Promoting Health for All Populations

The growing refugee crisis, one of the world’s most pressing global health issues, is addressed in Sandro Galea’s new book, Healthier: Fifty Thoughts on the Foundations of Population Health. An art therapy class (above) for Syrian refugee children at a Caritas Center in Lebanon. Photo by Jane Barlow/PA Wire

Huge strides have been made in advancing the health of people around the world over the last century. Life expectancy is higher now than it has ever been. With the introduction of antibiotics, safer water and sanitation, and broader availability of nutrient-rich food, the numbers of people dying from infectious disease have been dramatically reduced.

But vexing obstacles remain. Billions of people die prematurely. Substance abuse has become a worldwide public health crisis, and war and persecution have displaced tens of millions of people, creating a refugee crisis. Climate change poses serious threats to population health everywhere. And here in the United States, health disparities have either remained constant or increased.

These issues have long preoccupied Sandro Galea, Robert A. Knox Professor and dean of BU’s School of Public Health. An epidemiologist and physician, Galea has worked in remote areas in the Philippines, the Southern Highlands of Papua, New Guinea, and the Mudug region of Somalia, where he served with Doctors Without Borders.

In his probing new book, Healthier: Fifty Thoughts on the Foundations of Population Health (Oxford University Press, 2017), Galea examines the challenges and opportunities facing those working to improve population health and writes about “the need for a public health that is centered around the creation of social justice.”

The book comprises 50 essays, all originated as weekly Dean’s Notes written over two years for SPH community members. Topics range from suicide, LGBTQ health, and vaccines to the deadly toll of firearms, the health effects of war, and the heavy toll of substance abuse. He reflects on the teachable moments to be gleaned from crises like the water contamination in Flint, Mich., and natural disasters like the 2004 Indian Ocean tsunami, and he makes a compelling case for a more active role in global health by schools of public health.

Fortune magazine calls Healthier “the book everyone in health should read…what makes this book so radical—and thought-provoking—is its ingenious composition: fifty dart-like essays that shoot to the heart of an equal number of components of public health in the current age.”

“Social justice is so central to public health that it becomes, paradoxically, easy to overlook,” writes Galea in his new book, Healthier: Fifty Thoughts on the Foundations of Population Health. Photo by Cydney Scott

Galea will read from his book tonight at Barnes & Noble at BU at 7 p.m. BU Today spoke with him about the biggest obstacles to improving the health of populations, how the Trump administration’s agenda could impact health disparities in the United States, and how our current emphasis on lifestyle has come at a cost to public health.

BU Today: What do you mean by population health and how is it different from personal health, which everyone seems to be focused on now?

Galea: I am concerned with the health of all populations, leaving no one behind. Medicine aims to cure disease, maintain our personal health. Population health concerns ensuring that we prevent disease and promote health for all.

What do you see as the single biggest obstacle to improving the health of populations?

The biggest challenge is our lack of understanding that health is produced by social, economic, and cultural forces. That yes, an infectious disease can be the cause of death, but poverty, poor housing, and racism also shape the risks that we may face and ultimately influence our health. Unless we deal with all these forces, our health will be glass-ceilinged.

Is the Trump administration’s determination to repeal Obamacare likely to exacerbate this country’s health disparities?

Health insurance is just one part of the equation needed to produce health, but it is an important part. Congressional Budget Office reports show clearly that a repeal of the Affordable Care Act will result in more than 30 million people becoming uninsured. This will be catastrophic for these people’s health.

Your book addresses the gap between science and activism—why science’s findings often fail to result in clearer action, even when data clearly demonstrate its need. Can you talk about that?

The path between data and action is long and tortuous, and in some ways that is how it should be. It is very rare that any one piece of evidence is, in and of itself, dispositive. So we need the collective action of science, including the argument and back-and-forth that go with having clarity on what is, and is not, truth. In many ways, it is only after science has sorted out the answers that it can meaningfully inform evidence.

