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IGF 2020 - Day 8 - High-Level Leaders Track: Health Implications

The following are the outputs of the real-time captioning taken during the virtual Fifteenth Annual Meeting of the Internet Governance Forum (IGF), from 2 to 17 November 2020. Although it is largely accurate, in some cases it may be incomplete or inaccurate due to inaudible passages or transcription errors. It is posted as an aid to understanding the proceedings at the event, but should not be treated as an authoritative record. 

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>> The captioning is AI technology, right?  Because this is the future for the platform, right?  We already ‑‑ we have experience at AI.

>> ANJA GENGO:  That is true yes, although we're still Hume.  We have humans there also correcting.

>> Yes, yes.

>> all right.

>> In all languages?

>> Just in English.  So the captioning is only in English.

>> I thought you were doing it.

>> PATRICK LEUSCH: That looks great

 

>> Patrick, it's 9:00 here in Geneva.  That's our scheduled time.  I'll leave it up to you to decide when to start.

>> PATRICK LEUSCH: Thank you very much.  If you're all ready, we can start, I guess.  Okay

So ladies and gentlemen, very warm welcome to this High‑level Leaders Track in the framework of the IGF.  On health implications of the role of Internet Governance in the Age of Uncertainty.  This is the title of this session.  The session aims at discussing roles that digital public policy can have in preserving and improving the global public health particularly in emergency situations.  My name is Patrick Leusch.  I'm the head of European affairs at director general's Office of Germany's international broadcast based in Germany.  The COVID‑19 pandemic has shown that it makes our societies maybe more resilient to global health threats.  We have been fast learners in the past months I think.  The whole health community but also citizens have adopted to very new situations.  And we have seen grown a lot of digital tools also that could have people and health system to manage this crisis.

However, if technologies are explained as ineffective digital policies, these can have a detrimental effect on society.  So I think we are all on the way to something.  And no state on earth, no health system, no operator was really up to see what the digital potential is to manage that pandemic.

My guests will exchange roles on Internet and digital technologies and role to improve people's health on one hand.  Challenges and future of is an interesting point that goes far beyond this specific pandemic, and local and global stakeholder responses to global and digital policy for public health.

These are some of the topics that we'll be discussing in the next 90 minutes.

Here is the leading question for the session:  Could digital be the key to achieving Sustainable Development Goal number 3 of the SDGs to ensure healthy life and promote well‑being for all stages and all this under the impression of the COVID‑19 pandemic. 

So here are our guests.  First of all, let me welcome Mrs. Anuradha Gupta.  Thank you for being with us.  And Kira Radinsky, chairwoman and CTO of diagnostics robotics in Jerusalem which she cofounded in 2017.

She's an inventor and entrepreneur specializing in predictive data mining.  Kira earned recognition after software predicted the first in 30 years outbreak in Cuba.

We have among us Mrs. Precious Matsoso, director of the health rectory science platform at the university in South Africa and also in the World Health Organization director responsible for the development and implementation of the global strategy and plan of public health. 

We have with us Mr. Bernardo Mariano, director digital health and innovation and chief information officer at WHO.  In this role he's responsible for coordinating WHO's digital health vision and strategy for everyone.  Welcome, looking forward to your contribution. 

And last, but not least we have connected to Dr. Anurg Agrawal, director of the Institute of Economics and Interpretive Biology in New Delhi,, India and also of the WHO digital health Advisory Group.  This is a great panel.  And we're looking forward to your insights.  While we speak, I'm asking you to mute your microphones and to keep your cameras on to guarantee smooth running of the digital session.  But I assume you have all become experts in this new normal.  Thank you for taking part in this panel.  Let's start.  In recent times I think we agree that nothing has challenged the health systems as COVID‑19 pandemic.  And many countries were more overwhelmed with a rapidly growing number of infectious cases with high death rates.  And we have witnessed a heroic work of medical workers around the world but also their ‑‑ it's not surprising that many health systems turned to digital very soon to cover these challenges.  Databases created or improved.  Health information systems improved.  And there has been a range of measures that have been taken more or less assuming more or less power and more or less systematic approach.  We have seen how digital technologies have been deployed to help fight the pandemic as a whole. 

What is your experience in this regard?  How have digital technologies helped so far the health systems in times of the pandemic?  Give us an assessment how big is the links and how big is the contribution of digital systems to manage this pandemic.  And I'm turning this question to Bernardo Mariano, director of digital health and innovation and Chief Information Officer of the WHO organization first.

Bernardo, please come in, turn your microphone on and come in.

>> BERNARDO MARIANO: Thank you, Patrick.  Good morning, good afternoon, good evening to everyone depending where you are and happy to be here.  Let me start by saying that we at WHO promote the use of digital health technologies.  And appropriate use I have to say.  Appropriate use means it should be people‑centered, trust‑based, privacy and ethical based, evidence‑based, effective, sustainable, inclusive and equitable well as contextualized to where we are using that technology.

At WHO, I wanted to also say that since the pandemic we have missed a great collaboration across sectors.  We had a good support from our traditional partners on the agencies such as ITU, but also most important from the private sector.  We had good good support from private sector.  But it doesn't need to take a pandemic for us to work in a collaborative way.  We should actually have done that earlier.  Preparedness is key.  If we'd done earlier, we would do much, much better in this pandemic.  Now, how do we ‑‑ how did we ‑‑ what was the experience and how it helped health systems.

Let me take you to three areas.  One which is the people‑centric and the other one which is existing health system but also how to build a stronger health workforce.  So in these three areas, I just want to say that currently we are working with a number of countries us as well as G20 countries to look at how we can leverage on telemedicine to support health systems at national, subnational level.  The technology is mature enough.  But we need to adjust policies of regulations to really leverage them so we're working with a number of countries on that.  But early in the year we had a lot of calls from contact tracing asking us to test, track and tracing was happening and digital technology helped.  So WHO published a guideline on consideration of use of proximities tracking technologies for COVID tracking.  This was a topic that our member states and lots of countries were grappling with.  How can we make sure that those technologies support the current pandemic?  Of course, contact tracing has to be an integral part of public health response.  Because if it is not, then it doesn't add the value.  It doesn't ‑‑ we don't leverage the potential that it has.  But as part of that we also started working with estonia to develop a vaccination as we start thinking on vaccination which currently is the vaccine card for some people especially living in developing countries or the yellow vaccination card is required as others perhaps may not know.  But this is only with adults into vaccination card that keeps coming across borders, so we want digitally enhanced vaccination card.  We want a digital clearinghouse to help countries navigate the myriad of solutions that are appropriate to them on innovation and other areas to try to support and help countries to navigate and manage this pandemic well.

