Public Health Connects: A Conversation with Dr. Sandro Galea

I find that, you know, we may disagree on all sorts of things, but the one thing everybody agrees on is that everybody wants their children to be healthy. Yeah. So, I really can think of no other value in this country at the moment where I am pretty confident that in any room I walk in, everybody's going to agree. It's a universal tenet. It's universal. We all want our children to be healthy. And, you know, I'm saying our children specifically because sometimes when you talk about yourself, you're like, well, you know, I'm willing to trade it off for certain things. But our children, very clearly, we all want them to be healthy. So, I challenge us to say that's what public health does. And we should all want public health to be a robust, engaged, well-resourced endeavor so that we can create a world where our children are healthy. We spend a tremendous amount of time collecting the dots. We need to spend just as much time in connecting those dots. And that's what Public Health Connect is all about. My name is Dr. Umair Shah. I'm the Secretary of Health for the great state of Washington. This is Public Health Connect. Well, we are super excited to have Dr. Galea joining us today. For me, it's an honor. I've known you for so many years, but this is such an honor to have you here, Sandro. Just for people who don't know, you're the Dean and Robert A. Knox Professor at Boston University School of Public Health, currently. And you are the inaugural dean to be starting in January at Washington University in St. Louis. Do I have that correct? So, you talk about this real notion about people falling in the river, people falling in the river, people falling in the river. In clinical medicine, you're constantly taking people out of the river. I think a lot of this relates to the sort of transition that you're talking about in the middle of the country here as well. You want to really figure out how do we prevent people? Who's pushing people in the river in the first place? How do we prevent them from going in the river? Talk a little bit about what that means to you. Because that's a real population health. That's a very preventive health approach to a problem. Yeah, I think there are any number of metaphors that would apply here, right? We all would rather be healthy than be sick and get treated for illness. And when I talk to large crowds, they say, who would rather have heart disease than treated with effective medicine, versus who would rather not have heart disease at all? We all would say, no, I would rather not have heart disease at all. But that's actually not how we act as a society. As a society, we invest all sorts of money into effective treatments of heart disease, using that as a metaphor. And many fewer resources on the preventive actions to make sure that none of us have heart disease if we can at all avoid it. Now, I always want to be clear when I say this, I don't want to be misunderstood. When any of us have heart disease, we want to make sure there are effective treatments. So this is not in any way an argument against the importance of investing in treatment. But it is an argument in favor of investing in creating a world where we don't get sick to begin with. You know, when you look at globally, the burden of disease, the seven, ten top risk factors for disease are all preventable. They are things like pollution. They are things like obesity. They are things like having inadequate diet, inadequate exercise. These are all preventable. And when we think of them, we make the mistake of either thinking that we should just ignore them and treat the attendant disease, or that we should just blame the individual and say to the individual, why are you not behaving better? Forgetting that ultimately we all behave the way we do as a product of our context. You and I are talking this way because our chairs are arranged in this way. Just as a very simple example of complex. So what we do in public health is about creating a world, structuring the world that keeps us healthy. You know, one of the paradigmatic examples of this in the past 100 years, has been the extraordinary drop in road traffic injuries in this country. Now, road traffic injuries in our view remain far too high, but leave that aside. They have dropped about 200 fold in the past 100 years. It's not because drivers are better. You know, humans remain quite fallible in driving. No, but it's because we have safer roads. We have shoulders. We have shatterproof windshields. We have airbags. We have seatbelts. We have cars that are constructed with crumple zones. That's what has kept us safe. So it's a good metaphor for everything that we do in public health. And the role of public health, academic public health, which is the world I'm in, is to generate the science and scholarship that points to how those who are in public health practice, the world you're in, Omair, can then take that and figure out how to implement it so that we can create a world where we are all healthy. You know, I talk to people of all stripes and the privilege of doing so, and I find that, you know, we may disagree on all sorts of things, but the one thing everybody agrees on is that everybody wants their children to be healthy. Yeah. So I really can think of no other valley in this country at the moment where I am pretty confident that in any room I walk in, everybody's going to agree. It's a universal tenet. It's universal. We all want our children to be healthy. And you know, I'm saying our children specifically because sometimes when you talk about yourself, you're like, well, you know, I'm willing to trade it off for certain things, but our children, very clearly, we all want them to be healthy. So I challenge us to say that's what public health does, and we should all want public health to be a robust, engaged, well-resourced endeavor so that we can create a world where our children are healthy. That's fascinating and brings up this question for me, which is, how optimistic are you that we get there? So I absolutely agree. Walk into a room, 99% of people say, our children, next