody, then hopefully, and having policies, 00:53:03.776 --> 00:53:08.096 and we've advocated very clearly for policies that actually minimize the burden 00:53:08.096 --> 00:53:12.636 of disease, because a lot of the problems we see with COVID are because so many 00:53:12.636 --> 00:53:14.256 people lead precarious existence. 00:53:14.696 --> 00:53:17.876 Their life is precarious in terms of their income, their employment, 00:53:18.096 --> 00:53:21.456 their food security with the rise of food banks, and their housing. 00:53:21.736 --> 00:53:25.656 So therefore, Therefore, they can't isolate, they find difficulty going for 00:53:25.656 --> 00:53:29.216 a test because of the consequences, but also they're vulnerable to all sorts 00:53:29.216 --> 00:53:30.536 of other illnesses as well. 00:53:30.716 --> 00:53:35.356 So we need to look at the including and making sure they've access to early 00:53:35.356 --> 00:53:40.496 care when needed before complications arise, the so-called ambulatory care sensitive conditions. 00:53:40.956 --> 00:53:44.356 We need to invest because investment saves lives. 00:53:44.476 --> 00:53:48.456 One of the things we're doing in this Pan-European Commission work from my colleagues 00:53:48.456 --> 00:53:52.216 here from from the banking side, are arguing we need to look at healthcare after 00:53:52.216 --> 00:53:56.316 the pandemic, separate out the running costs and the investment, 00:53:56.576 --> 00:53:57.996 the revenue investment. 00:53:58.396 --> 00:54:02.196 And we should account for them separately. And they're arguing that the International 00:54:02.196 --> 00:54:09.116 Monetary Fund and so on should favor investment, even as it may want to question 00:54:09.116 --> 00:54:10.816 how much you spend on the running costs. 00:54:11.276 --> 00:54:15.916 But investment to change and innovation. And the innovations that, 00:54:15.976 --> 00:54:18.676 of course, we need, We need the technical innovations. 00:54:19.196 --> 00:54:22.976 We've been looking in particular at organizational innovations too. 00:54:23.116 --> 00:54:27.716 We've been looking at task shifting, but not task shifting as traditionally thought of. 00:54:27.836 --> 00:54:32.056 A recent paper we published under report for the European Commission looked 00:54:32.056 --> 00:54:36.796 at the shifting of responsibilities and roles between among healthcare workers, 00:54:36.936 --> 00:54:40.376 different types of healthcare workers, between healthcare workers and patients 00:54:40.376 --> 00:54:43.556 and carers, and between both of them and machines. Right. 00:54:43.868 --> 00:54:50.688 And so we're reconceptualizing the nature of these relationships in a way that 00:54:50.688 --> 00:54:53.968 is hopefully trying to lead to some sort of a paradigm shift. 00:54:54.168 --> 00:54:57.168 Because when we talk about task shifting, we're often saying, 00:54:57.288 --> 00:55:00.448 can we just give a job to somebody who's cheaper and it's more complicated. 00:55:00.448 --> 00:55:06.568 But the transition, of course, also is now really questioning fundamentals of 00:55:06.568 --> 00:55:07.908 the medical industrial complex, 00:55:08.048 --> 00:55:12.628 which is very hierarchical and also very much controlled by big egos that have 00:55:12.628 --> 00:55:15.588 become big egos by the culture and their own education. 00:55:16.128 --> 00:55:21.108 So this is, of course, not conducive to the change that you're now describing. 00:55:21.648 --> 00:55:27.948 So what are the key factors now to build this new collaborative medical system 00:55:27.948 --> 00:55:30.668 where the different stakeholders are more tightly integrated? 00:55:31.308 --> 00:55:35.448 Well, that's where I would look to the work of Mariana Mazzucato in particular, 00:55:35.468 --> 00:55:40.488 and look at the relationship between the capital markets and industry and so on. 00:55:41.068 --> 00:55:45.628 Essentially, we have a situation at the minute in medical technology and pharmaceuticals 00:55:45.628 --> 00:55:48.488 particularly, where governments are paying twice. 