Anja Schiel is a Senior Adviser & Statistician at the Unit for Health Technology Assessment (HTA) and Reimbursement, Norwegian Medicines Agency (NoMA). At the EHFG, she gave her perspective on “Making real world data real” during a workshop under the same title about improving regulatory approval of new therapies.

According to the World Health Organization, HTA is the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organisational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform policy decision making.

ER: What was the key message of the workshop “Making real word data real”?

AS: My message would be that drug development is complicated but there are new ways forward that are promising. In my opinion, we need to find good ways forward that ensure that we do the right thing and not fall for a hype. Sometimes we tend to think in isolated silos, but we have to listen to everybody who is involved if we want to succeed. For example, a solution that works for one stakeholder, like the regulator or the HTA agency, may not be a solution for patients or clinicians. This is the main reason why in the last ten years there has been an increased willingness in improving cross-stakeholder communication. We heard about the IMI project in this session [The Innovative Medicines Innovative (IMI) EHDEN project which aims to build a data network that allows access to data of 100 million EU citizens, standardised to a common data model].

I strongly believe in this project, because we have never witnessed such strong communication between different stakeholders. Even industry representatives have experienced it as a forum in which they can talk with each other at a very different level than ever before. And even the HTA agencies and the regulators have a much-improved understanding of each other’s work and perspectives. It is key that one doesn’t have to align everybody but one can at least understand each other’s needs better. And because of that, one might actually change one’s own behaviour and have other decision-makers in mind when giving advice or deciding on something.

AJ: Do you think that patients should have a bigger role, for example, by having an actual seat in the decision-making process at the European Medicines Agency (EMA)?

AS: Actually, the EMA currently runs a huge project on patient involvement. In the past, there was none and the EMA was criticised for that; now they are trying really hard to improve this. In particular, in the scientific advice process with companies in an early stage of product development, it is nowadays quite common that patient representatives are present at the meetings. It is very similar to NICE appraisals meetings, where there are always patients present. This also depends on the countries: for small countries, like Norway, it may be hard to find a patient organisation. In that case, you need to find someone who is willing to look beyond their own perspective and represent the patients as a group and not only their own disease-specific perspective. However, when you are patient it is extremely difficult to take on a group perspective.

The healthcare system has acknowledged that once you are diagnosed with something serious, you cannot be objective. No one would expect you to be objective in that situation. Our main task is to ensure that we do not pose questions to patients that are actually unethical to ask, like making a decision between A and B if both are unacceptable because they may be unsafe. We have a huge responsibility in protecting patients from these situations, which were common fifty years ago when patients were left alone in desperate situations. We really must prevent patients from having to make desperate decisions, because in these circumstances decisions can never be educated or objective.

AJ: Do you think there should be more room for the emotional perspective of patients? After all, it is their unique perspective on things.

AS: The unique perspective is actually quite often reflected when we talk about measures of success in a trial. Patients can explain to us what a relevant endpoint would be for them, whereas clinicians tend to measure things that are easily measurable and objective. Patients can bring in the perspective on what is relevant to their everyday quality of life. This is also a huge difference between HTA agencies and regulators, because for HTA, taking into consideration the quality of life is absolutely essential, whereas, for the regulatory side, it is more about an objective assessment of whether the risks outweigh the benefits.

This interview was conducted by the Young Gasteiners Elena Roel (ER) and Arjan van der Star (AJ).

As the Director of the Division of Non-communicable Diseases and Promoting Health through the Life-course, Bente Mikkelsen focuses her work on achieving the SDGs through the reduction of premature deaths from NCDs by one third before 2030, promoting health, and through impacting at country level in the context of the WHO General Programme of Work. WHO co-hosted the session “European alcohol policies – rethinking and strengthening implementation” at the European Health Forum Gastein 2019, which was organised together with EHFG, EU-HEM, MCI Management Center Innsbruck, IOGT-NTO and International Youth Health Organization, and supported by the Republic of Slovenia.

JK: WHO co-hosted the session “European alcohol policies – rethinking and strengthening implementation” at the European Health Forum Gastein 2019. Why does WHO prioritise this particular topic?