generation, absolutely. When we start to make our policy choices, we start to make our investments, and we start to go in a different direction. So what's the reason for that? Well, you asked me two different questions. I'm sorry. How optimistic am I and what the reasons are? Well, let's start with the optimism. I've known you for so long, and oftentimes I know you as an optimist. I am an optimist. To borrow a phrase from a colleague, I think optimism is an act of political resistance, and I think it's important to inhabit optimism. And I think what he means by that, and certainly what I mean by that as I borrow the phrase, is that optimism means you believe that it is possible to create a better world, that it is possible. Now, why is it possible? It's possible because more and more people understand this. And now, it may not happen in your or my lifetime, but the world is trending in the right direction. I often ask people, if you were to choose which time in history you want to be alive, when do you choose to be alive? And the answer to that should be tomorrow, because tomorrow is going to be better than today. Now, why do I say that? You know, sometimes people say, wow, all sorts of things are wrong, but they are, but so many things are better. You know, until 150 years ago, people all over the world could expect to live till age 40. Today, in high-income countries, people can expect to live till age 80. That is an extraordinary transformation to go to double life expectancy in 150 years. 150 years is not many generations. It is extraordinary. You know, Hans Rosling, who is a well-known population scientist, now passed away, he used to say, the world is a terrible place. The world needs to be much better. But the world is also much better than it's ever been. And those are all true. So, I am optimistic. Now you say to me, you say to me, now why do we deviate? Well, I think most people, most of the time, if they understand this, will make the right decision. And by most people, I mean people, policy makers, decision makers. So I can't help but feel like the reason we do not is because we lose sight of this. Because it's easy to think about, let me think about a pill that I can give you. And it's harder to say, well, I need to build a neighborhood that is safe and conducive for you to exercise. And so we make the mistake of investing in the pill, not in the neighborhood. Of course, your job in public health practice, my job at Academic Public Health, is to make sure we do not forget that. Very nice, very nice. So you mentioned this a couple of times, this real concept of practice in academia. Let's tease that out a little bit. How do you see the world of practice come back and inform theory? Does it? I'm assuming it does. It should. It should, it absolutely should. And I think theory is a framework, is how we think about the world, how we understand the world. And theory should refine and improve and change as our data refine and improve and change. I mean, 200 years ago, we used to think that health was generated by four humors, by bile, by brown bile and by yellow bile. That was the theory. Data changed our mind. We never used to be able to see bacteria. So we did not understand. I mean, cholera, which was one of the paradigmatic stories of public health 150, 175 years ago, where efforts were made to contain a spread of cholera in London. But that was at a time before bacteriology. We actually had no idea that there were little bugs that we couldn't see with our naked eye that go in water and that infect from you to me, from me to you. So at the time, there were warring theories. One theory was there was something invisible in water. The other theory was that there were these low-lying humors, like these little clouds on the ground that affected people. Now, sitting here today, you're like, wow, low-lying clouds on the ground, that's silly. But if you think about it, is that any sillier than invisible organisms in water? They both sound a little bit, right? They're both a little bit far-fetched. So, but then data, in this case, microscopes allowed us to see bacteria. And so, okay, well, that was the theory that was right. So I think theory provides the framework. Then we have data. Data helps provide the evidence. And that evidence then should inform how we act in practice. You have to stick with cholera epidemic. You have a theory. It guides somebody, in this case, when the paradigmatic story is public health with Jon Snow, recognizing that the data show that people who are drinking water from one particular place were carrying something which resulted in cholera. Public health practice then comes in and says, we should act on that, and we should make sure that the water is clean. So I think that's the link, theory, data, practice. So, and by the way, I can talk to you all day because this is fantastic. This is exciting. I want to really hone in on one thing, this notion about practice and also community and how do we go about doing our work. So at our agency, as you may have heard, that we have a transformational plan that we launched two years ago. And it's really based on the cornerstone values equity, innovation, and engagement. You hear those three cornerstone values. What comes to mind? Do any of them resonate with you more so than others? Or do all three resonate with you? Equity, innovation, engagement. How do you put those together in your mind? I think that equity should be at the heart of what we do in health. That we are not in the business only of generating health. We are in the business of generating health, and making sure that we promote health equity. That means generating health in the way that no one is a health left behind. That's equity. How do we do that? We do that through innovating. We do that through thinking of novel approaches that can move us forward. And we do that through engagement, through engaging the populations that we serve. So I think your equity, innovation, engagement three pillars are terrific. I think they're immutable. And I can well see how they can ground a transformational approach to public health. So I commend