The last part which is strong health workforce.  We fast tracked the WHO academy, the launch of the WHO academy, which is a strong digital component but also we added a number of trainings on our open WHO academy.  So it's open WHO.org which is a learning platform that provides training and 17 different ‑‑ sorry ‑‑ 41 different languages with 17 different topics on co‑individual and has carried 4.5 million users benefiting from that.  So all to say that we've ‑‑ we accelerate these digital technologies in the pandemic.  But we could do better, and we can do much better to prepare for the next one.  Thank you.

>> MODERATOR: Thank you very much for the first insights, Bernardo.  You mentioned a couple points, particularly the people‑centered trust base inclusive.  This is very demanding when you have to cover the world.  So what is the main aspect that you as a WHO organization are seen in this deliverable to people?  Is it more to have same standards from technology bases? Or is it more to improve the political systems in governing this kind of technologies?  You have said the performance of the technology is there.  The lack is elsewhere.

>> BERNARDO MARIANO: Let's recognize that the digital maturity of countries is very important as we look at how do we support countries moving through ‑‑ maturing through the process?  Also we are witnessing a living and digital transmission of healthcare sector.  Within that each of us has a role to play.  And we have an added value to protect and bring to the table.  At WHO we look at how ‑‑ for instance, how to address the interoperability challenges that every country has.  Health is silo'd by tradition.  So digital technologies to leverage them and really use them to accelerate SDGs related to health we need that interoperability to work.  So we have the mandate.  Yesterday they approved the goal of strategy on digital health.  So within that we want to make sure that the investments of digital health and maturity of digital health allow countries to move from the current maturity level to the next one.  So countries at different stage.  But then we issued as well in digital health investment guide, investment implementation investment guide which allow us to say if your maturity is at this level, the investment should ‑‑ the path we want to see the added value a year from now where that maturity is increased from where it was to where it should be.  And if not, we may take action.  So yes we understand that country in different phase.  And we need to work together to ensure that we bring them to a different level that we're all on.

>> MODERATOR: Yes.  Thank you very much.  Let me pick one aspect that you mentioned also and jump over to Kira, as you mentioned, that an interesting point here is the collaboration with the private sector that has been obviously boosted by the pandemic from the public health perspective to increase relations with the private sector.  Kira, as a chairwoman of a startup ‑‑ I don't know if startup is correct ‑‑ but private company, that has been involved very rarely in the management of the COVID crisis, is there any detection that you have on particularly that link from public healths to the private sector where things have moved forward to become a little bit more speedy or a little bit more ‑‑ better the link between the industries?

>> Kira:  First of all, we have been building triage systems for the last two years, the way the system worked, there were training based on historical 76 million historical medical visits obtained from the healthcare system both in Israel and United States.  The system would ask triage questions and predict the urgency of the patient and where in the medical setting the patient needs to be navigated.  The consequence was to reduce the work doctors were doing for years if not centuries.  And what we've seen especially during this pandemic is that this accountability of physicians came to the maximum.  We understand we cannot continue as we started before.  With shortage of 100,000 primary care physicians in the United States alone we cannot just continue training more doctors and assuming they're going to be enough for the growing population.  Until 2030 we're going to have 3.8 billion people without access to primary care.  It means 3.6 hours that people are waiting right now in the incidents in the western world is going to be quickly more than 8 hours.  And it's not a prediction.  It's just a fact because in different locations in the world, this is how long patients are waiting.  And during COVID it became more severe.  You have an entire population in crisis that needs to be triaged almost immediately.  They need to know where to go to the department, stay home, lockdown, what should they do?  There's just not enough call centers to answer everybody.  This is where the contact applications come into place is this okay to actually monitor people?  Do we actually want to monitor all of this clinically?  So what we started doing is extending our triage service, started automating all these processes.  Every time a person needed any interaction with the healthcare system our system would ask the triage questions.  If the system said patients ‑‑ stay at home but most importantly predict for the government which cities are in the very bad.  In other words, differentiations between lockdowns it was at the beginning of the pandemic when we deployed this system.  It was knowing where to send COVID tests because we just didn't have enough.  During the second it was around differential lockdowns so we can make the economy work faster.  I think this collaboration between government and a private sector, the private sector is providing tools for decision making.  It has been accelerated significantly during COVID.

 >> MODERATOR: Thank you very much.  The question was ‑‑ I understand clearly that the effect of your work.  If you had the impression that despite the fact that you have not started working in this sector just with the pandemic but is there from your perspective, is there any learning or improvement in the relations between private sector and public sector in that regard? 

>> Kira:  This is a lot we still need to improve.  Right?  The only thing that a private sector like us can do is provide recommendations.  It doesn't mean that the decision maker is going to follow this.  They have a lot of political aspects that they need to cover that became significant during COVID times that it outgrew some of the recommendations either the private sector or academic center or even healthcare center.  So we need to think at what time do we need scientific knowledge to overcome political aspirations.  This is the main aspiration we saw specifically in Israel that companies predicted that we're debt racing and still not actions taken.  Consideration theories about the fact that there is no COVID; lockdown has not helped.  We even have proves from data from interventions of lockdown significantly caused lower impact of COVID at certain locations.  We as a scientific community, need to also think how we clearly communicate with the governmental agencies to give them this information so they can take action.  In other words, for example it wasn't clear if going back to school is actually causing our non‑deterioration COVID.

Very lately it will show that children under the age of 10 they get COVID two times less than adults.  But still no study shows how infectious they are.  So I still think we need to supply more information, more with speed because it will create less trust between the decision making and private and research community.

