Dr. Marius Ungureanu, executive director of the Cluj School of Public Health in Romania, and Dr. Radu Meza, professor of journalism and media at Babeș-Bolyai University in Romania, join Rasika and Victor for a conversation about the health care systems and public health issues in the U.S. and Romania and how digital communications strategies play a role in communicating health information.

Rasika Mukkamala:

Hello everyone and welcome back to From the Front Row. Today we are delighted to have Dr. Marius Ungureanu and Dr. Radu Meza on the show. Dr. Ungureanu is the executive director of the Cluj School of Public Health and received his executive MHA from the University of Iowa. Dr. Meza is a professor in journalism and media at Babeș-Bolyai University with a focus on digital communication and social media. We are thrilled to have them here in person and on the show. I’m Rasika Mukkamala co-hosting with Victor Fontanez. And if it’s your first time with us, welcome.

We’re a student-run podcast that talks about major issues in public health and how they’re relevant to anyone both inside and outside the show of public health. Welcome to the show. …with a bit of background information about yourselves and let our audience know how you got to your positions today.

Marius Ungureanu:

Yes, first of all, thank you Rasika and Victor for inviting us here. It’s a pleasure. I am currently chair of the Department of Public Health at the Babeș-Bolyai University. I’ve been working with the department since 2010 right after graduating from medical school. I have worked as a researcher there and then took a position of faculty and since end of 2021, I’m serving as chair of the Department of Public Health.

Rasika Mukkamala:

Awesome. Thank you.

Radu Meza:

Hello. Thank you for the invitation. I’ve been with the College of Political Administrative and Communication Sciences since 2008. I started there in the Department of Journalism and in 2016 I helped found and coordinated the first digital media bachelor program in Romania. I’m now serving as the chair of the Journalism and Digital Media Program who has programs in four languages at undergraduate and graduate levels in the areas of journalism and digital media respectively.

Rasika Mukkamala:

Awesome. Thank you for joining us.

Victor Fontanez:

That all sounds very impressive. So could you give us an overview of the Romanian health care System

Marius Ungureanu:

Just to begin with, there are two things that I believe are worth mentioning. First that from a structural perspective it is very much different from the health system in the United States. But on the other hand, the second point that I want to mention is that in terms of challenges, we are very much similar. So coming back to how it is being organized, it is funded through a social health insurance type of funding. Which means that everyone in Romania who is an employee contributes with 10% of their income to the National Health Insurance Fund. Which then entitles everyone who is an employee and pays for this fund to be insured in the system and receive services.

That being said, there are still a large proportion of people in Romania who do not get insurance. It’s about 18 to 19%. Services are delivered mainly by public institutions. It’s a network of family doctors, which are general practitioners who are gatekeepers in the system, and then outpatient clinics which are located in hospitals and then hospitals, which is the tertiary level of care. Other than that, there are new developments, there is an increasing network of community nurses who are serving especially in rural and remote areas. In terms of challenges, because I was mentioning about challenges, underfunding is one of the serious challenges of the system.

Which leads then to other issues like the quality of health care services and also issues of access because access is unequal. There are various characteristics depending on the income level, depending on the other socio-demographic factors that makes it difficult for some categories of people to get access to services. And there’s particular categories like people residing in rural and remote areas where people coming from various disadvantaged or vulnerable groups like Roma minority or other ethnic minorities.

Rasika Mukkamala:

Can you talk a little bit about public health and maybe similarities and differences to the American health care system, whether that be social security, disability, any kind of supplemental insurance or projects that Romania has?

Marius Ungureanu:

Yes, public health is in the way you see it in the US health care system is maybe different in Romania because for many, many decades when we spoke about public health in Romania, we used to refer as almost exclusively to infectious disease epidemiology. And to a certain extent we still hold that old perspective of public health, but increasingly in the past years and especially after the COVID-19 pandemic, we have realized that public health is a lot more than that. And thus, the health system in Romania is more and more focusing on health promotion and disease prevention activities. And that is reflected in the funding that gets into these activities.

For instance, in the recent years, there is increased funding for family doctors who, as I said, are gatekeepers in the system. So everyone who has a health condition needs to go through the office of the family physician in order to either receive services for their condition or get referred to an upper level of care. With regards to the aspects that you’re mentioning, we are still lagging behind in terms of bridging the health and social care sectors, although we see that the need is…

I have been working in the past weeks with colleagues from the medical school, from the department of geriatrics and gerontology, and we have conducted an analysis on data collected on the frailty levels of elderly admitted to the Department of Geriatrics and Gerontology. And when we analyze the data, which is still to be sent for publication, but what we’ve seen preliminarily is that the scores for frailty are significantly higher than what we see in the scientific literature. So that is one of the causes, the fact that we do not have a strong connection between the health sector and the social care sector.