you to those. No, thank you for that. So the challenge, and this is where it goes back to the practices, how do you operationalize? So we can talk a lot, and even in our agency, we can talk a lot about any of these cornerstone values. It's a very grounding what we do. But operationalizing can be challenging when you have other forces that now say, we shouldn't be thinking about equity. We shouldn't be thinking about innovation. We should be not really engaging others. And obviously, that's a very insular view, and perhaps, but there are forces that are out there sometimes that are either visible or not so visible that create inertia, that stop from being. So how do you operationalize? One of them or all of them, or how many hours do you have? No. So one of my favorite or least favorite stories in public health is the story of Ignaz Semmelweis. Ignaz Semmelweis is the physician who first identified the need for hand-washing to stop transmission of disease. Ignaz Semmelweis did that while he was in hospital, observing that physicians were doing autopsies, and then without washing their hands, going on to deliver babies, and that as a result, mothers were dying from what at the time was called peripheral fever, which is postpartum fever, essentially an infection. He said, we need to make sure that there's hand-washing to stop transmission of something. Again, the theory between the autopsies and the actual practice of medicine. Now, the story is terrific in terms of science, observing something important. It is also terrifying because Ignaz Semmelweis was not listened to in his time. In fact, he was hounded out of the hospital. Other physicians did not believe him, and he died without a medical practice, penniless, and in what at the time was called an insane asylum. That's the story of Ignaz Semmelweis. And the reason I'm telling this story is it's a cautionary tale because he was innovating. He was thinking about ways to do things in a way that engaged all of us. And he was rejected by the orthodoxy of thought at the time. He was pushed out by the establishment. And that should remind us that while it may seem obvious to you and I as old friends and colleagues who have been trafficking in the work of public health for so long that equity, meaning nobody being left behind on health, innovating to achieve equity, and doing so in a way that engages communities, it may seem obvious to you, it may seem obvious to me, but history teaches us it is not universally embraced. So our job is to make sure that it is universally embraced, that the progress, to continue to make sure that the promise that I said earlier, that the healthiest time to live is tomorrow, it is meeting. And in this country, we have had setbacks on this. Leaving aside the COVID moment, which was an enormous setback, before COVID, the US had had three years of year-on-year drop in life expectancy. We were going backwards. And we should be better than that. So I think when you have health departments like yours who have such a clear eye to saying, we want to transform the health in our state, and we want to do that in a way that no one is left behind on health, equity, we are willing to innovate to get there, and we're going to engage all relevant stakeholders and communities and populations that we serve to get there. I sit outside and look at this and say, that's exactly what public health practice should be doing. Hats off. Well, I appreciate that. Thank you. I actually bring something else that you've mentioned maybe I'll unpack for just a moment. Are there parts of the world, I mean, you have so much global experience, right? Global health, global experience, global learnings. Are there parts of the world where you feel like they got it better? They got it right? They're further advanced when you come to how do we approach this notion of advancing community health, advancing the health of a population? How would you, maybe not necessarily saying this country or that country, but really thinking about, are there themes that come out, like the secret recipe on how do you advance that kind of health that we can learn here? Yeah, I'm often asked that, and I don't know that I can point to any one country in the world that I can say is getting it right in all dimensions. And the reason is because it's hard to get right in all dimensions, because I think we can point to places for example, which typically is in public health, Northern European countries that have really long had a focus on equity. But I'm not so sure that they've actually been as focused on innovation as you are being in Washington. And I'm not entirely sure that their engagement with communities is as broad based as is your and my notion of engagement with much more heterogeneous communities. So I think our job is to learn from as many places as we can, I think domestically and globally. The great American experiment is, as an immigrant to this country, I care a lot about the great American experiment. And there are tremendous ways forward that this country has moved based on a lot of elements that are foundational to it. One of the challenges I think sometimes we have though is we are too insular. We don't look out into the world. We aren't looking to learn from the world. And I think that's something that we can do better at. And there is a long tradition of thinking about the theory and data collection and actions of public health, for example, in South American countries, in Latin American countries. There is a strong tradition in social democratic countries in Europe. There is a long tradition of culture embedded in the health-promoting practices in Sub-Saharan Africa. These are examples from which we can borrow to integrate into what we do in whatever is relevant cultural context. And there's no one model that I think is wholesale transportable from country X into the U.S. And certainly the U.S. is heterogeneous enough that what makes sense in Washington state may not make sense in Missouri, may not make sense in Massachusetts, and even within Washington state, of course, there's enormous heterogeneity. So I think we need to have the flexibility