 >> MODERATOR: Thank you very much, Kira.  I think that is a very interesting point ‑‑ the relation between politic, science, digital, and relating to trust.  Because as Bernardo also mentioned a couple of questions regarding the use of digital technologies and for health is really the trust, the trust measure.  Both on politicians but also from citizens to my perspective.  Precious, in South Africa, from your perspective, coming back to the question what is your experience, how digital technology ‑‑ sorry, digital technologies have been deployed to help fight pandemic.  So what is your experience in that regard looking over the last six to eight months?

>> PRECIOUS MATSOSO:  Thank you very much.  Good morning, good afternoon.  The experiences that we started, firstly, by having a digital health strategy.  And that was important because we worked hard to make investments.  Investments in making sure that the digital platforms were in place.  There were a number of challenges, and I'd like to start with those.  In that firstly, we're invested a number of years we registered over 43 million patients on our health patient registration system.  Took us quite a while to deploy the systems across the whole country on all clinics.  In fact, you could only deploy this in clinics, not even in hospitals because of the complexities of the hospital systems.  So this is the first step that we took over a number of years.

But as we're ‑‑ you know, doing this, when COVID hit, we had to look at various digital tools that didn't exist.  Like, for instance, we had what you call connect based on our in‑health strategy which was useful in care.  We used this was a platform that was used for information dissemination in that we sort of developed a number of apps.  One was intended for contract tracing.  And I always say that contract tracing must not be techno surveillance which is likely to happen.

Secondly, we also had the tool set that could be used for self‑screening and COVID elated symptoms.  At a population level, we've had the district health information system.  I think it's a system that is used for routine data collection.  And it's used ‑‑ the risk that you've always had over time is that because of lack of interoperability we had multiple systems that developed to each other.  And I think Bernardo referred to this somehow.

But I'm happy to say that all these platforms that were developed over the years have actually come in handy in that we're able to connect all of these.  But it is not just tools that I use for the health systems.  It's also tools that I use for patients themselves.

For citizens themselves to monitor.  To monitor whether they have COVID or not so that they do not, you know, come to our facilities when it's a risk to do so.

But what is happening is that we've also had other tools like ATM pharmacy that have been rolled across the whole country.  And the nice thing about some of these tools that we've developed is that they've actually avoided having people come to the facilities when they don't need to.  For instance, for collection of medicines, they don't have to come to facilities.  The area that we could have done better and, you know, we could have invested over a number of years is on telemedicine.  We have, but it's only in selected areas and areas where I would describe as centers of excellence.  They're not widely implemented, and I think it's a lost opportunity.  For those facilities that have systems in place, it has been very useful to collect data because we're able to see and track patients and to know how well we're doing oncyo individual, for instance, the number of hospitalizations, the number of patients that are, you know, positive and number of patients that have recovered.  These systems were built over time.  And we learned from HIV and AIDS, as you know South Africa has been ‑‑ these have been very, very helpful for us and we've used some of the platforms you know for COVID and took advantage of that.  I want to raise a few points that we need to know.  One, there are too many applications and the risk is that you then get information overload.  Not only information overload but a risk of misinformation.  This sometimes undermines our efforts to contain and mitigate COVID.  So we need some governance frameworks so that we can see what kind of are out there and regulate them and whilst promoting innovation, we want innovation but ensure that it can be trusted and it can be used appropriately and it can benefit society.

So one governance structures are important but we still have infrastructure problems as you know.  Cost of connectivity is a barrier and also interoperable digital health systems and solutions.  Not all of them are interoperable.  And so it's one hurdle we have to address which will have some legal framework and have been implemented and these are intended to do data protection concerns to use privacy and security.  And one thing is to invest in digital skills so that the managements of big data and the capacity to do so exists.  I think.

>> MODERATOR: Thank you very much, Precious.  That was very interesting insight.  What I take is what you said at the end, you need a digital strategy.  You need a legal framework and digital skills and I think we will come back also to the point you're saying that how can we avoid information overload and the fact that there is too many applications which we deal and particularly citizens also.

I'm taking the opportunity to call on participants in the quick session, inspiring session to put questions or comments in the chat or Q&A section that you see on the bottom row below your screen.  They'll forward it to me. 

Anuradha Gupta, let's look further going a little beyond pandemic.  How can digital innovation help to protect health for people in more effective efficient and accountable manner?  We've seen so far we have looked more in the aspects how to manage the pandemic when it's there, when you have to avoid overload or the health system that is all related to tracking for instance orientating people to the right service, the triage questions we had.  But in the more forward‑looking and more forward‑looking terms, how could digital innovation protect from people from now?

>> ANURDHA GUPTA:  Thank you for that question.  Actually, I'm not sure whether everybody is aware that Govi has a massive scale of operations.  We support more than 70 countries in expanding live‑saving vaccination to about 18 million children every year.  So in the countries that with support, there are 80 million children born every year who need to be vaccinated.  And we're looking at about half a billion vaccine shots that are provided to these children because they have to be protected against a range of diseases.  So clearly, you know, these are big investments and big operations.  And some of the speakers actually touched on this whole dimension of private sector and private public sector partnership.  And Govi involves a setup and return of millennium in 2000 as a public/private partnership. And the whole idea was to set up a unique alliance that can leverage the comparative advantage of both public sector and private sector.  And, therefore, we have been able to leverage a lot of innovations in taking immunization to those countries and to those households if it have reached without these efforts. And we have indeed, exploited digital technology a lot as we have tried to do this.  Typically, I like to see that vaccination happens when three Vs come together.  And these three Vs are the vaccine, vaccinator and vaccinee.  You need these at the same time.  If you don't have vaccine, you can't vaccinate children.  If you don't have it, they won't happen.  And the child who has to be brought by the caregiver, so the three Vs have to come together.  And on each 3Vs we have exploited a lot of variety of technologies including digital technologies ‑‑ on how these vaccines are traveling.  And how stocks are being managed and really the level of consumption of these vaccines.  There are some very interesting innovations that we have done.  For example, remote temperature monitoring.   You know, this is ‑‑ so we have data loggers.  And we have temperature monitors that are put in the chain which actually start to send digital messages to managers when there are temperature excursions because what vaccines have to be kept at a certain temperature.  So, if there are temperature excursions, then the potencies of vaccines is lost.  So we didn't have digital things we could actually be vaccinating children but not immunizing them or protecting them because the vaccine could have lost its potency shows these are helping efficiency and effectiveness.  Other on vaccinee, for example, one of the biggest tools is by way of electronic immunization registries because a lot of these countries we work in have very weak health systems but not civil registration of births and deaths.  So clearly the denominator is very unclear.  What is the target population?  The children do not have identities.  So, therefore, what we are trying to do is to set up electronic registries on immunization is health workers absolutely understand who are the children who have to be systematically reached with different doses of vaccines?  In terms of vaccinators, we have invested a lot in scaling up digital technologies for the skills enhancement.