Rasika Mukkamala:

That’s really interesting. Thank you for sharing. To go off of that, can you talk a little bit about what each of you are working on within your current roles? This could include any research that you’re working on, projects or things that are coming up in the future.

Marius Ungureanu:

So one of my main research interest is in health workforce issues. And with the COVID-19 pandemic, we’ve seen that health workforce challenges have been exacerbated. Because when I started working on health workforce research more than 10 years ago, it was a very niche domain. But in recent years it has become increasingly popular and increasingly important and the European Commission has been allocated funding into that. So a couple of specific areas that I’m working on is health professional mobility and migration. Because up until a couple of years ago, we used to just speak of the fact that there are health professionals, either doctors, nurses or other categories going from country A to country B and that’s all.

But in recent years, we see not only that they go from country A to country B, but they might go from country A to country B for training and then to country C, D or E for practicing. What we increasingly see, and I have been working with colleagues from Germany conducting qualitative research with Romanian doctors working in Germany. We see that there is an increasing interest for Romanian doctors who are working in Germany to come back to Romania temporarily to provide services as a sign of “giving back.” This is a quote from the research that we’ve been conducting, to give back to the country where they have been trained.

So these are two new trends that we are seeing in terms of health professional mobility and migration. And another thing that we’re seeing, and we are working on that and we have published, is what has emerged in terms of challenges for the health workforce after the COVID-19 pandemic. And we see an increased rate of violence against health care workers and we’ve seen dramatic cases during the pandemic of violence against health care workers from people who were opposing vaccination, for instance.

Radu Meza:

My main area of research is in hate speech in online media, and I’m now looking into how emotional news coverage is triggering hate speech and polarization, but also of course how misinformation and also over-emotionalization of news coverage can lead to, let’s say, other effects and in connection to of course the public health issues. Looking at how various conspiracy theories spread over social media or online news sources that are unreliable may hinder policy or measures in the area of public health.

Most recently I’ve been looking, in the context of conflict in Europe at propaganda, again spread by online news sources and how the characteristics of propaganda in, let’s say, the past several decades has shifted towards a model that caters to the way people consume information and entertainment over digital platforms. Which is this on-demand model, giving people more of what they like, more of what they want, so that they become very, very skeptical about any kind of information or advice or any kind of contrary point to their beliefs. And in so doing, it makes for kind of society that is very hard to mobilize and that is very susceptible to conspiracy theories.

Rasika Mukkamala:

Those are super interesting topics. Thank you for sharing.

Victor Fontanez:

Yes, I agree. And I would love to hear what are some benefits and challenges of using digital platforms for communicating health information? Maybe what have you done to overcome these challenges as well?

Marius Ungureanu:

One of the things that I’ve been involved in the past, I believe, two or three years, very specific project, is to see the use of technology and artificial intelligence in mitigating the lack of health professionals. So our department has been contracted by one of the leading companies in digital health in Europe, Ada Health, and we conducted an assessment of one of their products, which is a symptom checker. So what we have done, basically we worked with a private practice of a family doctor in the city of Kruschnopoka, and we have tested to what extent there is a match between the diagnostic that was established by the family doctor versus the diagnostic that was suggested by the platform based on artificial intelligence.

And there are a couple of things that emerged from that research, which is published preliminary, but now we’re working on an academic paper as well. So apart from the match between the diagnostics, what was a pleasant surprise for us was the acceptability of the use of digital means involved in health care for patients. And that was in a way surprising because if we would have had, for instance, a sample of young people, maybe that was intuitive because young people are more likely to be very friendly with technology or knowledgeable or literate.

But we had a very diverse cohort of people age-wise, and we were surprised to see that there’s a high degree of acceptability even for people who are, let’s say, older than 60 years old. So I believe there’s a great potential, especially in the situation in which, as I said, we have significant shortages of health professionals and using digital technology for symptom checking and deciding whether you have an urgent condition that would necessitate that you go to a health care facility or to see a health professional can reduce the burden on our emergency departments or on our general practitioners. And also it’s a great way to contribute to improving people’s health literacy.