BM: Worldwide 3 million people die from alcohol consumption every year, in Europe, it is 1 million people. It is one of the biggest causes of premature death, especially among men and the youth. Alcohol is a risk factor for cardiovascular diseases and cancer and causes a lot of ill-health. Reducing the harmful use of alcohol as a risk factor for NCDs (non-communicable diseases) is a very important priority in the WHO European region of 53 countries.

JK: In how far is there a need to “rethink” the implementation of policies?

BM: First of all, I think that the policies we have in the region, under the WHO European Action Plan for reducing harmful use of alcohol, are already fairly good. We have had three consultations this year – one with the Member States, one with multi-stakeholder organisations like NGOs, and just this week (1^st week of October 2019) we had a consultation with 35 Member States in Prague. It was confirmed that what we call the WHO “best buys” are still the “best buys”. This is confirmed scientifically; the measures are proven to be affordable and really effective.

JK: What are the WHO “best buys”?

BM: The “best buys” is sort of a buzzword for cost-effective policy interventions. In the whole area of NCDs, we have 88 defined interventions and 16 of them are labelled as “best buys”. It is about banning or restricting marketing, pricing and taxation, and reducing access to alcohol, and it is about. This is the winning strategy if you want to protect the population against harmful use of alcohol.

But we can see that industries and retailers react to these strategies. For example, they can adjust to tax increases by reducing their price and consequently the price for the consumer is still the same regardless of the tax. Therefore, we need to refine the policies and interventions in place. Even if we have the right tools, we are not able to scale up the implementation in all countries in Europe in order to improve the health of the population.

JK: You mentioned that the ones who suffer the most are men and the youth. Do you think there is a gendered dimension to harmful use of alcohol?

BM: 1.5 years ago, the WHO European region put forward a “men’s health strategy”. This was done because we could see that we are generally doing well when it comes to the reduction of premature deaths – except for men. We see that so-called masculine lifestyles are unhealthy, as men take a lot more risks, they drink more, they smoke more, they do not go to the doctor, they are not health literate, and they underuse the health system. So, there is certainly a gender difference on the use of alcohol. And if you add drink-driving you have yet another component. We know that in the WHO European region, one in every 5^th death in young people is attributable to alcohol consumption, namely due to injuries; the most important category is road traffic accidents due to drink-driving.

JK: What needs to be done?

BM: I think we need to scale up the implementation of the tools which we then call the “best buys” the “good buys” and also the “buys”. And we have figures on how impactful they are on mortality and on DALYs (Disability Adjusted Life Years). We are looking more and more into the lifestyles, and we start with health literacy at an early age. We see that we have to regulate social media and advertisements much more, because the youth is being bombarded by unhealthy choices via these channels. And through the life course, we have many different options; we can work with kindergartens, schools, workplaces, and also cities quite easily. At the national level it always takes very long to pass legislations etc. while on city level you can implement measures much more quickly. And also, we have to follow very closely how the commercial sector is acting. Unfortunately, the alcohol sector is also learning from the tobacco sector and many of the already identified tactics used by the tobacco industry are now also being used by the alcohol industry, as already documented in several scientific publications.

JK: In how far does WHO collaborate with the industry to work on these issues?

BM: In the context of alcohol it is not really a partnership. We organise ourselves at WHO under what we call the “framework for non-state actors”, used to assess conflicts of interest or perceived conflicts of interest. For example, accepting funds from an alcohol producer, even if it is a very small amount of money, can be perceived as a conflict of interest. It is very important to note that our interaction with the alcohol industry should never lead to or imply “partnership”, “collaboration” or any other similar type of engagement that could give the impression of a formal joint relationship, the reason being that such engagements would put at risk the integrity, credibility and independence of WHO’s work.

JK: How is the “framework for non-state actors” organised?

BM: WHO holds dialogue meetings with the umbrella organisations for alcohol producers. The nature of this interaction is limited to dialogue and exchange of information for achieving positive outcomes for public health.

JK: This year’s theme of the EHFG was about disruption. Can you think of a disruptive way forward regarding harmful use of alcohol?

BM: I think the disruption lies in the way of implementation rather than in the actual tools we are using. Just now we published a case study from Russia. What we can do is use more nuanced instruments, as for example models for differentiated prices according to the drinking patterns. But I would call that refinement. I think the disruption is more about how to mobilise the population so they actively request from their governments to be protected from alcohol.

