On 21 November 2024, our Director, Professor Ilona Kickbusch, delivered the keynote speech at the Global Forum for Health Promotion in Geneva. Speaking on the topic of Digitalization as a Growing Determinant of Health and Well-being, Ilona used the speech to highlight the need for action from public health agencies, governments and digital tech companies to address the digital determinants of health.
The following is an edited transcript of the speech, the accompanying slides are accessible here.
I’m delighted to be here and look forward to sharing some of our thinking around what we call the digital determinants of health. I consciously say we because what I will present to you is not just my thinking but has the input of the extraordinary staff of the Digital Transformations for Health Lab, and many of the partners and consortium members that we work with.
The starting point when speaking about digital determinants is to first understand how much this technology has been changing our lives. This relates to the central premise of health promotion: that health promotion is created and lived by people within the settings of their everyday life. And the virtual, the digital, AI, whatever terminology you want to use, is now totally integrated into our lives. Therefore, we must understand how it contributes to health.
We understand the digital world, as a new sphere in which health is created, but also where health is endangered. Health promotion aims to understand how digital transformations can contribute to empowerment and help moving health forward, but it also has a responsibility to analyze where digital determinants hinder and endanger health – and to respond.
Our work in DTH-Lab is mainly on the impact of digital transformations on children and young people. And I want to stress that we work with young people and integrate them fully into this work.
The digital revolution and its impact on health
Digital transformation is a societal transformation. Health promotion is built on the premise that health is, amongst other things, a social concept. We cannot understand health without understanding the social environments within which health is created.
We are in the midst of a major societal transformation that is linked to the development of technology. Some people call this the fourth industrial revolution. This revolution brings with it a new interaction between people and technology. And this social change is what we feel and what we fear, particularly around artificial intelligence.
We were able to explore this development and its consequences through our work as a Lancet Commission on Governing Health Futures: Growing up in a digital world. Our work in DTH-Lab follows up on the recommendations of this Lancet Commission, which stated that digital transformations are in themselves a determinant of health. But, of course, they also interact with many other determinants that define the health and future of children and young people. For example, the major equity challenges that are part of the digital transformations.
There are basically two other families of determinants that we always interface with when we talk about digital determinants. One is the social determinants and the equity issues, and the other is the commercial determinants, because of course this revolution doesn’t just happen. It is driven by financial interests from major companies and investors. It is driven by profits and a specific mind-frame concerning innovation.
So when we look at the digital determinants we look at it on three levels. First, the impact of the application of digital technologies. And here, particularly in healthcare and health systems, what is now possible through data, through monitoring, through off-site and many other elements. DTH-Lab has a programme on “digital first health systems” that looks at that.
Second, we look at the digital determinants of everyday tech use and how that influences physical and particularly mental health and well-being.
And then third, we look at the digital ecosystems and how they change our lives. Some of the digital technologies are obviously changing how we interact with healthcare ecosystems. Take India for example, that has provided improved access to health care for underserved populations. We have greater convenience and efficiency for patients and providers. Individuals can get active, can get involved patient organizations through the digital applications. And of course, we get nudged by technology through wearables. Monitoring, decision-making, diagnosis are elements that are pushing solutions forward, that are being developed both by startups, by big companies, by individuals, and by groups of users.
Yet the formal healthcare system is not really ready for what is actually happening and especially what is possible. And the possibilities can be a great opportunity.
Technology and young people – a challenge for health promotion
The use of technology is less and less linked to a screen we sit in front of at home or at our desks. The key factor is the portability and much of the research that actually looks at negative impacts of digital technology is particularly linked to the portability. It is the fact that it is everywhere, that it nudges us everywhere and in all situations, that we have this feeling we must always be ready for something. That can create new vulnerabilities.
We asked young people on positive and negative impacts of the use of social media and found the positive and the negative are relatively evenly distributed. This makes it so difficult to deal with this issue because every time we draw attention to a negative impact, we are confronted with positive examples of how it can help and support young people.
Indeed, there are very few issues in health promotion and public health, where the positive and the negative impact are so closely linked. This is a new challenge for us in health promotion that we have to deal with.
These technologies are everywhere. Globally one in three internet users is a child under 18. Young people, particularly teenagers, are very keen to be linked up with each other. But we’re seeing from the research that the younger children are the more it impacts on their development. And we have some very disconcerting data on that.
But also, we see that young people are using digital to support their health and well-being and all the young people we have surveyed and talked to speak particularly about mental health issues and how much the web can help them.
We have tried to show how diverse these potential harms to health and well-being can be. One of the most disconcerting is linked to cognitive development. We are seeing that many parents in the hopes of fostering the cognitive development of their children are giving them, for example, iPads very early on with little learning games. And research data now shows this does not help cognitive development; it can actually impair it.
In Singapore. I was introduced to a study which showed us that some parents in the hope of helping their children have given them iPads at age six months. And with the best of intentions they are actually endangering the cognitive development of their children.
There are obviously other physical impacts like a lack of physical activity. There is the eye health issue that we’re not looking at enough. There is disruptive sleep.
Addiction – often one of the first things people raise – is not the primary problem. Rather it is
everyday anxiety, everyday well-being. As health promoters, that needs to be our focus when we look at digital transformation. We must keep in mind how this helps empowerment and how this helps well-being and health in everyday life.
There’s cyberbullying, there is online violence. There is the body image issue, the beauty issues for many girls. There is the direct and indirect marketing of products. And the issue of the pervasive design features of many of these platforms.
We feel very strongly there is sufficient evidence to act. If one in nine adolescents show signs of problematic social media use then we’ve got to do something.
In our work, we are talking with tech companies in trying to address some of the issues around protection of children. They have introduced a range of features to protect children, including strengthening parental controls, anti-bullying tools, screen time management tools and of course, age verification. They are also developing child-specific platforms and collaborating with child safety organizations.