Radu Meza:

Maybe I would add to that. Some of the challenges that digital platforms have come from the way that they’re different from traditional mass media that contributes to existing command and control structure. That maybe favor the pushing of information from authority sources to the general population. In the sense that you have alternative messages coming out in various places and then the cumulative effects of group thinking, confirmation bias and maybe general mistrust in authorities or in science that has taken root in some places of society, especially in groups that are often marginalized.

This contributes to people refusing or becoming polarized or becoming antagonized against, well essentially their own good, as authority sources recommend.

Rasika Mukkamala:

Thank you for sharing. I think one thing that we’ve been learning in some of my classes is about how to use AI in technology. So it is really interesting to hear that that is something that all of you are looking at too. The symptom tracker, that’s something that we’ve talked about, especially when it comes to emergency rooms and especially symptom triaging about who necessarily needs to go to an ER. Especially here in the US where sometimes that’s people’s only way to get care triaging, what could be done at maybe an urgent care or what could be done at some sort of other alternative.

So it is really interesting to hear that that is kind of happening across multiple countries. How have you both seen digital health communication change over your career and where do you see it in the next 5, 10, 15 years?

Marius Ungureanu:

That’s a very good question, and I remember reading a quote, I can’t remember whether it was in a scientific journal or in a lay article saying that COVID-19 achieved for digital health what health system did not achieve in 10 years. And so that is just to speak of the fact that in extreme circumstances when we did not have an alternative, we had to use telemedicine, teleconsultation, various other types of technology to overcome the fact that we were not allowed to have physical meetings so health professionals could not see patients for some conditions in person.

So yes, if I were to look in the past five, 10 years, there is a great progress in the use and acceptability of digital health within the medical sector. And I believe that apart from the very ugly consequences of the COVID-19 pandemic, there has been something good in the sense that people became aware of the importance of using technology in delivering health services and not only curative services, but also using technology. And we see the increase of mHealth applications to promote healthy behaviors or to do disease prevention apart from, as I said, curative services or applications that help with disease management.

Now, it would be interesting to see how these will evolve with time, and I do not have answers to that because we see that there’s so much unpredicted. We look at the artificial intelligence tools that basically exploded in just a couple of months. It’s been one year and a couple of months since we’ve had these applications and we see that there’s hundreds I know. And it’s complicated for me to see how that would impact the health sector because apart from the fact that yes, we are having an increased use of them, let’s not forget that the health sector is still very conservative. So we are not maybe the first sector that you would have in mind in embracing new technologies or new approaches.

So that being said, I am still hopeful and I would like to commend what you’re doing here because I look at you, at the new generation of health professionals and I believe it’ll be people like you at the forefront of innovation and change in the health system. Because you come with a different appetite for technology, you come with different exposure and sets of skills and knowledge, and I believe really that the future in general and the future of health is in your hands. And I am really hopeful that you will be able to change some of the old paradigms that we’re seeing in many of our health systems.

Rasika Mukkamala:

Thank you. I definitely agree. I think especially working in health care over… I’ve only been in health care for a couple of years, but seeing how much technology has changed since I’ve even started just using different electronic medical records and how we can integrate symptom triage into that and wait times. There’s just so much to do out there and I think it really is up to people who have that technological experience to kind of pave the way and show others that this is what can be done.

Because I think sometimes people just don’t know what the technology can do, so if we can show others what the technology is and how to use it, sometimes that’s the easiest way to get buy-in, is to show them the pros and the cons and to walk them through it because oftentimes you don’t know what’s out there until someone shows you.

Radu Meza:

I would also like to add. On a general level, I think mobile devices and wearable media especially have done a lot to foster this idea of individual responsibility. Because with all the sensors that wearables have, with all the tracking capabilities that mobile media has, it’s a lot of trust on the shoulders of each individual, and this is contributing to this feeling of individual responsibility for tracking your data, your heart rate, your number of steps, drinking enough water. It’s the small things, but that often got neglected or maybe were considered to be the responsibility of caretakers, medical doctors.

But now I think a lot more people who have started using these technologies have… When using these technologies understood that it’s also of course a matter of individual responsibility. It’s not only the system that has to take care of them, but it’s also of course, “Okay, I am seeing that maybe my heart rate is going up or I am having some trouble that comes out of the data.” And then that can of course make me realize that I have a problem. I need to go see a professional, a doctor and say, “Okay, maybe what’s the problem that comes from this data that my devices are giving me?”