You know, skills are important.  And if vaccinator do not not have those skills ‑‑ particularly as we deploy new vaccines because there are new precautions and regimens that the vaccinators have to be aware of.  So we found this extremely convenient to do capacity building at scale in a much more efficient and effective manner. 

Last thing is vaccinee.  How do we work with caregivers to spur demand?  So one we have lack of demand in some sectors.

We have SMS and things to make sure caregivers are made aware of the benefits of immunization.  But there's also a lot of misinformation, as you know.  We think that good information is the best antidote to bad information and just making sure that we make use of technology to counter false propaganda.

>> MODERATOR: Thank you very much.  From your perspective, what is the point that have deciders all over the world when you look at the global scale, learned first when it comes to the link of digital innovation and digital systems and managing such kind of crisis?  What was the first thing really that triggered people?

>> ANURADHA GUPTA:   I really think it is lack of a sort of opportunity to have a physical contact.

You know.  Because in a pandemic situation, we're increasingly talking about lockdowns and social distancing. One of the things we realized is there was widescale disruption of health services in countries we support.  And actually among health services that were disrupted immunization was the worst hit and that was because of two reasons primarily.  Because there were fears among the caregivers.  Mothers did not want to bring their children to facilities any longer for immunization but also the health workers were fearful of catching infection.  They were also redeployed in many cases.  So, therefore, the whole ecosystem got completely topsyturvy.  And that is what put pressure on the system to start to think innovatively.  And we saw that a lot of digital tools that we have been deploying but which hadn't been really scaled up, you know, in many cases actually were really sort of adopted at a pace and at a scale that was unprecedented.

>> MODERATOR: Thank you very much.

Doctor, last but not least, same question to you. After the intervention of your colleagues and from your perspective, what is the main point where digital innovation will help in the future to make people more resilient to make health more efficient, to citizens, to people?  What is from your perspective, the main point here?

>> ANURAG AGRAWAL:  Thank you, Patrick.  I take the point on how digital is making something physical.  When you vaccinate something, there's a human and you're giving a vaccine and a physical thing.

There's three more levels that you can see in digital medicine.  The most obvious level is the people are still there, there's still a doctor.  There's still a patient.  But the medium of communication is entirely digital in digital medicine.  If you take another level from that there's a patient.  He's digitally connected, but the person on the other end is not a human being.  It can be a check part.  It could be giving answers.  And the last level, which I think we will see very soon, is digital.  The person does not really exist for the healthcare.  It's a ‑‑

lots of vices creating additional image of a person that is continuously being analyzed.  Only when they do find something that is both communicated to the physical world does information come to the physical world.  Each of these is possible.

And in the field that I come from, genomics, for example, digital is not an option.  It is essential.  There is no possible way in which a human being can look at anything and figure out anything.  So the way I see digital transforming health is number one, for example, in countries like India, India does not have the number of doctors per thousand people is less than one.  WHO recommends one.  If we take all doctors India barely hits one.  Otherwise it's less.  Europe, for example, is typically 4.

And in most countries similar to India, doctors are more well distributed.  So you need digital to create the connections.  And if you can use your skill and upgrade their skills, you don't even need ‑‑ simple intelligence of augmentation pertaining basic guidelines into practice that can be done.

You need smart infrastructure.  That's going to change everything.

An example where human comprehension and ability becomes limited and continuation of medicine the ability at least of assistance, and perhaps at some point there is from this stable additional.  At some point we can't exactly comprehend this.  But we run rigorous tests to make sure the system works faster than digital.  There's nothing more scalable.  The most important part is does it work?  And that's something that we're spending a lot of time on in the time to come to make sure we don't get blinded only by the speed and scale.  We also continue to imagine is it really helping people?  And that's only time there.  I'll stop you.

>> MODERATOR: Thank you very much.  That's really a far beyond outlook that you present here.  I understand from your inspective digital could be a solution that the classical health services we know in some countries apply to everyone on earth.  I think that is the background from which you come.

How do you see the trust item that we had several times in the discussion here when you deploy this?

>> That is a phenomenal follow‑up question.  Trust is central.  When the time comes telling doctors what when to do ‑‑ it will come soon ‑‑ and doctors not necessarily being known for mathematical skills are unable to fully comprehend the reason, but they can only see the data showing outcomes.  Trust is going to be central.

Patients phenomenally trust doctors.  Doctors trust hard quality clinical outcomes, control trials that is data related and governance needs to be lean and balanced.  Sometimes you think these words are impossible.  But it has to be.

You have to figure out a way in which data can grow rapidly, trust is high within the system for everyone.  And the only way it comes is transparency.

In my opinion, when everything is transparent, when doctors know the data from the trials, outcomes and they're sure, every step whether by block chains or any method, non‑tempered, original, visible to everybody.  Then that transparency and trust will bring the progress in the field.  So transparency in the end.

>> MODERATOR: Thank you very much.  Obviously, you are really convinced about the vision that you're presenting.  I'm looking at the chat here and the Q&As that are coming in that are more and more.  And they are pointing to two points.  One, obviously, is how to ensure the right to privacy is respected regarding digitalization of health data.  I think that is really a big challenge and that is a discussion on the whole world.  Here in Germany we've had intensive discussion about a simple tracing app which is completely decentralized.  It's not interoperational with other ones.  And even here it was difficult to bring it to the people.