00:55:48.708 --> 00:55:53.728 They're paying much of the cost of discovering and developing the drugs, 00:55:53.888 --> 00:55:59.328 the early, the risky costs, and then they're paying high prices for the drugs. 00:56:00.027 --> 00:56:03.487 And, you know, and there's a lack of transparency. 00:56:03.507 --> 00:56:08.687 We published a paper in JAMA recently where we tried to work out how much it 00:56:08.687 --> 00:56:14.047 really does cost to produce a new drug by going to security and exchange commission filings. 00:56:14.447 --> 00:56:18.607 Very difficult to work out. It was a lot of hard work. And we estimate that 00:56:18.607 --> 00:56:21.927 it's a lot less money than the companies are claiming. 00:56:22.227 --> 00:56:26.067 And the experience of the Drugs for Neglected Diseases initiative would support 00:56:26.067 --> 00:56:31.007 that. But then I think, as Mariana is saying, then if governments are investing, 00:56:31.267 --> 00:56:33.567 then they're entitled to a return on their investment. 00:56:34.107 --> 00:56:38.427 Now, we already do have lots of mechanisms, advanced purchase agreements, 00:56:38.767 --> 00:56:47.267 and we have procurement for innovation and pre-competitive procurement and things like that. 00:56:47.407 --> 00:56:52.927 So I think we need to look at those. But I think what we need to do is to be 00:56:52.927 --> 00:56:57.827 very clear about who is winning in all of this. Where is the power and, 00:56:57.907 --> 00:57:01.087 quote the Latin, quobono, quobono, who benefits? 00:57:01.667 --> 00:57:05.967 That's absolutely crucial. Okay, but that brings us to the incentives, right? 00:57:06.067 --> 00:57:11.067 So on the other hand, what I was trying to emphasize is the idea that we have to move from a, 00:57:11.087 --> 00:57:15.227 how do you move from a hierarchically structured system that's also very much 00:57:15.227 --> 00:57:21.447 short-term oriented to a more egalitarian stakeholder relationship that you were just describing? 00:57:21.447 --> 00:57:26.787 Describing, where also relations between, let's say, the patients and the healthcare 00:57:26.787 --> 00:57:32.047 system and the healthcare providers, industrial providers, need to shift. 00:57:32.287 --> 00:57:36.047 How do you achieve that? Is that the question of communication? 00:57:36.607 --> 00:57:43.167 Is the question of just deploying a new generation of core players? 00:57:43.347 --> 00:57:44.447 How do we make that transition? 00:57:45.300 --> 00:57:50.420 Yeah, so, you know, it's a $64,000 question. You know, how do we make the world a better place? 00:57:50.600 --> 00:57:54.500 And fundamentally, this is actually going to be about institutions and politics. 00:57:54.560 --> 00:57:58.180 It's not going to be something that we will do bridging that gap between research 00:57:58.180 --> 00:58:02.780 and policy and health. because what you're talking about is stakeholder capitalism. 00:58:02.980 --> 00:58:07.940 You're talking about reform of the capital markets, in particular private equity and accountability. 00:58:08.520 --> 00:58:14.040 You're looking at transnational relationships, particularly with financial flows, 00:58:14.160 --> 00:58:19.280 in a world in which there is free movement of goods, services, 00:58:19.400 --> 00:58:20.880 and capital, but not of people. 00:58:21.200 --> 00:58:24.200 There are lots of issues which are going to have to be addressed there. 00:58:24.500 --> 00:58:29.320 And that fundamentally is about re-engaging with society. And unfortunately, 00:58:29.680 --> 00:58:34.620 as we're seeing in many countries, maybe Biden will change that, actually. 00:58:35.200 --> 00:58:40.020 And I think maybe some of the people in the G20 are seeing that we need to do things differently. 