In Conversation With Ilona Kickbusch

About what is needed to bring health to all policies

Prof Pat Casey and Prof Lim Soon Thye

Ilona Kickbusch talks to MEDICUS about the fault lines that emerged during the pandemic and the need to incorporate health in all policies

From the rising cost of living to climate change, the world faces a growing number of crises as we emerge from the worst pandemic since World War II. But in this polycrisis, we have an opportunity to transform how we think about health. MEDICUS talks to global health reformer Professor Ilona Kickbusch, founder and chair of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva, about the future of healthcare as countries seek to be better prepared against the next pandemic and rein in healthcare spending. Kickbusch is a member of the Global Preparedness Monitoring Board, an independent body set up by the World Health Organisation (WHO) and the World Bank to chart the way to a safer world. She is also a long-time advisor to the WHO and currently serves on the WHO’s Council on the Economics of Health for All. She also co-chaired a Lancet Financial Times Commission on “Governing health future 2023: growing up in a digital world”.


MEDICUS: Many societies are enjoying the return to life as it was before COVID. So how did the world fare during the pandemic and is now the right time to reflect on our performance?

Ilona Kickbusch: Taking the assessment of the Global Preparedness Monitoring Board, then the answer is we did not do well. And we’re not finished yet, we still are in a public health emergency of international concern.

At the same time, because we’re looking back at roughly three years, it’s good to analyse what worked, what didn’t work. And that’s difficult to do because responses were so different: countries were so differently prepared in terms of their institutions, political processes, but also—and that’s always forgotten—in terms of their communities and populations. The Global North, in particular, didn’t do very well because we had thought, pandemics is something for someone else. And so, even though we had the institutions, they were not prepared for pandemics. Our political processes were not prepared for all the decisions that needed to be taken in relatively short periods of time and in periods of great uncertainty. And we were not prepared for the political disruption that the pandemic brought where wearing a mask wasn’t seen as understanding public health guidance but virtue signalling. And that’s when things went desperately wrong.

And if you take the global response, vaccine apartheid and vaccine nationalism are key issues that I think global health will have to deal with for years to come because it has destroyed global trust.

MEDICUS: Zooming in on Asia, how would you assess this continent’s level of preparedness and how much of that preparedness was because of SARS in 2003?

Ilona Kickbusch: The analyses so far say that many Asian countries were better prepared and that that was due to SARS. They had reinvested in their public health and surveillance systems. But this was also happening in their “neighbourhood”, so they paid attention. We saw a much larger amount of trust in Korea, Taiwan, Japan and Singapore. If I take masks as an example, that was not catapulted to be an issue of personal freedom but was something that’s very much part of everyday life during certain parts of the year. And the whole issue of how to protect myself and those around me, some analysts are saying that in Asian societies, communal feeling of protecting one another is stronger.

MEDICUS: But with respiratory viruses, basing decisions on geographical proximity is overly optimistic given international trade and travel.

Ilona Kickbusch: Absolutely. As the Global Preparedness Monitoring Board presented our first report in the autumn of 2019 at the UN General Assembly, I remember standing in a fifth-floor room that was not very big nor very full, watching New York City traffic. We said, “Look, guys, we think something is around the corner.” I even referred to some of the science fiction movies and said, “You know, if this happens that street back there is going to be empty”. Half a year later, that was the case. But nobody was interested then, just nobody.

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MEDICUS: While the world achieved many things during COVID, it also highlighted some deep-seated inequities. On top of that, we’re facing an erosion of public trust. How do we go from here to advancing the agenda of bringing health to all?

Ilona Kickbusch: COVID was something new. I would not say unexpected, but countries, decision-makers, virologists, everyone was confronted with a situation in which they had not been in before. We needed to take decisions, and not all of these decisions will be right with hindsight. There might have been better decisions. But the important thing is that this evaluation is a learning process. Like the famous airline example, you analyse what went wrong, and you learn from it. You don’t sack the pilot.

As we found out, we can develop a vaccine in roughly 100 days, you can’t develop trust in 100 days. That means you have to start here and now, and it is a continuous enterprise. Building political trust is a very long-term enterprise. Political parties, civil society and the media all play a role. And here we continue to face a very difficult situation because a major part of the loss of trust was due to the social media response. Do people trust science and scientists? And what was always forgotten, I feel, is do people trust each other. There were these blips, at least in the countries where I live, where people seemed to come together during lockdowns, buying groceries for older neighbours, and clapping for healthcare workers, but that was very short and got lost very quickly.

Involving communities in all of this is critical, and is already starting to be forgotten.

MEDICUS: Going on from your point about trusting your neighbour, sickness and even death used to be common events that people lived through at home, in their communities. But in modern medicine, a lot of it has moved out of the community and into hospitals. So what sort of levers beyond the healthcare system do we need to bring healthcare to all?