And second one is about the link between the public and private ecosystem.  Because the aspect of commercialization was raised.  And I understand when I look at questions that there is a massive ‑‑ I wouldn't say fear.  But that there is ‑‑ who is driving it.  That is the question.  Is the commercial side driving it or government?  What about civil society?  Who is setting the standards to go forward with digital technology in the health system.  Maybe let's pick one by one.  I'm turning to Bernardo again because I think you mentioned at the very beginning the privacy issue regarding digitalization of health data where is the challenge here, Bernardo?

>> BERNARDO MARIANO: Thank you.  I think for the first challenge really is the fact that digital and health are two different ‑‑ they have two different cultures.  So you have the culture of monetization of data and digital tech.  And you have the culture of donation.

We donate blood.  We donate organs.  And I think it was mentioning that how we conciliate the two extremes in such a way that we add and we bring ‑‑ extract the value that both in this campaign and bring benefits that we all want to see.

So the privacy and data sharing, those are the two extremes where we can ensure that we extract benefit of health data to ‑‑ for health outcomes and also we do not harm people because of health life science.  Do not harm very enshrined in the culture of medicine medical health specialists.

So, from our perspective, what we did and we're doing, we proposed in our global strategy in digital health a framework to regulate for international regulation of health data.  It's a framework that we need to put in place that addresses both the privacy but also allow the digital technologies to leverage on that data to bring those health benefits we are all looking for without infringing on privacy or without infringing on ethical ‑‑ now, our strategies say people at the center.  And to build a trust ecosystem, we need not just private public partnership.  We need to bring academia, civil society.  I think there's a question there as well.  There are other stakeholders that need to be in the discussion.  WHO will be creating what we call a network of networks.  Because today ‑‑ and we have as a culture.  And we have to ‑‑ I mean, I want to dwell on this culture because we are creatures of habit.  Many institutions were created after Second World War and the framework we work was to address the challenges we had at that time.  We have new challenges.  We have digital age.

This is the first pandemic in the digital age.  So we need new rules, new engagement, new normal.

And I think to make sure that there's a trusted ecosystem, we need to bring all the stakeholders together.  So the power of WHO is to bring, create convening element, to bring these different entities in the ecosystem and create what we can all trust.  The framework of regulating health, international health data, a framework to create an interoperability or others.

But we have systems and players that we need to bring together to work in the new normal.  And bring the players that we normally don't interact with even at WHO, our tradition is not interact with private sector.  So we have to step up and start that engagement.  But the understanding that we have two extremes that we need to negotiate and bring those benefits to the public.  Thank you.

>> MODERATOR: Thank you very much, Bernardo.  That was very clear.  Precious to hear your experience the most important thing is that you have a digital health strategy, if I understood correctly.  And you base a lot of things that were set up now for pandemic on the fact that you already have a kind of digital health strategy which gives you a framework to work and new applications for instance to widen the scope.

So, from your perspective, who are the important stakeholders to design that trust in this applications particularly from data protection point of view?

>> PRECIOUS MATSOSO:  Well firstly, I think we need to have the most confidence to increase.  Firstly, we must have digital health governance.  That recognizes that digital health is not just for the health sector.  It must envelope a different ministries of communication, (audio cutting out) and engaged different ‑‑ a sector like we said public, private civil society organization and academia.  But it is not just enough to engage them.  It is also trying to send, for instance, in South Africa what we did when we started our work on development of the digital health strategy, we started with ehealth strategy and mhealth strategy.  And whilst we did that, we looked at all the digital tools that were in both the public and private sector.  We came up with a normative framework to assess all the tools both in the public and private.  It was the very useful exercise in that we could see the weaknesses and the strength from both sectors.

Those systems worked, those that didn't and those that you could build on.  So it was a very useful experience.  But it's not enough to build systems around patients when you don't involve them.  And I agree with Bernardo that whatever systems we develop, they be in the public or private sector must put the patient at the center.  In fact, I don't see patients because sometimes you're not necessarily sick to use the systems.  It is about well‑being.  So there must be people‑centered because when you have patients who are already sick.

So for those who are not sick but need to use digital tools for their own well‑being, they still need to access those digital tools.  So we must make them people‑centric.

And I think this is an approach that we've been developing.  And the digital tools cannot just be for those who work in the health system.  We need also digital literacy.  Digital literacy so that with this people centered approach, those who need to use these tools must also have skills to do so.

Thank you.

 >> MODERATOR: Thank you very much, Precious, for that.

Is there something that you want to contribute to ‑‑ it's an open question to the panel.  Any contribution to this that have been here.

Kira.  I'm looking a little bit to you because particularly the ‑‑ I'm not sure if I'm correct by interpreting the term.  As you mentioned at triage, this is something that, from an ethical point of view, can be seen very difficult.  And we're talking here about our digital systems can take decisions by artificial intelligence that has been mentioned in the couple of times.

So that seems for many, many people very, very unusual potentially dangerous also so who is taking the decisions to do that?  How is the system designed as a former journalist I come to the point?

>> KIRA: Very quickly the concept of clinical triage has been deployed for hundreds of years.  Patients should be treated by urgency.  The problem today is how it's being done.  It's being done by protocol manually.  This is part of the problem in getting healthcare to be streamlined.  Knowing which patients needs to go where is a extremely important for running healthcare system.  Give you an example.  If everybody goes to the emergency department like they do today, we're not going to have enough time for my patients that are acute.  Only in the U.S. there's $200 billion spent on avoidable emergency department visits that could have been handled somewhere else.

However, I do agree with you that, when developing artificial intelligence systems and in general any type of protocol especially in healthcare, you need to think about fairness.  There was a very nice paper published approximately a year and a half ago about the fact that algorithms predicting which patients are unfair to the African‑American community in the United States.  The reason they were ranked lower is they were receiving less attention for medical setting in general and previous 10 years and algorithm identified that patients that are costly at a higher probability of doing preventable in‑patient visit in the future.  It created a full bias in the way the algorithm did those recommendations.

So it's a bleeding edge research topic on how to make the algorithms more fair.  And it's our responsibility as the scientists here to provide systems that are explainable, in other words, that decisions that are not making the decision and to be as transparent as possible and there's several mathematical algorithms to actually ensure the fairness across several subgroups while not hurting performance.  I definitely agree that in clinical aspects you have to understand how to do it correctly.  It doesn't mean that we should not do it because the problem is currently we're losing the fight in a scale.