and imagination to think how do we translate the data that emerges from our population health science to generate the health of populations wherever we are. That is where you are leading us in public health practice. And that is what I look at from the outside and think, that's pretty awesome. I often reflect that, and I say this publicly, I have the privilege of being in the academic space. Academic space is much easier than the real world because, you know, we can do data. Last few years have been a little tough, yeah. But we can do data, we can have ideas, but you implement them. And that is harder, but, of course, also more direct to me, yeah. Well, a few things that you said earlier, context matters. The learnings and the bidirectional nature of being able to share matters. And then this real notion of imagination. I love just putting that all together. Okay, so maybe my final question is about, and maybe you brought this up, or maybe it's my second to final question. You brought this notion about tomorrow, that tomorrow is better than, and then you fill in the blanks, right? So I was gonna ask you about tomorrow as in next year, 2025. Obviously, you'll be in a new context as well, but our nation is going to be going through a tremendous amount, potentially, of change, regardless of what happens at the national level. We have so many challenges and issues. What gives you hope for us being on the other side from 24, getting into 25, that it's going to actually speak to what you said earlier about tomorrow being better than yesterday? I think two things give me hope. Number one is, you and I are talking at the end of 2024. We are now four years into getting close to five years past acute COVID. And the COVID moment, which was a horrific moment, at least 1.2 million Americans died. Americans ended up having long-term sequelae of COVID. I mean, it was the most dramatic setback to population health in this country, really, since the 1918 flu pandemic 100 years before. When we emerge from a moment like that, there are learnings. It is a moment of eye-opening for opportunities. And I, it's a bit of glass half full, glass half empty, right? Or mug, it's a mug half full, mug half empty. Then glass half, in the glass half empty perspective is, we're not paying as much attention as we should to the lessons learned from the moment. Glass half full is, but actually we are paying some attention. And there are issues that we are discussing now that were not as commonly discussed before COVID. 2019, 2018, equity was not front and centre in the nation's agenda around health. Now, you put equity as one of your three pillars, and nobody backs it up. It's like people understand that it is central to what you do. So I think number one, what gives me hope for tomorrow is, there are issues that are on the table now, much more front and centre on the table. More so than ever. More so than ever, so that's number one. Number two is, what gives me hope is always the same thing we just know about tomorrow, which is the next generation. When I have the privilege of being the Dean of the School of Public Health, which means it's a school, we have students. And the students are, well, they're just phenomenal. And they're just smarter, better, more dedicated than my generation was when we were at their stage. And I think the next generation will be even better than them. And that is, as it should be, right? The students are scaffolding their learning on previous generations, and subsequent generations will do that on theirs. So I think it is important that we lean into hope. And that propels us forward. Now, we can be afraid of many things. But to quote Maya Angelou, fear and hope cannot coexist. And we should invite one to stay. And given those two, I'd like to invite hope to stay. I love that. That's fantastic. And I think you're so right. The next generation of leaders, next generation of public health practitioners, that always gives me inspiration. Whenever I go to an academic centre or a school of public health, and I talk to the students, I come back even more reminded of the mission and why we do our work. So I love that. Thank you so much for this conversation. I have one more last question. I'm going to roll over here to this apple. And this is the launch of our initiative, Be Well Washington. And we're very excited about this initiative for 8 million Washingtonians promoting health and wellness, and movement, nourishment, emotional well-being, and social connection. But what we're saying to Washingtonians is find your apple. What's your apple? What gives you energy or your vibe or your jam? Whatever the words are you want to use. Some people say it's growing apples. Some people say that it's dancing. I want to give this apple to you. But as I give this apple to you, I want to ask you, what is your apple? Dean, Dean Galea. Do I get to keep the apple? If you answer the question. Okay. You got to answer the question. I will answer the question. I didn't say even well, it's just your answer. I like this apple. I think my apple is purpose. I actually, I think it's such an extraordinary privilege to be able to get to do what I do, to engage in the world of ideas around generating health and populations. It is something which I never imagined that I would be able to do. And to have the opportunity to do that, I've been able to do it now for 25 years, to have the opportunity to do it, and creating a new school public health area, that motivates me. It contributes to my emotional wellbeing, which is one of your four pillars of your Be Well Washington. And it moves me forward, keeps me focused on tomorrow. And I'm talking about this as an individual, but actually we do have plenty of population-based studies that show that actually purpose is immensely motivating and well-associated with people's mental health. That actually having meaning, having reason, having areas to contribute to, propels us forward. That is my purpose. I love it. Now, can I continue? Yes, you can. Absolutely. Just don't eat it. Thank you so much, Sandro. It's so fantastic to be here. You heard it from the expert right here.