JK: Alcohol consumption is also very much of a cultural practice. How can social norms be changed? Does it need disruption or will change occur over a longer period of time?

BM: It is said that drinking alcohol is part of a larger European culture, and this is also why we (Europeans) are the biggest consumers of alcohol in the world. Nowhere else is alcohol used to that extent. And of course, alcohol marketing is aimed at reinforcing these so-called “cultural practices” that sustain high levels of alcohol consumption. Unfortunately, I do not think it will be possible to change this immediately but we know that social norms can be changed. I think there are countries that want to protect their youth by waiting longer until alcohol is accessible to them, like in the Scandinavian countries, where you have alcohol monopolies, for example. I think it is probably a bit of both (disruption and change over time), because we know what works but we just have to do it.

That said, one of the big misconceptions is that one glass of red wine protects your heart. But we have proof that this is not true at all. So, there is absolutely no health in any one unit of alcohol. If we are at least able to present science in a good way so that people can take healthy choices, then this is the way forward. And maybe this is a slow way, but it is still the way we need to go.

You know when we went to this consultation in Prague, we only had non-alcoholic drinks. For the first time, there was non-alcoholic champagne, wine and beer. We can see that producers are also refining the taste. You would not have guessed that there was no alcohol in it. So maybe that’s some disruption?

JK: Imagine the EHFG in 10 years from now with yet another session on alcohol policies. What would you like to see there?

BM: I think we need a Greta! (referring to environmental activist Greta Thunberg). We need somebody who really understands the harm of alcohol. And maybe then we will also see a lot of youth mobilising for healthier lives, where alcohol is not included. We already see a steady decrease in consumption. But in the end, we are not talking about a full ban on alcohol, but we clearly say that “less is better”.

The WHO “best buys” to reduce the harmful use of alcohol [1]

Increase excise taxes on alcoholic beverages

Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media)

Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale)

[1] World Health Organization (2017), Tackling NCDs – “best buys” and other recommended interventions for the prevention and control of non-communicable diseases, www.who.int/ncds/management/best-buys/en/

The interview was conducted by Young Gasteiner Johanna Kostenzer, Marie Sklodowska-Curie Postdoc Researcher at Erasmus University Rotterdam.

Paola Kruger, Patient Expert, European Patients’ Academy – EUPATI Italia

Patient expert Paola Kruger contributed to the event “Medicinal use of cannabis and cannabinoids: is the grass always greener?” that took place during the 2019 European Health Forum Gastein, bringing the patient perspective on this important issue. 

AC: First of all, for those who aren’t familiar with your organisation yet, could you briefly explain what EUPATI is?

PK: EUPATI started as an Innovative Medicines Initiative (IMI) project several years ago and is currently run by the European Patients’ Forum. In a nutshell, the aim of EUPATI is to train patients in the R&D of medicines in order to bring their expertise of the disease into the development of medicines in a meaningful way.

AC: What are the key takeaways from the discussion we had today on medical cannabis?

PK: There are clearly two dimensions in the discussion about medicinal cannabis. The first point is about patients with an unmet medical need who support the use of medicinal cannabis as this can benefit them. The second point is related to its impact on society, and especially young people.

As a patient, but also as a mother of two teenagers, I am concerned about both dimensions. In my experience, young people are exposed to recreational cannabis daily and aren’t fully aware of the risks. We need a Europe-wide communication campaign for young people to raise awareness about this. We need to find a balance between these two dimensions so that we can bring them together.

AC: What is the patient perspective on this issue? Does the patient community have a unified view on medical cannabis?

PK: Very much so. Even if there are some exceptions, the majority of patients recognise that there is a big unmet medical need in a number of different therapeutic areas. When I posted on LinkedIn that I would go to Gastein to speak about this issue, I received plenty of messages from patients that would like to see more medicinal cannabis therapies brought into the market.

AC: As a multiple sclerosis (MS) patient, have you ever benefitted from medicinal cannabis yourself?

PK: I have a very stable form of MS so far, which hasn’t required me to use it. But I know many patients who find it beneficial. We can argue why or if it is just a perception, but if patients say that medicinal cannabis makes them feel better and stops them from having pain all day, it’s important that these patients can access it.

AC: When talking about medicinal cannabis, do you consider medicinal products based on cannabis and cannabis preparations being on the same level?