I worry that our expectation that a finding will lead to immediate action is unrealistic and not grounded in the reality of how the world actually works. Having said that, there are ample examples about how uncertainty in science has been used to mask political agendas that essentially ignore the science. We see this now in the political challenge to climate change, for example, science that has long been settled. So at core, we need excellent science to have a space to grow and flourish and a societal commitment to empirically grounded policymaking. If we can nudge both forward in our lifetimes, the world will be better for it.

How do we address that gap in a meaningful way?

I think it is the responsibility of scientists first to do the best possible science, but second, to also make an effort to communicate their work clearly so that it is accessible to those who can make change happen. I would not, in particular, ask individual scientists to have to communicate their work: I would rather scientists focus on the basic science. But it is the responsibility of institutions that produce science (first and foremost, universities) to be actively promoting the science, communicating findings, with the end of bridging the data-policy gap.

You stress the importance of “making the acceptable unacceptable” if we are to continue to advance the cause of healthy populations. What do you mean by that?

A hundred years ago it would have been acceptable for you and me to be having dinner in a restaurant while outside the restaurant a child was sick with cholera. We no longer find that acceptable. And that is a testament to our collectively changing what is acceptable, saying that we can do better, raising the bar of our expectations. This is not my original idea. Sir Geoffrey Vickers, a pioneering systems scientist, articulated this idea more than 50 years ago, but it is an idea that I think remains immensely salient today as a motivation. Our job is to say: nothing less than the healthiest possible population is acceptable to us, enormous health gaps are not acceptable, and having the life expectancy of newborns vary by 30-plus years because of the bad luck of birth geography across the world is unacceptable. If these are unacceptable, we can work towards finding ways to abolish them. There is something very powerful about saying that some conditions are simply unacceptable.

You state that too much emphasis has been placed on lifestyle, at the expense of improving public health. How so?

Focusing on lifestyle is simply not enough. Yes, you want to exercise more, eat healthier food. But that is not enough if the color of your skin is subjecting you to racism and marginalization, it is not enough if you cannot afford nontoxic housing, and it is not enough if you are exposed to polluted air that is triggering heart disease. So, lifestyle matters, but it is just one small part of the equation. We have focused on lifestyle, correctly, but have done so far too much, mostly because lifestyle is tangible, we can all see it. But politics, culture, environment, neighborhoods, all matter as much as lifestyle, if not more, and we need to shift our attention to these forces.

You explore the growing challenges of climate change, economic disparities, and firearms. Given the current US political situation, are you optimistic about meaningful change to address these issues?

I am not particularly optimistic if the Trump administration is able to enact its agenda. I am, however, optimistic that there are enough forces for good in the country that will push back, that will make sure the current administration does not dismantle the social and economic structures that we need to create a healthier world. If the current political times serve to galvanize a generation who will act towards a progressive vision of a healthier world in coming decades, our current political moment may be worth it. Almost.

Last, you argue that public health schools need to promote an activist public agenda. Why is that so important and what is SPH doing on that front?

It is not sufficient for institutions that house scientists to settle for being a place where science is generated. We have a responsibility to push an understanding of that science forward, to make sure that science is part of the public conversation.

At SPH, we have launched an Activist Lab to be our lead on intersecting with the real world, including advocacy and education of the general public. But perhaps even more importantly, I think the whole school needs to speak with a clear voice when forces are acting to dismantle the structures that promote health. After all, our school’s mission is “to improve the health of local, national, and international populations, particularly the disadvantaged, underserved, and vulnerable, through excellence and innovation in education, research, and service.” We simply would be failing in our own mission if we did not speak when forces clearly act to harm the health of local and national populations.

Sandro Galea will read from his new book, Healthier: Fifty Thoughts on the Foundations of Population Health, at Barnes & Noble at BU, 660 Beacon St., Boston, tonight, Monday, September 25, at 7 p.m., followed by a Q&A. The event is free and open to the public.