00:58:40.180 --> 00:58:44.400 We can learn, but I'm in the United Kingdom. them. 00:58:44.540 --> 00:58:48.680 Will Hutton has been writing for two or three decades about the benefits of 00:58:48.680 --> 00:58:54.200 the Rhineland capitalism model with union representatives on the boards of companies, 00:58:54.360 --> 00:58:59.300 of the role of the regional banks in investment and all sorts of things like 00:58:59.300 --> 00:59:00.800 that, the more long-term investment. 00:59:01.300 --> 00:59:05.040 Also, more recently, we have seen when you move to a more Anglo-Saxon model 00:59:05.040 --> 00:59:08.960 of capitalism, some of the problems that have arisen with the payment company 00:59:08.960 --> 00:59:11.180 and things like that. I think. 00:59:11.847 --> 00:59:17.247 There is a recognition among many people, and I have a book, 00:59:17.387 --> 00:59:22.427 Values, by Mark Carney, who's former governor of the Bank of England. 00:59:23.907 --> 00:59:26.427 And he is making many of these arguments, 00:59:26.507 --> 00:59:28.907 a former governor of the Bank of Canada and the Bank of England. 00:59:29.067 --> 00:59:32.107 So there are a lot of people in senior positions who are making these arguments, 00:59:32.367 --> 00:59:36.787 but that doesn't mean that they're going to happen. happen, and particularly 00:59:36.787 --> 00:59:41.647 in some countries, to go back to what we were saying earlier about the rise of identity politics. 00:59:44.347 --> 00:59:48.147 What would you see as the ray of hope in that transition? 00:59:48.407 --> 00:59:52.067 What's the best example you could give us of what that future, 00:59:52.327 --> 00:59:58.567 rethinking the hospital, rethinking health systems, is going or must move towards? 00:59:58.807 --> 01:00:01.007 What's the best example you would have today? 01:00:02.007 --> 01:00:05.287 Yeah, that's a really difficult question. this one. I don't know that I need 01:00:05.287 --> 01:00:09.247 to think a little bit more because I think there are lots of good things around 01:00:09.247 --> 01:00:11.487 in different places, but I'm not sure. 01:00:11.627 --> 01:00:14.687 I couldn't say that there's one country that's absolutely got it right. 01:00:16.667 --> 01:00:20.767 This is where maybe I think a roadmap is needed. 01:00:21.007 --> 01:00:26.587 If we don't sketch out these future scenarios, also interested stakeholders 01:00:26.587 --> 01:00:28.227 have nothing to put their teeth in. 01:00:28.227 --> 01:00:31.127 Right so so i think that there will be a need to 01:00:31.127 --> 01:00:34.147 develop and also to include in that a rethinking how 01:00:34.147 --> 01:00:37.887 the different moving parts really work work together and 01:00:37.887 --> 01:00:43.067 are organized because i think the way the system works today is not necessarily 01:00:43.067 --> 01:00:49.267 so so effective for a large list of reasons and then a number of which we we 01:00:49.267 --> 01:00:55.247 have we have discussed but what what would you see as the biggest risk of the healthcare system? 01:00:56.327 --> 01:01:03.147 I think the biggest risk is actually populism because populism thrives by creating 01:01:03.147 --> 01:01:06.107 divisions in society, by othering people. 01:01:06.327 --> 01:01:11.087 We saw this in the 1930s. I think a number of us are very worried that we could 01:01:11.087 --> 01:01:16.227 actually see the 20th century as our dress rehearsal for the 21st because we 01:01:16.227 --> 01:01:23.767 have now got a situation which frankly was unimaginable 20 years ago in the United States, 01:01:23.867 --> 01:01:26.027 where one of the major parties, 01:01:26.187 --> 01:01:28.547 the party of Lincoln, is actually, 01:01:28.767 --> 01:01:34.087 you know, 75% of its supporters believe that the last presidential election was stolen, 01:01:34.327 --> 01:01:40.787 and which are supporting an armed insurrection on the center of government. 01:01:41.027 --> 01:01:45.587 That, for any European who knows the history of the 20th century, 01:01:45.707 --> 01:01:48.507 is incredibly worrying. 01:01:48.507 --> 01:01:54.887 But at what point do you believe do we have to bring issues of disinformation 01:01:54.887 --> 01:01:57.687 in the domain of public mental health? 