Health » Overview

Salzburg Global Seminar has long been a leading forum for the exchange of ideas on issues in health and health care affecting countries throughout the world. At these meetings agendas have been re-set affecting policy and practice in crucial areas, such as patient safety and the engagement of patients in medical decision making. In 2010, Salzburg Global Seminar launched a multi-year series of seminars to crystallize new approaches to global health and health care in the face of emerging challenges affecting us now and set to continue on through the coming generation.

Interviews and coverage from our Health programs

Sheila Payne - Will caring for your loved one bankrupt you emotionally and financially?
Sheila Payne - Will caring for your loved one bankrupt you emotionally and financially?
Sheila Payne 
This article first appeared on the EAPC blog, which will continue to publish more posts on the Salzburg Question series. It refers to the fourth Salzburg Question: Will caring for your dying loved one bankrupt you emotionally and financially?

To mark the International Day of Families today (15 May 2017), Sheila Payne, Emeritus Professor, International Observatory on End of Life Care, Lancaster University, UK, launches the fourth of the Salzburg Global Seminar questions.
Palliative care interventions have historically neglected the essential role played by family and friends in supporting people near the end of life. This is surprising since virtually all of us will at some point in our lives be, albeit unwillingly, witnesses to the final illnesses and deaths of close family members. This is therefore a common, shared global experience. But will caring for your loved one bankrupt you emotionally and financially?

The answer to this question probably lies in a number of factors including your personal resilience and resources, the network of social and emotional support available to you in your extended family, community and faith group, and in the health, social care and welfare system that your country provides. For most families, facing the loss of a family member is a distressing time but is mitigated by adequate resources and support systems. However, for those with inadequate social support or networks – perhaps because they are refugees, are older people or poor, or live in countries where health care or health insurance is too expensive, or social care is not available – then facing a loved one’s end of life can be literately devastating.

What can you do?

There has been a growing acknowledgement of the emotional impact of witnessing the decline and death of a close relative. This is usually labelled as ‘carer burden’, which includes both the emotional impact and also the caregiving tasks involved in supporting a dying person. There are now many ‘tools’ that attempt to measure this ‘burden’ and even a few that recognise that caregiving can have both positive and negative elements. Palliative care professionals can ensure that the emotional and support needs of families are regularly assessed and addressed, before a crisis is reached.

What has perhaps received less attention is the financial impact of having a dying family member within one’s family. Evidence from the USA and Australia suggests that illness and medical debts are a major reason for bankruptcies. A recent analysis of out-of-pocket expenses in the last year of life for older people in 13 European countries indicates that they ranged from two per cent to 25 per cent of median household income (Penders et al 2017). Once again, routine assessment of economic circumstances and the need for welfare support should be included within palliative care.

Finally, as an international palliative care community could we be doing more to highlight the often hidden impact of the final illness on the emotional and financial welfare of family members? After the death, as we receive their gratitude and thanks for the palliative care that we provided for their loved one, do we stop to ask how they are managing? Can we be more proactive in highlighting their needs to governments and policy makers?

Reference Penders YWH, Rietjens J, Albers G, Croezen S, van den Block L. Differences in out-of-pocket healthcare in the last year of life of older people in 13 European countries Palliative Medicine 2017, 31(1) 42-52 doi: 10.117/0269216316647206.
Fourth Salzburg Question looks at emotional and financial toll of losing a loved one
Fourth Salzburg Question looks at emotional and financial toll of losing a loved one
Oscar Tollast 
An online conversation on care toward the end of life will switch its focus to the emotional, and financial toll suffered by the family and friends of a dying loved one.

People taking part in the Salzburg Questions series will be posed a new question on this subject on Monday, May 15, which coincides with the
International Day of Families.

The Salzburg Questions series has engaged people in conversation on Twitter since February 20 with discussions related to palliative care. People taking part in the discussion use the hashtag #allmylifeQs.

May’s question is, “Will caring for your dying loved one bankrupt you emotionally and financially?” Sheila Payne, an influential leader in promoting multidisciplinary work in palliative care, will help launch the discussion.

Each question in the Salzburg Questions series is launched on an international day of observation and led by people with expertise in the field of palliative care. These people were involved in a Salzburg Global session in December: Rethinking Care Toward the End of Life.

April’s question was launched by Dr. Suresh Kumar, a palliative care physician and health activist. He asked, “How have you prepared for your death?” This question led to several interesting responses, which Dr. Kumar summarized in a blog post for the European Association for Palliative Care (EAPC).

At the time of writing, the #allmylifeQs hashtag has generated more than 7.5 million impressions on Twitter. There have been 1,895 tweets posted involving 367 participants from across the world. Salzburg Global is encouraging as many Fellows as possible to join in with this conversation on the day, beforehand, and afterward.