Rasika Mukkamala:

I think that brings up a really good point. I think it brings up a lot of autonomy for the patient themselves, especially I know with the Apple Watch. And if you go on the Apple Health app, it will tell you your walking trends for the past 10 to eight weeks. And so if you look at that as a consumer, you can tell, “Okay, maybe I’ve been more sedentary for the last six weeks. My doctor told me at my last physical I need to walk more.” Those kinds of things can make you more of an informed consumer I think of health care, and I think it provides people with data to back up the claims that physicians or other nurses or health care professionals provide.

So I think it is kind of a nice balance if patients know how to use it appropriately, and if one day we can hopefully partner our health care with that technology. Because I think that is really where AI and other technologies are moving toward is having, especially I think here in America, it be patient-centered care. So I think having that data and also having the professionals give opinion based on the data, it will all eventually, I hope, work together to create a really integrated system.

Marius Ungureanu:

If I may add on this, because these are very good points. Another angle that maybe brings value to the discussion is the issue of trust. Because whenever we’re speaking about this collaboration between individuals and health professionals, we need to have trust. Trust is a key component. It’s a core component in this relation, and from what you’ve said, these are all situations when it works for the best of the people because it either prevents them from being sick or helps them manage their condition, but then there’s a positive impact on health professionals and also on the system because it reduces the burden of the system.

One other thing where we are not seeing that encouraging results is the fact that many times people do not trust professionals and do not trust the science behind them. Specifically, I’m looking at the example of our home country Romania, where we see a dramatic decrease in vaccination rates. And unfortunately, this is not looking good because we’re seeing resurgence of diseases that we haven’t seen in years and they have been eradicated. We’ve seen cases of polio and that’s maybe most dramatic, but we see also an increase in the number of measles and rubella for which we know that we have vaccines and science has proved over the years that they are working.

I believe that there’s still a lot to do in that regard in strengthening the trust between population and health professionals in the area of vaccination. Be it for children or young people, but also in the case of vaccines for young people. In Romania, we have a great progress now. The government has subsidized HPV vaccine, so now women even up to the age of, don’t remember exactly, 40 or 45. They are eligible to receive free HPV vaccination, which is really great, but still we need to work under trust so that is really deployed and has a significant impact on the health of the population.

Rasika Mukkamala:

I totally agree. That’s a great point. Thank you for sharing.

Victor Fontanez:

So speaking about trust, how do you think social media has impacted health care and the patient-physician health care professional relationship in general in terms of trust and personal responsibility, that kind of stuff?

Marius Ungureanu:

From my side, and I’m sure Radu has a complementary perspective. From my side, I believe that there’s a mixed result because on the one hand, social media has erased some barriers between people and health professionals. And if I were to think about the Romanian health system, which was historically very hierarchical, very paternalistic, we’ve seen some of these barriers disappear. We’re not where we should be from my perspective, but still there is some progress. And so there’s improved communication, there’s improved trust between the population and health professionals.

The flip side of that though is that many times with this increased access to various types of information including misinformation, disinformation. This has eroded the trust that has been built between the population and health professionals. And many times it’s very difficult for health professionals to rebuild this trust. We know that we have shortages of health professionals. We know that the volume of work is really high. So many times there’s not enough time for health professionals to sit with every patient and debunk all of the myths that they might have encountered on a dubious Facebook group, for instance.

So I believe that is where the danger comes from. And I know that Radu and his team has done a lot of research in that regard, and it’s not all us. So I do believe that we need to be optimistic, but nonetheless, I see it as a serious challenge.

Radu Meza:

Definitely. I see the positives as well. You have health professionals and having access like never before to public spaces, to also audiences whom they can speak to directly, and then they can sort of narrow or bridge this gap between professionals and authorities and the people. But on the other hand, of course, you have a lot of people who out of ill will or poor expertise come into these public arenas of debate and foster mistrust in official discourses, in authorities, in the health system itself, or tend to direct people on maybe a wrong path that is away from the scientific method, path that is looked at or constructed as just an alternative.

But that alternative is not scientifically sound. It is not the same to say, “Okay, this is your opinion and then this is my opinion and everybody’s free to choose,” is a position that is supported by evidence and by the scientific method and usually by the authorities in charge of a system. And then other opinions or from fringe groups or from various, let’s say, strategic communication aimed at misinformation. They don’t have the people’s interests as a priority and they’re just trying to sow mistrust. And of course that may lead to catastrophic results as in lower level of vaccination.