01:01:59.073 --> 01:02:03.333 Bringing in disinformation, did you say? Well, the challenge of disinformation 01:02:03.333 --> 01:02:09.433 and the effects of disinformation can also be seen as a public mental health risk. 01:02:09.873 --> 01:02:14.553 Absolutely. And you will see whenever we publish it, the background material 01:02:14.553 --> 01:02:16.133 for the Pan-European Commission, 01:02:16.333 --> 01:02:21.693 we actually have a model of the determinants of health, which has at its heart 01:02:21.693 --> 01:02:25.693 the relationship between humans, animals, and the natural environment, one health. 01:02:25.693 --> 01:02:30.313 But then it has a whole series of things which are the typical prerequisites 01:02:30.313 --> 01:02:32.313 for health, which improve health. 01:02:32.513 --> 01:02:36.313 So going back to the Ottawa Charter, peace, water, shelter, and so on, 01:02:36.373 --> 01:02:41.053 but working conditions, digital inclusion, access to justice, 01:02:41.273 --> 01:02:43.753 for example, we argue why all of these are important. 01:02:43.753 --> 01:02:47.853 But going the other way, damaging health, we obviously have conflict, 01:02:48.053 --> 01:02:53.293 organized crime, corruption, populism, racism, disinformation, 01:02:54.013 --> 01:02:56.753 cybercrime, cyberattacks, and so on. 01:02:56.753 --> 01:03:02.093 So I think that is now recognized as within the realm of public health. 01:03:03.073 --> 01:03:06.733 And we've, I in my own writing, have argued organized crime, 01:03:06.853 --> 01:03:09.493 corruption are central to understanding 01:03:09.493 --> 01:03:15.853 public health and also digital exclusion in all sorts of ways. 01:03:16.713 --> 01:03:24.453 So, you know, I think that that's there. I think there's an interesting challenge 01:03:24.453 --> 01:03:26.433 here to concretize that. 01:03:26.753 --> 01:03:33.393 For instance, I'm also active in ETMO, which is the European Observatory for Disinformation. 01:03:35.293 --> 01:03:39.073 And also there, I try to link disinformation to mental health because I think 01:03:39.073 --> 01:03:43.573 this opens up approaches to actually respond to it, which right now are not being considered. 01:03:43.853 --> 01:03:47.733 Now disinformation is very much considered in the realm of, let's say, 01:03:47.773 --> 01:03:53.193 media journalism, but much less in the domain of health and medical response. 01:03:53.513 --> 01:03:56.453 And I think this is a bridge that also needs to be built. 01:03:56.753 --> 01:04:02.313 I agree. So, but then if you could, so do you believe humans will ever manage 01:04:02.313 --> 01:04:04.553 to really collaborate effectively? 01:04:07.613 --> 01:04:15.533 Well, there is a book which I've, forgive me, I've forgotten the author is about human kindness. 01:04:15.693 --> 01:04:20.153 And it starts with the story of the well-known story in English literature of 01:04:20.153 --> 01:04:24.253 Lord of the Flies, in which it's a sort of Hobbesian analysis. 01:04:24.473 --> 01:04:28.673 Hobbes talked about how in the absence of a strong power to keep people in order, 01:04:28.753 --> 01:04:30.853 life is nasty, brutish, and short. 01:04:31.313 --> 01:04:36.173 And in Lord of the Flies, you have young boys who are wrecked on an island, 01:04:36.233 --> 01:04:40.173 and they all fight among themselves and kill each other, and it all descends 01:04:40.173 --> 01:04:42.273 to sort of primeval emotions and so on. 01:04:42.673 --> 01:04:45.373 And there was an example, a contrary 01:04:45.373 --> 01:04:49.453 example, where some young boys were shipwrecked in an island in Tonga. 01:04:50.198 --> 01:04:54.938 For over a year and then were rescued. And in fact, it was the opposite. They all collaborated. 01:04:55.278 --> 01:05:00.178 There is a book called The Evolution of Collaboration, which is based on the 01:05:00.178 --> 01:05:02.118 idea of the iterative prisoner's dilemma. 01:05:02.498 --> 01:05:06.798 It is actually intrinsically better for people to collaborate and cooperate 01:05:06.798 --> 01:05:10.978 unless you're in a situation where you only have a single interaction. 