PK: Absolutely not. Medicinal products have gone through a rigorous path of testing and scientific evidence gathering, which means side effects are reduced to a minimum and monitored. Patients should have access to both, while we wait for further access to such therapies and further scientific testing.

AC: What policies at national and European level would patients like to see promoted on this issue?

PK: Leaving the potential negative outcomes to society aside, from a patient perspective it is key to enlarge the number of patients that can access medicinal cannabis through the increase of therapeutic areas covered. To do so, we need more testing and we need to include the voice of patients to see whether and when hard evidence is coupled with the patient perspective.

The need to get the patient perspective on board throughout trials is especially important as we talk about symptomatic medicine. This is something we need to do in a systematic way. We have the means to do so through the development of Patient-Reported Outcomes.

The interview was conducted by Young Gasteiners Andrea Corazza & Kira Koch

Interview with Nikolai Pushkarev, policy coordinator for Food, Drink, and Agriculture at the European Public Health Alliance (EPHA)

The theme of the European Health Forum Gastein 2019 was ‘A healthy dose of disruption? Transformative change for health and societal well-being’. Right after the Friday lunch session ‘We are what we eat – the power of a healthy gut and disruptive nutrition policies’, Young Gasteiners Camilla Hende (Scientific Officer at The Norwegian Medicines Agency, Norway) and Joreintje Mackenbach (Assistant Professor at Amsterdam UMC – Vrije Universiteit, the Netherlands) interviewed Nikolai Pushkarev who leads EPHA’s Food, Drink, and Agriculture campaign which advocates for evidence-based policies to reshape the European food system towards better health and well-being. The lunch session reflected on the ways in which an unhealthy diet influences our gut health and other chronic diseases such as obesity and type 2 diabetes, alternatives for antibiotics that do not harm our gut, Israel’s reform of their nutrition policies, and Nikolai Pushkarev’s views on where European nutrition policies should head off to.

JM: We would like to ask you a couple of questions about the session and your vision on European nutrition policies in general. First of all, how did you like the session?

NP: It was very good. There was actually quite a lot of alignment between the various speakers. And: the right type of alignment! [referring to the need for more regulation] But there is always the issue that debates around diet and nutrition policies – outside good sessions such as this EHFG session – often focus on individual responsibility. But that is not supported by evidence, and you end up stigmatising people!

JM: So, do you think that we should have had different stakeholders present in the session? To have more of a debate? Was this preaching to the converted, in a way?

NP: I frankly don’t think you can preach enough, because the health community is really not that homogenous. In this panel, we were more or less thinking in the same direction, but that is not always the case. Quite often you see a focus on themes like personalised nutrition and tailored interventions, rather than society-wide approaches. That is an entirely different perspective. And in my point of view, that is really problematic. Not because such a focus does not have any benefits, but it should not be the starting point. We need to start from the binding elements: the living environments, the food environments. And then, of course, you can go down to all kinds of granularities and fine-tune the system.

JM: What is the main message that you wanted people to take out of this session?

NP: That this is a collective issue. And that we need to act collectively on this problem.

JM: I thought that the examples from Israel were quite interesting, and encouraging as well, to see that the implementation of such policies [taxes, regulation of marketing] is possible, at least in a country like Israel. What do you think us Europeans can learn from their approach?

NP: Obviously, what they have been doing is super, and entirely in line with the WHO best buys and other recommended interventions. They have been following the WHO ‘best buy playbook’ in a way, and anyone can do it. Maybe it would be good for policymakers to ask Israel what they have been doing to overcome the barriers. As that is the fundamental thing: overcoming barriers.

JM: So, what do you think the barriers are which explain why we haven’t implemented these policies in Europe?

NP: Commercial determinants and governance mainly. The industry will not be happy about a number of these policies. And it is essentially in their long-term interest, but not their short-term interest. The industry also continues to argue that they don’t need regulation because they will solve it themselves. But obviously, you cannot give private companies the responsibility for public health. Because they are not made for that – they are made for making money, which is fine as that is what companies do. But then you cannot put them in the driver’s seat for these issues of public interest.

JM: Do you think that one barrier could also be that Europe is not united enough in dealing with the industry?