People are also encouraged to write blogs, which could be hosted on ehospice; the European Association for Palliative Care (EAPC) blog; Palliverse; and the International Association for Hospice and Palliative Care (IAHPC) newsletter. Vlogs are also welcome and should be sent to so they can be posted to a dedicated YouTube channel.

Please join in the conversation on Monday, which coincides with the International Day of Families, and remember to use the hashtag #allmylifeQs. A Twitter list of Salzburg Global Health Fellows has been created. If you would like to be added to this list, please let us know by subscribing or contacting us on Twitter at @SalzburgGlobal. List of dates, questions, and people leading discussions 20 February 2017 - World Day of Social Justice - Why aren't countries accountable to commitment on #EOL care for vulnerable people? - Agnes Binagwaho

20 March 2017 - World Happiness Day - Is dying well as important as living well? - Lynna Chandra

07 April 2017 - World Health Day - How have you prepared for your death? - Suresh Kumar

15 May 2017 - World Family Day - Will caring for your dying loved one bankrupt you emotionally and financially? - Sheila Payne

20 June 2017 - World Refugee Day - 145 countries signed why do refugees have limited access to quality health care and #EOL care? - Emmanuel Luyirika

17 July 2017 - World Population Day - How and what do you measure to ensure palliative & EOL care? - Richard Harding

28 September 2017 - International Right to Know Day - Doctors, Nurses, do you want to die the way your patients die? - Bruce Chernof

13 October 2017 - World Hospice and Palliative Care Day* - Do you know how to access #palliative care when you need it? - Stephen Connor

10 November 2017 - World Science Day for Peace and Development - What future research is needed to improve care for people with advanced illness & towards the end of life? - Irene Higginson *This year's World Hospice and Palliative Care Day is taking place on Saturday, October 14. We will launch the question the day before to generate more discussion.
Sir Harry Burns – “It would be a mistake to think the health care system on its own can tackle the determinants of health”
Sir Harry Burns – “It would be a mistake to think the health care system on its own can tackle the determinants of health”
Nicole Bogart 
Members of the inaugural meeting of the Sciana network have spent days contemplating the challenges facing the health and health care systems of today, and of the future. But when theorising solutions to  these challenges, Sir Harry Burns, professor of global public health at the University of Strathclyde,  Scotland, stresses the importance of not falling victim to the belief that one grand scheme is the solution.

“The way in which to change a  complex system isn’t through a  grand plan – it’s through people  examining problems, coming up with  solutions, testing those solutions, and spreading learning,” Burns says.

Burns’ focus is on how societies can create overall “wellness” for  its citizens, where health is a state of physical, mental and social wellbeing, not just the absence of illness. But this approach, he explains, is one based on a series of  complex systems coming together.

“It would be a mistake to think that  the health care system on its own can tackle the determinants of  health,” he says. “First of all, the  health care system tends to focus on illness, whereas wellness goes  hand-in-hand with treating illness in terms of creating a society where wellbeing is the aim.”

He continues: “A society with lots of wellbeing isn’t just a society where  health is good, it’s a society where  education attainment is good, where people are engaged, where there  is a high level of social cohesion,” noting there is scientific evidence indicating this process begins with children and young people.

“Children who experience difficult in  early life through parental absence,  through mental illness of parents, through poverty, will often find it  harder to learn, to behave correctly  in stressful situations,” he says. “As a result they’re more likely to  fail. So giving support to families who find themselves in difficult  circumstances is the basis of a  wellbeing society. But it doesn’t stop, it continues through life.”

After spending just three days with members of Sciana, the health leaders network, Burns, whose  involvement will continue with the  network in the coming months as a senior ambassador, says he has  gained a greater insight into the way  different health care systems are financed, and how that financing  determines their functionality and  ability to change.

“What I’ve heard in some systems  is finance doesn’t seem to be a  huge problem, therefore what’s the  incentive for change? Whereas in  the UK system our government has decided there is a limited amount of  money for health care, [so] we are  forced to discover new, more efficient  ways of delivering care, which is why  we focus on wellbeing as a way of  reducing the need for care.”
Ina Kopp – “We need to start caring for our societies at an early stage”
Ina Kopp – “We need to start caring for our societies at an early stage”
Nicole Bogart 
The German, Swiss and British health care systems are very different, each tackling distinct difficulties regarding reform, funding, and political trials. But despite these differences, they still face many of the same broad challenges; from ageing populations and depleted workforces, to the ever-increasing costs of health care. Ina Kopp, Director of the German Association of the Scientific Medical Societies’ Institute for Medical Knowledge-Management, believes these three nations also share difficulties regarding social care and the promotion of wellbeing in societies.