As was mentioned, it's not far off that we're going to have a system running on thousands of billions of data points and thinking a human can actually do it.  We need to change the way we think and move to a more digital world.  We've already done in finance for example so why not even in healthcare?  It doesn't mean we're not going to have the human touch.  It means we're going to have more human touch because doctors can actually do more face‑to‑face meetings instead of doing administrative work.

A few hundred years ago they were having 200, 400 patients for primary care physician.  Today it's 2,000, maybe 5,000 in some countries.  It doesn't scale.

>> MODERATOR: Thank you very much.  Dr. Agrawal, I'm sure you also have thoughts about this aspect.

>> DR. AGRAWAL:  Yeah, I do.  My first thought is a very, very local context.  If you look at the GDPR in Europe versus laws elsewhere, it all depends on how you perceive health data and its use or misuse.

The reason for privacy is primarily not one of simple choice.  It's one of preventing misuse.

And how you go about handling health data to make healthcare systems better but preventing misuse is a very dynamic level.  To illustrate the point, if somebody was able to download your data and misuse that's clearly ‑‑ however, if your data was to be secure, better able to utilize it.  Procurement results develop better parameters and nobody has lost anything.

I think we are at the beginning of an age of computer science where many things that are possible are not fully understood by the public.  It is entirely possible for your data to stay on your phone and by federated learning for the laboratories that work on the data to get better and better and better so you get a better experience.  There's nothing wrong with it.  Similarly, genomes can be downloaded.  They can stay on the same place.  My intuit probably has the largest collection of genomes in the country.  We will not want to let people download it because you can always crack a genome to some degree to second level especially in a country like India where people are very illiterate because of lack of communities over thousands of years.  But, at the same time, we would want that decision health systems to Indians to become better.  And that's very important.  Why?  Recently we did 1,000 genomes for Indians.  We discovered 13 million new genetic variants not described in any genomic data across the world at that point.  I assure you if this kind of study 1,000 whole genomes is done in Africa,, you'll find another 15 million.

The genomic data is very dominated by white western European determinant in America and western European for this purpose.

And yet you must make this data available around the world.

It should not simply become a point of if you spend a few thousand on sequencing somebody.  I think there's a lot more ‑‑ we must prevent misuse, yes.  We must lock data up so nobody can use it.  No.

I'll stop here for the time being.

>> MODERATOR: Thank you very much.  That's a very interesting point, obviously.  I see a very likely debate here in the chat about these questions.  There was a question on have there already been cases where companies, multilateral organizations and hospitals and communities regarding COVID‑19 investigations of patient data that links very practically to how to secure the systems and then there is also this more ethical discussion about who is taking decisions and where is the interface between human being and digital world.  I think that that is something that is really to shape for the future as we see that there is a big potential in digital technology and at the same time it is entering a space where we didn't expect it maybe so much.

It's quite different to be used ‑‑ to use a mobile phone to check your friends and family or your peers or to see your doctor only on the mobile phone and sending some data to the doctor for consultation.  Very short because I want to move to the next step in the discussion to look a little bit in the future and to start developing some recommendations, some points that you want to give to the community to deal with that challenge.  But one point, again, on trust.

Why you have this experience with vaccination which implies a direct contact?  Tell us very briefly what you see the fact that one must work most if you turn more health services into digital?  What is the point to temper to make that work?  

 >> ANURADHA GUPTA: I think we have to be very deliberate on how we choose to use them.  The value of human interface also needs to be reshifted.  So I think that's the point made by Anrag also.  Whatever we can digitize we must ‑‑ for example, we're doing it dashboards to understand the functionality of coaching, right?  And to the point that Anurag was making, would you argue that countries should not be uploading that data?  Or would you argue that that data is added for global good, right?  That's one debate.  But the second is that the trust that communities repose in front line health workers and their providers should not be underestimated.  And therefore, you know, I think that human intervention and human intervention will continue to be extremely critical.  One thing that I think that hasn't been touched and I is about equity.  So we talked about fairness but I would really want to sort of highlight if we have to make sure that the digital divide that already exists is not exacerbated.

You know?  And that we ‑‑ the pendulum does not swing to the other end and lose sight of the fact that there is highly access to technology and digital technology and that if we are serious about SDG, we will have a, you know, file aspect of leaving no one behind.  That is something that must absolutely be kept in mind.

>> MODERATOR: Thank you very much.  That is exactly the point where I wanted to come now.  We are not equal in our online.  We have discussed that.  Systems are quite set up in different regions of the world.

Roughly half of the planet is still unconnected.  Many are not meaningfully connected.

Most of them in remote areas of the rural areas, digital technologies are not accessible to all and often they're not equally accessible.  And it seems to me that it builds on the situation that we have seen before that many vulnerables that have been vulnerable to other conditions are also vulnerable to digital improvement somehow because that is exactly the groups that we need to connect? 

Now, here's the question:  How to endure digital connection for all and how do we make sure leaving someone behind?  I would turn to a very structured approach now and give you one by one again two to three minutes to give us some very practical points from your standpoint and your experience how we have to make sure that digital health innovation delivers for all and we make sure that no one is left behind.  Let's start with Bernardo.

>> BERNARDO MARIANO: Thank you, Patrick.  I think some panelists alluded that the issue about what we ‑‑ the challenge we have in the physical world and the challenges that we have in the digital world and some leaders are already starting to also discuss and I recognize that we need new rules in the digital world because of the trying to trance ‑‑ the rules in physical to digital are not necessarily working.  From equity I also wanted to ensure that we don't forget the gender equality in addition to health equity approach but also accessibility for people with disabilities as we create these digital ecosystems.  From our perspective, we see it as our role to support countries as they get digital health strategies to make sure those are included.