01:05:11.438 --> 01:05:16.078 So should you give a tip to a taxi driver in a city you'll never visit again? 01:05:16.598 --> 01:05:20.678 There's an argument from self-interest, not. But in any other situation, 01:05:21.138 --> 01:05:22.958 there is an argument for collaboration. 01:05:23.058 --> 01:05:26.298 And people would argue that from an evolutionary perspective, 01:05:26.658 --> 01:05:28.938 collaboration actually has many benefits. 01:05:29.358 --> 01:05:34.618 So I think maybe I would be a bit optimistic. But the problem is there are powerful 01:05:34.618 --> 01:05:36.898 vested interests, political, economic, and others. 01:05:37.058 --> 01:05:43.098 And in particular, those who are using racism and xenophobia to undermine the 01:05:43.098 --> 01:05:49.718 European model of the welfare state by telling people, as happened in the 1930s, okay, 01:05:49.898 --> 01:05:55.118 you to the petty bourgeoisie, you've had a dreadful situation. 01:05:55.338 --> 01:05:59.958 You've suffered from austerity, but it's not our fault. It's the fault of them, 01:06:00.098 --> 01:06:02.598 the others, the people who are identifiably different. 01:06:02.818 --> 01:06:08.258 And they're doing that because essentially these are the people who are promoting 01:06:08.258 --> 01:06:10.278 that message just don't want to pay taxes. 01:06:10.438 --> 01:06:16.018 They don't want to pay for the the white working class or whoever. 01:06:16.618 --> 01:06:19.458 And what they're doing is dividing them among themselves. 01:06:19.738 --> 01:06:24.078 And I think that is terribly worrying, fueled by a media that is dominated by 01:06:24.078 --> 01:06:25.798 a very small number of people. Okay. 01:06:26.058 --> 01:06:29.858 And this might also be an irreversible trend by now, right? 01:06:29.898 --> 01:06:35.818 Because so much power has been accumulated in a very tiny slice of society that 01:06:35.818 --> 01:06:38.938 there might not be a way back. I don't know how optimistic you are about that. 01:06:39.578 --> 01:06:43.258 Well, you know, if we look back to the beginning of the 20th century, 01:06:43.558 --> 01:06:47.338 Theodore Roosevelt, who was a Republican, unlike his namesake, 01:06:47.358 --> 01:06:51.918 he was the one that broke up the monopolies of the Standard Oil and others. 01:06:52.318 --> 01:06:54.658 And so he used what he called the bully pulpit. 01:06:55.266 --> 01:07:00.226 And the Bell Corporation was broken up, the power of the Bell Corporation under 01:07:00.226 --> 01:07:01.066 the Reagan administration. 01:07:02.146 --> 01:07:04.846 You can never tell in this world. 01:07:05.946 --> 01:07:11.046 The last question on this topic would be, if I could give you the magic wand 01:07:11.046 --> 01:07:14.886 to just change humans in any way necessary, 01:07:15.426 --> 01:07:19.106 what's the one thing you would change so that I could manage to collaborate 01:07:19.106 --> 01:07:21.646 effectively on these challenging Well, 01:07:22.226 --> 01:07:25.326 you know, I'm not sure I would like to give me any power like that at all. 01:07:25.386 --> 01:07:28.766 I think having, I've already complained about other people having too much power. 01:07:28.966 --> 01:07:36.706 But I think the art of listening, I think, and British Judge Lord Denning said, 01:07:36.926 --> 01:07:41.306 no matter how high you be, you know, the law is always above you. 01:07:41.566 --> 01:07:47.086 To recognize, I think, I think humility and ability to listen, 01:07:47.166 --> 01:07:51.646 I think is always incredibly important. All right, Martin McKee, 01:07:51.646 --> 01:07:53.486 thank you very much for this conversation. 01:07:54.106 --> 01:07:58.666 Thank you very much indeed. Hi, you listened to one of our podcasts in the series 01:07:58.666 --> 01:08:03.806 on collaboration produced by the Ernst Trumund Forum and the Conversion Science Network. 01:08:04.586 --> 01:08:07.466 You can find more episodes on our website.