“We need to go for prevention – we need to start caring for our societies at an early stage,” says Kopp.

Sciana members echoed this concern, one describing the German system as a “sick care” system instead of a health care system, noting most fail to see a doctor until they are already ill. But this promotion of wellbeing is a societal responsibility, one that must begin outside of the health care system, in schools and workplaces to encourage healthy living, says Kopp.

“Prevention must take place where the people are. Where the people work and where the people live,” she notes. “What might be different in Germany is that we have 80 million people to care for, and last year we had one million refugees we [now] need to integrate, not only in the health care system, but really in our society.”

Yet it is these shared challenges Kopp believes will empower Sciana, the health leaders network, to become a platform to facilitate ideas, allowing members to share unique outlooks on problem solving.

“We can share some experience from pilot projects,” she says. “I’ve heard so many other approaches to the same problem that I really expect we can learn from each other.”

Kopp describes the inaugural Sciana meeting as an exciting opportunity to network with health care professionals from other countries, noting discussion between members blossomed within minutes of arriving in Salzburg.

“I do hope the next days will really bring us some opportunities to not only develop new ideas, but also write them down and work on some recommendations," she says.
Lynn Ross - When did you first fall in love with nature?
Lynn Ross - When did you first fall in love with nature?
Lynn Ross 
This post was first published on Lynn Ross' LinkedIn profile. Ross attended Session 574 - The Child in the City: Health, Parks and Play, which is part of the multi-year Parks for the Planet Forum. I first fell in love with nature as a child playing for hours on end in the backyard of my family home where the grass, trees and flowers were animated participants in all my magical backyard adventures. Even as a dedicated city dweller my love affair with nature has continued into adulthood, so I was honored to become a fellow of the Salzburg Global Seminar last month during Session 574, “The Child in the City: Health, Parks, and Play.

This session, hosted over 4 days at the amazing Schloss Leopoldskron in Salzburg, Austria, included advocates, researchers and practitioners representing 20 countries. Each participant brought a unique perspective and a wealth of experience. Here are just a few of the interesting initiatives I learned about:
  •     Urban95 is a global initiative of the Bernard van de Leer Foundation that asks what city leaders, designers, and planners what they would do differently if they viewed the city an elevation of 95 cm – the average height of a healthy 3-year-old.
  •     The Laboratorio para la Ciudad in Mexico City is using research to explore play and developing tools for engaging children in government through their Playful City initiative.
  •     Park Rx America is handing out “park prescriptions” to reduce chronic illness by mapping parks and providing info on making the most of the park (including transit tips to get there).
  •     City Health, an initiative of the de Beaumont Foundation, has rated 40 cities on nine evidence-supported policy areas that support community health and well-being.
  •     Natural Neighbors is an international effort designed to promote expanded alliances with museums, schools and universities and parks and conservation areas by linking exhibits, outreach materials and activities across organizations.
During the session, I also had the pleasure of leading a discussion on moving from incremental change to transformation. Through case studies from the United Kingdom, the United States and Singapore, the panel shared the following key takeaways which apply not only to kids and nature, but to any community building effort:
  •     Have a big, inclusive vision that people can see themselves in.
  •     Clearly articulate the value proposition and theory of change early in the process.
  •     Build meaningful, inclusive partnerships and are those partners with the tools they need support the work and outreach.
  •     Prioritize crafting and customizing messages for diverse audiences.
  •     Build a culture of learning and plan for evaluation into the effort from the start.
There were many more efforts, takeaways and resources shared throughout the session and I encourage you to check out the “Resources” section of the session page.

On the final day of the session, we started the process of transforming our collective learning into a set of principles that can be shared broadly. A smaller group of participants is continuing that work post-session. In addition, each participant shared personal commitments to continue the work of the session in their daily practice. It’s no surprise that my experience in Salzburg is already influencing my work on the Reimagining the Civic Commons initiative, but what has been a surprise is how much the experience has me thinking about the role of nature, parks and play as part of housing affordability and equitable community development.