Ilona Kickbusch: We need to learn how important health in a much more general way is. As the Director General of the WHO says: we need to move away from the understanding that health is created in clinics and hospitals. He makes the point as the Ottawa Charter for Health Promotion did, that health is created where people live, work and shop, and how they interact with each other. And this is also where our investments need to be to address the big inequalities because as with every health issue, who dies first? It’s the vulnerable.

So, what do we do with these extremely expensive medicalised systems of care that don’t really answer to a lot of the community needs of palliative care, of a death that’s dignified, of taking care of older and chronic patients. It will need enormous reform, and that is partially what the WHO Council on the Economics of Health for All is trying to deal with.

MEDICUS: And that is a particularly interesting committee because it consists solely of women.

Ilona Kickbusch: Yes, we wanted to make female expertise visible, signalling that here are the women you can invite to the councils that you are setting up around the world to diversify the white male face of these committees. And we have seen women on this Council, who were famous before, becoming sought after because they have gained much more visibility through the Council.

MEDICUS: Are you also working differently?

Ilona Kickbusch: Well, we’re definitely working more. It’s a very hard-working group. There’s an incredible spirit of cooperation, a wonderful way of working together, and very intense.

MEDICUS: From your global vantage point, are there any countries that stand out to you for delivering health for all, or are, at least, moving in the right direction?

Ilona Kickbusch: Well, it’s difficult to say getting it right because many of these “getting it right” things are things that these countries did long before the pandemic. They had a healthier population. They had a healthcare system that was easily accessible and reasonably equitable. They had trust in government.

While the global research community came together, it has now become clear how Global North heavy that community was. Where were the Global South Research Institutes? The Global South authors, virologists? They existed, but they weren’t in this network and lacked the enormous resources that the institutes in the Global North got. And that is why the negotiations for a global treaty, for the revision of international health regulations, are so critical because this just cannot be. We cannot punish the Global South as we did when they first reported the Omicron variant. If they find it, we should be highly thankful, and then all work together to respond.

MEDICUS: Can we turn to technology to help us better our systems, so that we can be more equitable and can bring health to more people?

Ilona Kickbusch: The potential is definitely very great. If you think of what some people call digital-first health systems, of all the projects where community health workers gain access to expertise in the capital or wherever through phones for easy diagnostics, health literacy for young people, etc. There’s a great opportunity to use these systems to spread health in that way. Even though in parallel, ill health is also being spread with ads for sugar, sweet beverages, and everything. And so long as we don’t have rules that govern many of these algorithms around false health information, we are really in a very difficult situation.

There’s another side too: the more our health systems are data-driven, the more valuable the data becomes. And we just don’t have enough governance yet to really regulate health data generation and use.

And we always have the problem that we approach it on the one hand with a very individualised mindset. Individuals consent to data, even though no set of data tells a story only about yourself. It always tells the story of all your relationships. There needs to be better data-sharing governance. I worked with The Lancet Financial Times Commission on Governing Health Futures, and we have developed a concept of data solidarity and a call for applying the same set of public health values to health data governance.

And we mustn’t look at health data only. It turns out mobility data are health data, shopping data are health data, and even your values are health data as we now know. This is a very serious business, and it’s neglected in global health governance.

MEDICUS: In Singapore, we’re re-purposing some of the resources and systems that have been built during the pandemic to monitor public health better and support the rollout of a preventive care plan led by primary care physicians. Are those the sort of learnings that we should be implementing?

Ilona Kickbusch: Absolutely. We see, at least in the countries that that I live in, an understanding that we need to learn and reform our systems. But the willingness to invest, particularly in public health, is not as strong as it should be, partly because of all the other crises that need to be solved in parallel. While COVID is winding down, the whole environment and climate discussions are winding up. The part of the world where I live is very much defined by the war in Ukraine and the resources needed, and the ongoing economic crisis. This takes us back to the work of the Economics of Health for All Council, which highlights that much of what is done on those fronts also contributes as determinants of health to a healthier society. But this appreciation that health needs to be in all policies is not really there yet.

And through everything we’ve discussed, the gender issue is prominent. Any issue around the pandemic was incredibly gendered. Either women were more affected or women were the ones who carried the burden. Our Council wants to draw attention to that if we calculate the progress of our societies based on gross national product, then we’re actually excluding an enormous amount of contribution to society, the global good, and public value because what women contribute just does not get counted. And that doesn’t mean it all has to be turned into an economic measure. That’s not what we’re saying. But how do we count the contribution to communities and families and how do we calculate who carries the burden, and who pays the cost?

MEDICUS: It’s clear that we think about health in all that we do, a bit like how we have accepted that all policies have a climate impact.

Ilona Kickbusch: While we have accepted it for the climate debate, we have not yet accepted it for the health debate. Even though the health debate is so much older. But that’s a thing we will need to achieve in our societies.

MEDICUS: Thank you for your time and insights.


The interview was conducted and edited for length and clarity by Nicole Lim, Senior editor. 

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