And as Marius previously said, resurgence in all sorts of infections that had previously been eradicated or we have a clear solution to, but people are not willing to apply any longer due to mistrust. So that’s perhaps one thing that ties together this area of digital communication with public health. And I think in the future is going to become an important pillar of public health to first monitor and then second, deal with what is going on in public spaces.

Rasika Mukkamala:

And I think one thing that as a young person going into health care that I feel the need to do is to educate myself on what really is truth and what is not truth. And I think it comes down to researching different articles or finding multiple journals that corroborate the same argument rather than just believing the first thing that you see. I think that’s one of the things that we learned during Covid, was kind of the mistrust and a lot of false arguments that were posted online. And a lot of people were just reading them as if they were fact. And kind of like you mentioned, it was just a Facebook group, someone posting.

But it really is about making sure that we’re educating ourselves about the topic appropriately and then the information that we as leaders or as health professionals are sharing that it’s accurate and based on scientific truth because we don’t want to be sharing wrong information. So I think that’s something that’s really important and that we’ve kind of learned in our classes is to make sure that everything’s evidence-based rather than just made up. So I appreciate your thoughts on that as well. Our last question for you is something that we ask all of our guests on the podcast, and it can be about health care, it can be about whatever you’d like.

But what is one thing that you thought you knew but were later wrong about?

Marius Ungureanu:

This is a tough one. If I were to think maybe in terms of health systems, and this is something that I’ve been discussing during some of the discussions here at our visit at University of Iowa. When I was at the beginning of my career, I was very much thinking that the challenges of our own health system are unique to us and they stem from the fact that we had the past that we had, the system has been organized in a very different manner than how it is today or than how other health systems are being organized.

But as I progressed in my career and as I visited other health systems and collaborated with other colleagues, I realized that we are sharing very similar challenges regardless of how we are being organized or the structures or processes in place. And the implication to that is that it gives great opportunity for learning. Because if we are to think of global health, we tended to have this perspective that knowledge needs to go from north to south, from well-developed economies to less developed economies. And the reality is that that’s not the full picture.

There’s a lot of learning that can happen from south to north and from less developed to more developed countries. And we are all in this together and we don’t have to be ashamed of the challenges that we’re having. I guess just like in medicine, the first step to a great diagnostic is recognizing the full array of signs and symptoms. And so similarly, we need to be open and transparent about our challenges and then be willing to learn from others and find common solutions.

Rasika Mukkamala:

That’s great. Thank you.

Marius Ungureanu:

That’s very hard to follow up though. But I’m thinking in terms of what I learned in my research on hate speech and polarization online is that I thought that it’s going to be the things that are already happening in the, let’s say, real world. So that the main polarization will be between, let’s say ethnic, and cultural groups like we have had for millennia.

But what the new digital media ecosystem changes is that a lot of the reasons why people start becoming polarized against each other, hateful and mistrustful of each other has to do with political campaigning and the aftermath of some discourses that are constructed in a certain context to win some elections, but then have long-lasting consequences on all of our lives because they create new reasons why we should hate each other, new differences that were not there before. They’re just constructed at the level of discourse because of course you have some or other political candidate that wants to construct this us-versus-them picture of the world.

And then what that impacts is that maybe we have this us versus them in the area of trusting science or in the area of vaccination. And then that leads to effects like larger and larger groups being convinced that vaccination is not okay or that there’s an alternative to the scientific method and to scientific truth and to scientifically tested medicine. And we are seeing the effects of that. And I think that comes from discourses constructed within the context of political competition, political game. And I think we should be wary of them when we see them on digital platforms because they have longer lasting effects than we might think.

It’s not because maybe politicians, after they win the elections, and the science shows this, even the most radical of the radicals, after they win, if they win, they become moderate. But the problem is then what do you do with all the radicals that you have constructed so that you can get the votes and you still have them and the effects of the messages and maybe the effects of this polarization are longer lasting. And I think we need to try to understand and try to find ways to deal with that.

Rasika Mukkamala:

Thank you so much for being on our show and coming to visit the University of Iowa. It has been a pleasure to have you both on the show. For our listeners, be sure to check back next week for our next episode, and in the meantime, stay healthy and stay safe. Please like and subscribe if you liked this episode. This has been Rasika and Victor. Have a great day.

Lauren Lavin:

This episode was edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.