So, I’ll leave you where I started but with an addition: when did you first fall in love with nature? And what can you do in your practice to ensure that all children will someday get to answer that same question?
Lynn Ross was a participant in the Salzburg Global program The Child in the City: Health, Parks and Play, which is part of the multi-year Parks for the Planet Forum, a series held in partnership with the IUCN. The session was supported by the Huffington Foundation, Parks Canada and Korea National Park and the W.K. Kellogg Foundation. More information on the session can be found here:
Dr Suresh Kumar - Have you prepared for your death?
Dr Suresh Kumar - Have you prepared for your death?
Suresh Kumar 
This article first appeared on the EAPC blog, which will continue to publish more posts on the Salzburg Question series. It refers to the third Salzburg Question: How have you prepared for your death? Dr Suresh Kumar, Director of the WHO Collaborating Center for Community Participation in Palliative Care and Long Term Care & Technical Advisor, Institute of Palliative Medicine, Calicut, Kerala, India, explores the third question in the Salzburg Questions series, that encourages a global discussion about the key issues affecting palliative care. Most people are taken aback by a question about their own death, because death is something that happens to other people!

So, reactions to the question ‘Have you prepared for your death?’ posted on social media recently were not totally unexpected. This question was posted on Facebook and Twitter with a hashtag #allmylifeQs by more than 250 people on 7 April as a Salzburg Question. Salzburg Questions are a series of questions to bring attention to issues related to end of life, death and dying. More than 750 people participated in the online discussions that followed the ‘preparations for death’ question. Responses varied, from a calm, calculated yes to a big no in surprise and horror. A few people said they had already thought about this. Most haven’t.

Many people have already pointed out that there is a huge difference between the philosophical statement: ‘We all will die one day’ and the awareness of: “I am not going to die in a few months’ time”. Though we all know that we have to die one day, most of us have never reflected on what it would be like to die. And society does not generally encourage such thoughts. Thoughts and words about death are usually considered ‘dark’ and something to be avoided.

Why should one think of death much before it comes, when one is busy with life? For one thing, Death is an unpredictable guest. Many of us working in the area of end-of-life care realize that deliberate avoidance of death as a topic of discussion from the social and medical deliberations has resulted in society becoming more and more ‘death denying’ with a lot of negative implications. Though it is very important, it is extremely difficult (and very often insensitive) to take up the topic of preparing for death when someone is on his/her deathbed. Even when possible, it is often too late to address many of the issues raised. The best time to start discussing preparations for death is when we are sure that we are not going to die immediately! Such discussions can help in reflecting on one’s own philosophy of life, in identifying unfinished priorities in life, and in looking at how one wants to face the inevitable final event in life. It is particularly important to make choices since the available technology can prolong the dying process for days or even months.

Our experience has been that informal discussions about death and dying will go a long way in helping people to identify and address key issues in their life and death. Because you cannot die well unless you live well!

Have you prepared for your death?
Tweet your answer to #allmylifeQs 
Ilona Kickbusch – “A small group really can make a difference”
Ilona Kickbusch – “A small group really can make a difference”
Nicole Bogart 
When confronting the key issues facing health and health care over the next 20 years, Ilona Kickbusch believes demography cannot be discussed without addressing inequality. As significant portions of the population in the UK, Germany, and Switzerland grow older, Kickbusch says addressing the inequalities of aging is vital. “All of our societies are faced with major demographic change; ageing is one of them, migration is another. But the fact is, usually when we talk about the ageing of society, we don’t look at some deeper social factors that are actually a dimension of that demographic development,” Kickbusch, Director of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva, and a member of the Board of Trustees of Sciana network partner the Careum Foundation says. “Ageing [is] something that is very unequal in our societies. A significant number of people do not have the same amount of healthy life expectancy, so people on the lower social stature will tend to have up to 7 to 10 years less of healthy life expectancy, meaning that they have more chronic disease and disabilities.” The Sciana network is an international collaboration between the Health FoundationCareum Stiftung and the Robert Bosch Stiftung, facilitated by Salzburg Global Seminar and hosted at Hotel Schloss Leopoldskron. The health leaders network will bring together leaders in health and health care policy over the next two years to find solutions to shared challenges being faced in health care across Europe. Kickbusch explains that while all people are indeed getting older, we are not all living to the same age and with the same level of health thanks to socioeconomic disparities. This challenge of ageing inequity will certainly continue over the next 20 years – making initiatives like the Sciana network invaluable in developing positive change. Reflecting on the international aspect of the collaboration within the Sciana network, Kickbusch, whose key interests have long revolved around health policies and global health, notes: “The interesting thing is that, in the end, very similar issues emerge… I think there is a great opportunity that a group like this can come up with at least a unique framing of some of these issues, or a priority-setting that can be very important and taken forward by the next group. That’s my own experience working in this field for a long time – that a small group really can make a difference.” Although Sciana is in its infancy, Kickbusch says bringing together three European organisations to discuss shared problems in health care, along with a cohort of bright minds, is a very significant step.
“If a certain kind of idea, or manifesto emerges from here, it can really have an impact on discussion in Europe, and maybe even around the world,” she says.
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