But I think we ‑‑ today we have a digital divide.  Close to half the world still don't have access to broadband.  So do we work ‑‑ the way we're trying to address that is to ensure that as we promote the use of digital technologies, we also promote the accessibility to those that are not connected by working with the entities that are working on the ground with countries to ensure connectivity.  So we have ITUs.  We have the national governments to ensure that ‑‑ and I think even Precious mentioned it's not an issue of health but of finance and technology.  So I think bringing those entities together to address those multiple challenges but also to understand better, we are in the framework to ensure that we have all the benefits in the center of what we strapping issue in global strategy and digital health where we plan to implement a number of solutions, frameworks, and technologies to ensure we all have the benefits that digital technology can bring.  So yes, we are recognizing that the fact that there's still the world is not equal.  But also we are recognizing that by working with the all levels, even community level because we cannot forget the community health workers that require the skills and the knowledge to ensure that we transcend and create information on digital that we can bring benefits.

So working together is key.  Working together in a different way of that we've been working in the past is very key to ensure that we bring those benefits.

>> MODERATOR: Thank you very much.  Bernardo.  Precious?

>> PRECIOUS MATSOSO:  Yes.  Thank you.  We have to address the fulcrum of inequality and inequity.  And to do that, we have to reset and reform our health system so that we can meet the challenges of digital health advances.  As we do that, it must be with the explicit purpose of improving access.  And ensuring that regulation safeguards are in place.  Now, in resource constrained settings, the investments in human capacity development are important.  They're important because they need to match this digital revolution.  What Anurag was saying in countries where the basics are needed, we need to ensure that you can benefit from both high‑tech technology and the basic day‑to‑day things that can help us improve access to quality healthcare.

So this must ensure that the health system is transformed.  The health system, as we know it, it must be transformed in such a way that service delivery is improved.

But it must be done in such a way that the users of services are empowered.  They're empowered to manage and monitor their own health.

So that they do not run to large facilities for every small health problem.

And if this is the case, it must help us reduce costs and ensure that health is affordable and accessible.  But that extension of services is also for the benefit of those who are in remote settings.

Those that are in rural environments.  It cannot be that when you have a particular address then it is a access and geographic location must no longer be a barrier to access.  So we have an opportunity to improve our outcomes and an opportunity to improve the effectiveness of our patient management with these digital decision tools that refer to that area.  Of course, this will improve our targets for the SDGs and SDG in 2030.  Thank you.

 >> MODERATOR: Thank you very much, Precious.  Let me point a little bit on this.  I ‑‑ do I understand you correctly that your hope is that with digital technology if you organize the skills you can overcome the injustice and access to health services.  That is your perspective?  While, when I understand Bernardo correctly, he's fearing a little bit more that digital health ‑‑ digital health based services risk to mirror the circumstances that we have from the physical world and are not necessarily overcoming this injustice.

If I'm correct, there is a risk of mirroring if you're not looking at the whole infrastructure in the country.

I know, Anudhra, I'm hunger to you now.  Which side do you have a little more, to Bernard or Precious.

>> This is something here because we're working on understanding inequities immunization.  And we've been trying to study why 11 million children in GOVI supported countries do not receive a single dose of the most basic vaccine.  And for that we call that child zero dose child is actually an acute marker of inequity, and you would be surprised by what we discovered.

You know what we discovered was that contrary to this popular notion that these children are living in remote areas, you know, it is all about delivery.  Actually, a lot of them are living right under the nose of the governments and capitals in urban slums.  And a lot of these children actually existed in every village and every town because, actually, the barriers that are operating, you know, against access to these populations are embedded in poverty.   You know, 2 out of 3 zero dose children live in households that subsist on less than $1.90 a day.  So there's a connection again extreme poverty and zero dose children.

Ethnicity is a big barrier.  And then gender barriers.

You know, because the mother is not educated, mother is not empowered.  So there are complex predictors and stratifiers of these inequities.  So my first humble plea here is not to synonymize inequities with geographical locations which are difficult to access.

Now the next insight I would want to share is, therefore, it is possible for us to actually use big data and artificial intelligence to try and ‑‑ very complex data sources to understand where exactly these marginalized populations live and what exactly are the latent profiles.  Why is it that they're missing all those?  So it's not ‑‑ this is not directly linked to connectivity issue on the issue or challenge of digital domain.  We can still use our leverage technologies to improve access for marginalized populations.

And the last thing I would say is that you know the level of technology that exists in some of the remotest areas that is not connected is highly variable.  So we really,, therefore, have to think about differentiating and contextualized approaches.  For example some of the countries we found that the use of mobile phones could actually access the gender divide because women did not have ownership of mobile phones.  Some other context be found ‑‑ there was high ownership on the part of women, of mobile phones.  So I just think that just retaining that ability to actually study habitation by habitation community by community some of the barriers and then making an intelligent sort of decision about how do we leverage technology would be extremely important.

>> MODERATOR: Thank you very much.  Very good example.

Anurag, again, how to ensure digital healthcare delivers for all.

>> ANURAG AGRAWAL:  Thanks.  I'm going to start with a comment for the most precious comment today was made by Precious and how do you keep from unnecessarily visiting healthcare systems?  That is absolutely critical in most systems.  In India the average time for a patient to be seen by a doctor is under five minutes.  Of that 50% of time is in prescription refills and basic measurements.  You want to extract the maximum value of every time, every patient, spends with an experience the medical personnel and minimize the wastage of time otherwise.  So you must allow people with non‑specific complaints to get advice in their own houses or community such that numbers of doctors.  You must enable the system with digital health codes they have to be built by the government.  How the government will pay for them is a question I leave for smarter people like Bernardo.

On the other hand, after these basic health services are taken care of and internationally we have to find models, on top of it you need the private sector to create innovative ecosystem for more and more high quality products.  So I see both Bernardo's vision in the end there will be high cost differentiated products not available for everybody.  Whether you stay digital or not.  I don't know.  But essential good services should be available to everybody by public distribution of goods and commitment towards making sure that basic medical advice can be given to people without having to leave their houses, without having to waste time in which they could have gone.  Huge number of people get into poverty because they're unnecessarily going around all over the place wasting ‑‑ getting answers that could have come to their houses.  I'll stop here.

>> MODERATOR: Thank you very much for this contribution, particularly on this human interface that you're mentioning.  I could share from Germany that the impression here the study between patient and doctor you see many, many visits are from a health perspective, obsolete.  It's more obviously a social thing.  So it's more kind of to have contact which applies obviously to many elderly people that are doing kind of doctor hopping also.

And that is filling the waiting rooms and that is challenging the system.  But on the other hand it's needs.