NP: Yes, that is an issue. EU institutions don’t tend to take the commercial determinants of health seriously enough. In terms of Member States, some do not want to act in certain areas, while others would like to, and some only want some of the policies and not others. There are some isolated initiatives, but it is rare to have a comprehensive approach. Perhaps some of the WHO best buys can be phased in at different times, but you really need a comprehensive food strategy. An interesting recent example is the Public Health Alcohol Bill which has been adopted in Ireland. This bill takes exactly this approach: implementing different strands of the strategy at different speeds, but you can see that it is well designed – there is an all-encompassing vision.

JM: And how would you describe the change in European nutrition policies in the last decade?

NP: (laughs) Well, the issue is that in the area of nutrition there is not a lot to speak about. At least, if you really look at regulation. Of course, you have the Food Information to Consumers legislation, which was a good thing. That didn’t involve FOP labelling, which is now entering the debate quite seriously: whether or not we should have a common European system. So that’s a good development. And another big thing has recently been around trans fats, which have now nearly been banned. I would frankly say that these are the two highlights of the last decade. There may be some other things, such as the school scheme of DG Agriculture, but these are more funding mechanisms. And of course, there are lots of things that are being done, but if you look at impressive legislative developments, I can essentially only think of these two.

JM: So, no disruptive changes?

NP: No, definitely not.

JM: Do you see any disruptive changes happening in the near future?

NP: I see it through this ‘food policy, food systems’ approach, and more concretely the ‘farm to fork’ strategy for sustainable food promised by the Commission. The nutrition debate is being rejuvenated through discussions about climate change. For example, there is really no question that we will be able to eat the amounts of meat in the future that we are currently eating, so this frames the debate from the perspective of how you replace meat. Eating healthier requires these healthy food environments which has triggered a change in the debate about climate change. And of course, obesity and other non-communicable diseases are also triggers, but these have been around for much longer. I think climate change will really be an additional push for the debate.

JM: Do you think an issue like multidrug-resistant bacteria is something that could be a trigger for change?

NP: I think that is definitely a contributing factor because it also links to the livestock debate. I think it is still not entirely clear whether you could have very intensive livestock farming while using significantly fewer antibiotics. For instance, in the Netherlands and Denmark, they continue to have quite intensive farming systems but have reduced their use of antibiotics by half.

JM: But it sounds as if some of the nutritional policies could tackle a multitude of problems, like obesity, our gut health, antimicrobial resistance, climate change, etc.

NP: Definitely. And that is what the co-benefit argument is about, that you have these synergies. It is really all connected; eating more plant-rich diets is better for many things. And I would also argue, given all the passion around animal welfare, that this is an issue we could tackle as well. For example, if we want the cows back on the pastures, we really need to eat significantly less meat.

JM: It seems like we need a lot more change in the upcoming decade. And I think you would argue that we need to advocate much more for such a systemic approach towards these linked issues?

NP: Yes, indeed. But the fact that we need change couldn’t really be more obvious, because we are heading into a disaster from an environmental, nutritional and biodiversity point of view. And we still have a very politically correct way of talking about it. What we are heading towards is really a crisis. So, what we are doing currently is disproportionately low.

JM: Thank you. Is there one last thing that you would like to add?

NP: Yes, maybe I would like to add that we shouldn’t be afraid of regulation. Because that is the single most effective way to create level playing fields for the industry and for people. And that will allow us to move forward much more quickly. But it seems like we are always speaking about regulation from the point of view of those who would be regulated. You could also say: well, actually, regulation is protection. It is about creating the conditions to ensure that the aspirations most people have – to lead healthy, fulfilling, creative lives – are enabled, not stood in the way. But the mere fact that we use the word regulation implies a feeling of punishment. For me, it would be a liberation if there was no more marketing of junk food. For some, it may be a restriction, but for others, it will be a liberation. We should be careful about our wording because words are often loaded.

JM: Yes, that’s a great point. As public health scientists and policymakers, we should really be the ones determining the narrative.

NP: Yes, perhaps we should draw up a list of words that we should no longer use, or at least provide alternatives for. For example, the term ‘lifestyle’ sends me reeling, because that implies that everyone just chooses their own way of life.

JM: Yes, as if it is a style reflecting their preferences.

NP: Exactly. It entirely fits the narrative that wants to place all the burden of responsibility for health on individuals. It is as if every individual very rationally decides what lifestyle they will adopt, which is of course untrue.