But the issue really is the issue of the design features which are structured to keep kids online. This we have to take up much more significantly. The commercial motives of digital platforms do not always align with public health.
With virtual reality, the sort of indirect introduction of commercial motives also is done through games and gaming. So it’s not just about addiction. It’s about many different factors that, just like in real life, exert influence on us.
In our work, we are talking with tech companies in trying to address some of the issues around protection of children. They have introduced a range of features to protect children, including strengthening parental controls, anti-bullying tools, screen time management tools and of course, age verification. They are also developing child-specific platforms and collaborating with child safety organizations.
But the issue really is the issue of the design features which are structured to keep kids online. This we have to take up much more significantly. The commercial motives of digital platforms do not always align with public health.
With virtual reality, the sort of indirect introduction of commercial motives also is done through games and gaming. So it’s not just about addiction. It’s about many different factors that, just like in real life, exert influence on us.
Global support growing for safer digital environments
In the last two years or so, we have seen growing calls for digital environments to be made fit for children. I’m very happy to say that UNICEF and UNESCO have been very, very active in this field. And I must say a little bit earlier than WHO.
The UNICEF report on the Future of Childhood in a Changing World which was just issued yesterday on the International Day of the Child states that mental health must be a priority. We must collectively try and keep pace with frontier technology safeguarding children and their lives, and their health.
The report provides a range of policy proposals. One that has gained most attention, because it’s so closely related to everyday life is the smartphone-free childhood. And what we can see that all around the world, parents’ associations are being created to move that forward. And many of the organizations are actually linking this issue to children’s rights. We have to support proposals to rework the Convention on the Rights of the Child in view of the virtual developments.
Meanwhile the United States, the UK, from other countries, from the European Union, have increased efforts to ensure that children and their data are protected. New regulations and laws have emerged with a focus mainly on protecting children’s data. That and the issue of data privacy was the starting point.
Protection and safety is critical. The early voice for health promotion and public health, has been the Surgeon General in the United States who issued a Surgeon General’s warning: social media may cause profound harm to the mental health and well-being of children and adolescents. This has really been an important signal.
We do see now that legislation is being taken up and DTH-Lab is monitoring those legislations. And we will be working with the Polish presidency of the European Union, they have made this one of the priorities of their Presidency. We will be doing an overview of policies and research to be able to take this forward. We want to ensure that public health must be at the table in shaping new policies and laws.
Whenever a digital law is being considered, health should actually be at the table because the health impacts, positive and negative, are absolutely critical.
You can see here that some very, very top level policymakers have woken up. I was thrilled when I heard Ursula von der Leyen’, President of the European Commission, state: “We will convene the first ever European-wide inquiry on the impact of social media on the well-being of young people.” That is a health promotion agenda!
But many such opportunities might also arise in other countries across the world. The Prime Minister of Australia has introduced legislation to set a minimum age for social media use. In Ireland, the Minister of Health has initiated a task force in response to online harms, and Ireland wants to take this into the WHO and have one of the future World Health Assemblies agree on action.
Adopting a public health approach
We looked at existing public health strategies and how they can be used to address digital determinants of children’s health and well-being. We can delay children’s use of digital media devices. We can limit children’s use of digital and media devices. And we can mitigate the negative impacts.
And of course, one of the most obvious is, just like we have tobacco free spaces, we can have device free spaces. We have very positive experience with the “settings for health” approach. Maybe we now need the notion of “devices for health” in relation to smartphones and wearables.
Many of the arguments we sometimes hear such as ‘this is so new’ and ‘we don’t know what to do’ are not correct. We have 50, 60, maybe even 150 years of experience of public health strategies – what our task is and our role must be – let’s look at those and let’s see what they can do for us in terms of dealing with digital transformation.
We obviously need to make sure that young people become empowered digital health citizens. We are now working with the Council of Europe on digital health citizenship, which has put digital citizenship as their priority. We are not only looking at the interface of digital and health literacy, we are adding civic literacy. How do you interact with one another as people in a social way and what rights and choices do you have?
Action needed to address the digital determinants of health
We are suggesting to address the digital determinants of children’s health and well-being.
We have drafted three calls to action:
That is absolutely critical and it is up to us to really make this point: the real world has to be healthy and the virtual world has to be healthy. So don’t forget, if you take digital away, then give young people something else. Where’s the playground? Where’s the youth centre?
The real world has to empower children, as does the virtual world. And we have to, as health promoters, show how they best interact: that one cannot replace the other. It is at this interface that we can create well-being societies.
If you are interested in joining DTH-Lab and other partners to develop a call to action on digital determinants of health, please email team@DTHLab.org
Ilona Kickbusch is the Director of the DTH-Lab. She is a visiting professor at the University of Geneva, the founding director, chair and senior distinguished fellow of the Global Health Centre at the Geneva Graduate Institute of International and Development Studies.
© 2024 DTH-Lab. All Rights Reserved.
Ilona Kickbusch is the Director of the DTH-Lab. She is a visiting professor at the University of Geneva, the founding director, chair and senior distinguished fellow of the Global Health Centre at the Geneva Graduate Institute of International and Development Studies. She is known throughout the world for her expertise and is a sought after senior adviser and key note speaker. Her areas of expertise include the determinants of health, health in all policies, and global health governance. She advises countries on their global health strategies, trains health specialists, and is involved in German G7 and G20 health activities. She publishes widely and serves on various commissions and boards. She has been awarded the Cross of the Order of Merit of the Federal Republic of Germany (Bundesverdienstkreuz) in recognition of her invaluable contributions to innovation in governance for global health and global health diplomacy. She has also been awarded the WHO Medal in recognition of her contribution to global health.