But the question is there ‑‑ is it the right place to fill that need obviously?  Thank you very much and very interesting point I think.

Kira, how to make sure that digital healthcare delivers for all?

>> KIRA: I'll touch on several points.  One is there's algorithmic methods showing that an AR algorithm is fair.  But I think let's talk about virtual care.  Actually brought the notion democratization of healthcare, everybody can get a doctor no matter where they are and which home they live to get the best doctors to where they are.  The problem is access.

Even in virtual care, 75% of the population even the western countries doesn't know they have the possibility of using virtual care.

And I'm talking not about poor people.  Most people just don't know they can have this.

So we need to work a lot about education around this.  Maybe this would be part of the education in school.  As virtual care at least once, know that you have the possibility of using something that's going to change your life dramatically.  Number 2.

And number 3 is education even for physicians, physicians at different countries have different education times, different training.  And I think building decision support systems across all the data in all the world in the best institutions and giving access to those decision for systems for physicians during training an other countries is going to help us supply the knowledge in a much more equal and fair way.

>> MODERATOR: Thank you very much.  That's very clear.

So last step in our panel ‑‑ I'm asking you to be even more concise than you have been in your contributions so far ‑‑ now when we look at what we have said, what would be the policy message or the concrete action point or recommendation that should come out from that panel when we look at the points that we have discussed before?

So I'm really looking at the clock now.  You are all very experienced in shaping policy messages or knowing what one should do and what would be the message that comes out of that panel to challenge what we have ahead of us to make match the digital world and the health world for best purpose for best purpose for the patient.  So what is what you want to see on the document when we close this session here?  Anurag, starting with you.  Max one minute.

>> ANURAG:  Okay. Digital health is not just usual health.  It requires a comprehensive strategy that takes into account local consideration, infrastructure and goals.  Each country should have a national health mission subject to its own preparedness in a digital world and health needs of its populations.  And I'm glad to see a mission.

>> MODERATOR: Thank you very much.  Very good point.  Anudhra.

>> ANUDHRA:   think a good healthcare delivery has to be applied and focus now followed by efficiency and accountability.

And digital health actually is an enable letter and we have to stay ‑‑ enabler and we have to stay focused on these objectives and exploit digital health technologies to allocate resources much more prudently and equitably to make sure that we actually leave no one behind and we constantly improve the quality of services that are provided to population at large.

>> MODERATOR: Mm‑hmm.  Thank you very much.  Kira?

>> KIRA: So in addition to all the topics we raised about equality and better collaboration between government and private sector, I want to raise the concept of data sharing.

I think on a global level, if they would have shared data from medical conclusions that made during the pandemic we could have saved more lives in the country.  I think getting to a point we have shared resource or all researchers can work on the same data, all government have visibility even to other countries can bring lots of healthcare and treatment.

>> MODERATOR: Thank you very much.  Very interesting point I guess.  Bernardo?

>> BERNARDO MARIANO: Thank you.

I think from a key recommendation will be for certainly to reinforce some of what the other panelists mentioned is every country should have a structure ‑‑ a digital health strategy.  With that strategy we shall address a number of issues including health data, interoperability, and equity and all others such as ethical and privacy that was mentioned.  So that's first thing. 

Second, each country needs to understand before the country is in that ‑‑ in the digital health and maturity.  So ensure that the third part that the investments are addressing ‑‑ taking that kind of maturity from where it is to the next level.  So my understanding that the maturity of the country in digital health implementation use the digital technologies, then we can drive investments into appropriate areas to enhance that maturity. 

And last, but not least, is that the digital health or digital ecosystem requires a constant improvement and enhancement.

10 years of digital technologies is equal to 60 years of human life.  So let's make sure that we do not create strategies that are sitting there for 10 years and five years thinking it still work, if a country developed a strategy five years ago, it needs to develop a new one.

>> MODERATOR: Thank you I. think this strategy must be ‑‑ if I have gained any understanding of change that has occurred by data in our world so it's more like you know, design thinking process than having a five year strategy.  I have to understand that.  Okay.

The last, but not least, Precious.

>> PRECIOUS:  Yes, we need good digital health governance and improved access.  But of course for that to work, we must invest in human capacity development.

So that we can match the digital revolution and ensure that you've got a sustainable infrastructure that is expandable and maintainable.

It's not good to just say infrastructure.

It must be expandable and maintainable.

Thank you.

 >> MODERATOR: Thank you very much.  You made very, very, very clear points I guess.  And I'm looking at what you have said earlier.  And I think these six recommendations or points that you've raised is really at the key of the challenge.  I particularly took in mind a subtopic that ‑‑ or a kind of crosscutting issue that was skills.

Skills on all levels to know more about how digital healthcare, digital systems can work, what it can do.  And skills is not only to know ‑‑ to manage them but also to understand how they work which is linked to transparency that was mentioned several times.  And Anurag also said if the systems are transparent.  Kira came in in the same point that is very important.  And somebody said digital list receipt which, obviously is a challenge in many sectors but I keep this is really key when it comes to health because as Bernardo said, we are ‑‑ we are bringing together here two very different cultures when he said that on one hand the ‑‑ the health, very much is based on relations between humans and on the other hand you have digital world and he described how far from culture they are one from each other that was for me a very interesting point when he said that is something that we barely need to address how do we make that match for any operator for any people that is dealing with it, be it in the role of a doctor or physician or scientists or in the role of a patient and even in the role of governance.

I would like to thank you very, very much for that very, very inspiring high‑level panel. 

Thank you very much for your time, for your contributions.  All this is recorded and will stay on the YouTube channel of the IGF on the UN web TV from what I understand.  You also can follow the chat.  

Thank you all for your questions.  Your remarks that are in the chat.  Some of them we could address and others are self‑explanatory and interesting to see because you can see what people think about this very, very complex topic.

I would like to thank the organizers, the team behind it.  And have a great day wherever you are.  And I hope that the next IGF, despite the fact this is very interesting format ‑‑ I really hope that the physical aspect will not completely drop out in this pandemic and while have the chance to meet in person and discuss this further as we'll keep really the topic will really be kept on the agenda.  Thank you very much.

 

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