This interview was conducted by Young Gasteiners Camilla Hende, Scientific Officer at The Norwegian Medicines Agency, Norway, and Joreintje Mackenbach, Assistant Professor at Amsterdam UMC – Vrije Universiteit, the Netherlands

Interview with Dr Hanna Tolonen (Finnish Institute for Health and Welfare)

In the framework of the EHFG 2019 workshop on ‘Facts. Figures! Fiction?’ Hanna Tolonen introduced the EU-funded INFACT project, which attempts to streamline health information activities across Europe. I spoke with her about the challenges of establishing sustainable systems in the age of technological revolution, priorities of European public health, and key lessons Young Gasteiners should take away from the European Health Forum Gastein.

MZ: It was great to learn from you about the challenges you face in Finland when it comes to data integration and also about the research infrastructure initiative prepared by the INFACT project. Could you tell me a little bit more about what was the inspiration behind this work?

HT: INFACT is a continuation of work we have been doing for the past 10-15 years in Europe, first within separate projects, and then under an umbrella project. Initially, there were many isolated, individual projects on health information. Then, in 2015 the BRIDGE Health project was set up. Its intention was to pool together several of those existing smaller initiatives on injuries, perinatal care, and so forth which had a lot of common features on the data side..

The BRIDGE Health project focusses on the idea of establishing a shared, sustainable system for health information in Europe. This led us to the INFACT project and a concrete proposal for the infrastructure that needs to be established to achieve this goal. We are now aiming for the European Strategy Forum on Research Infrastructures (ESFRI) roadmap, which we will be updating next year. This is the next step to get this research infrastructure more formalised, and then step by step start building the actual infrastructure.

MZ: Do you have an idea for the timeline of the INFACT project? How many years are we looking at for it to become reality?

HT: Well, I would say that with some good luck, if everything goes smoothly, within five years we should have certain steps already in place. However, ten years might be the timeline within which the infrastructure becomes fully functional, with all the components we can see at this stage. Obviously, the world is changing quite fast – just look at developments in Big Data, artificial intelligence, and things like that. While we start working on establishing the infrastructure in one way, we might need to re-direct it at some stage in the future. We should therefore look at it as an ongoing process that will be evolving over the years.

MZ: You talked about the vast differences in estimates of obesity rates in Finland as an example of how various data sources can yield completely different results. Could you mention some other examples of this?

HT: On the health side you have hypertension, where you also see a variety of results. When you go to see a doctor, they might measure hypertension or not, but hypertension medication is also used as primary prevention among diabetics and for people who have other diseases. Obtaining reliable information on the prevalence of hypertension from the register is very difficult, so to measure it you actually need to examine people. We know that approximately one-third of the people who are hypertensive do not actually know they have elevated blood pressure. This is the case in Finland, but it is also true for Europe more generally. As hypertension can be asymptomatic many hypertensive people end up not seeking any medical help.

MZ: What have been the highlights of the Gastein Forum for you this far?

HT: I really enjoyed the session on big data this morning [‘When epidemiology meets Big Data’, organised by ECDC], especially the message that while there is a lot of data out there, it is rarely complete. We need to validate also the registered base data to identify the gaps in data quality and coverage. That is something we have been doing a lot of in Finland, where we can do direct linkage to the survey data and administrative data.

I also liked the session on health inequalities [‘Changing the game on health inequalities’, organised by WHO Euro]. It raised the issue that health inequalities are not only related to health and healthcare, they are tightly intertwined with economic considerations, housing, and many other issues which can be easily neglected with our traditional approaches to health. We have started looking at socioeconomic patterns behind inequalities, but we are not digging deep enough to understand what their root causes are.

MZ: How useful do you find the frame of ‘disruption’ that has dominated the Gastein Forum this year?

HT: I think it is useful and it is generating good discussions. It is not straightforward, and it therefore allows for new ideas to be explored.

MZ: One final question – what would be the main message you would like the Young Gasteiners to take away from this year’s meeting?

HT: Step out of your own comfort zone and take a broader perspective on health – environmental determinants, social determinants, financial determinants, and the many other angles that exist out there. Take a more holistic approach to your work!

This interview was conducted by a Young Gasteiner Mateusz Zatonski, University of Bath (UK) and Health Promotion Foundation (Poland)