Jake speaks with Dr. Sandro Galea, who proposes how to address, or at least how to think about the American crisis of faith in public health in the wake of the pandemic in his new book, Why Health: What We Need to Think about When We Think about Health. Dr. Galea is the Dean of the Bursky School of Public Health at Washington University.
Transcripts
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Health, definitionally, is political.
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There's no hiding from this reality.
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It is okay to say health is political.
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I mean, what a great name: Make America Healthy Again.
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This is a wonderful way to capture the imagination.
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And I am trying to push us to reflection.
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And I think now —
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I think it is a better time than any to reflect, because it is a moment when we're
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under pressure, and it is a moment when there is an opportunity
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for reinvention and reimagination within public health.
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And that is the right moment for reflection.
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Hello and welcome to Wooden Teeth,
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a podcast about truth-telling on politics and health.
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I'm your host, Jake Williams. Today's truth:
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our approach to public health is going to change in the wake of the pandemic.
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The only question is how. Our guest today,
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Dr. Sandro Galea, describes this point in time as our post-war moment
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in public health. His new book,
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"Why Health? What We Need to Think About When We Think About Health,"
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examines the values that underpin the work of public health as
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a means to determining a way forward.
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Dr. Galea is the Dean of the Bursky School of Public Health
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at Washington University in St.
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Louis, and we had a great conversation about politics,
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disagreements, MAHA, and more.
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You're gonna like it. Here we go.
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Dr. Galea, welcome.
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Thank you for having me.
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All right,
so I think this might be our first,
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perhaps our second, I can't remember,
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repeat guest. Welcome back to the podcast.
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The first time you were with us,
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it was to cover your book, "Within Reason:
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A Liberal Public Health for an Illiberal Time,"
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which addressed
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some of the misdirections you observed
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that hampered public health during the pandemic.
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And now here we are, nearly three years later,
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we have this book, "Why Health?"
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which you've positioned interestingly as speaking in a post-war moment.
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Please expound: what is this moment we find ourselves in,
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and why did you feel compelled
to deliver this book right now?
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Yeah, well, first of all,
thanks for having me back.
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I enjoyed our first conversation.
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You know, I mean that...and the term is not mine.
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It was a term that was used by
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an effort at creating a commission after COVID
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that didn't happen, but the report that the folks behind it issued had
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the title "Post-War."
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You know, it's been six years since the pandemic started.
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And there has been a lot of conversation,
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there's been a lot of discussion,
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a lot of thought about what happened then.
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A lot of the issues that flared in the public consciousness remain live to this day.
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We have a movement like the Make America Healthy Again movement that
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really emerged as a direct result of challenges
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and, I think, public fractures around what we think about when
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we think about health. And I felt like I wanted to try to bring some
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ordered thinking to this moment, and to say: look, we are past the acuity
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of what we experienced in the pandemic, and as we get past that, what should
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be our underlying thinking about health going forward? You know, the book
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is called "Why Health?" but the subtitle of the book is "What We Need
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to Think About When We Think About Health," and it is a deliberate subtitle, because
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what I'm trying to do is articulate
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what I call a practical philosophy of health.
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It is to try to elevate issues that I think should be
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on our minds when we think about health,
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when we make decisions about health.
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And my aspiration, if one were to articulate it, a long-term aspiration,
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is just that these ideas become commonplace
in the health conversation.
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That, as we navigate thinking about health
on a practical implementation level,
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thinking about health at a policy level,
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thinking about
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trade-offs that we have to make as we
as a society aim to be healthier,
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that we do not forget some of these ideas.
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That's my goal.
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I enjoyed the book, and I enjoyed the format, first off.
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It's a series of short essays,
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which I regarded as really
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insightful small bites that a small brain like mine
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can get its arms around. And a few
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of those chapters
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caught my attention. And naturally,
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given that this is a podcast about
politics and health
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the one about the political decision
that health matters
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is really what piqued my interest first.
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You say that sometimes,
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when we consider political issues
related to health,
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we think about the trade-offs,
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but more often than not
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we approach these issues with a spirit of neglect.
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What do you mean by that?
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Well, I suppose a core argument I'm making throughout the essays in the book
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is that health, ultimately, is a social construct.
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Health is not the absence of disease.
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I mean, disease itself is a construct.
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What we consider to be healthy and unhealthy is a construct.
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These are lines that we draw, that we negotiate amongst ourselves as a society,
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and that we renegotiate. To take — well,
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let's take one concrete example,
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because this sounds pretty abstract.
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You know, what we consider
to be harmful drug use,
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for example, has shifted from generation to generation.
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Now, let me move to something perhaps a little bit less touchy.
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What we consider to be
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healthy,
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or reasonably healthy, functional —
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cardiac or physiologic function — shifts from generation to generation.
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And when you think of it that way —
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not to mention, of course, today we're having this whole conversation about what
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is mental health, what is mental illness —
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all of these things are ultimately constructs.
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When you realize that these are socially determined constructs,
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anything that's socially determined ultimately is political.
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Because what do we mean by politics?
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Politics is about
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how we, as a society, decide to allocate resources.
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And it is resource allocation —
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be it actual physical resource, or be it attention and time —
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it what determines what we,
as a society, invest in.
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So health, definitionally, is political.
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Now, once you accept that,
then becomes the question of,
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well, what do you do with that?
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And how do you intersect with
the decisions that we make
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about generating health?
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And what I'm trying to do in the book is to encourage us to realize that
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there's no hiding from this reality.
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It is okay to say health is political.
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And that should lead us to thinking about health in a particular way:
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to be very clear about what the empiric work is,
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to be very clear what the complementary but different
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thinking, perspectives, values,
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decision-making are, and that we, as a society, have to bring those two together
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in any important decisions that we make.
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You know, when I think about the role of government and health,
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it's apparent in my brain
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that, if keeping people healthy isn't what government is for,
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then what the heck is it for?
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And I also recognize that
not other people think that.
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Do you think that we could ever
get to a place where
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the prevailing political sentiment is that?
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Is that people expect
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the governor — excuse me,
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the government — to
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create the conditions necessary
for us to be way healthier
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than we are right now, at a level that is correspondent to our
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economic state here in the United States?
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I'm an optimist. I'm a pragmatic optimist,
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but an optimist. And I think the short answer, then, is yes.
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But in order to get there, we need to move beyond thinking of health
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as being about disease. Because if you were to survey a thousand people
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and say, "Do you think that the absence of disease should
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be government's top priority?"
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you're gonna get very few people saying yes.
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But if you survey those thousand people and say, "Do you think government's
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top priority is making sure that you have the potential to live a
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fully realized life in accordance with your own personal aspirations?"
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I bet a thousand people would say yes.
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“That's what government should do.
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I want government to create the way for me to live a fully,
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richly realized life, the way I would want to live it."
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Well,
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that
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is the same as saying we want governments to create health.
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That's why I go through quite a bit of pains, in multiple essays in the book,
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talking about what we mean by health.
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Health is not the absence of disease.
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Health is a means to an end. That end being that you and I can live richly realized lives
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in accord with our own personal aspirations.
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Once you understand that, then I think we have a lot of shared ground.
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Now we have a lot of commonality.
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Because, you know what, Jake, you and I
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don't need to agree what that aspiration is.
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You have your aspiration for
how you want to live your life.
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I have my aspiration for how
I want to live my life.
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But what we can agree on is that
we want to be able to do that.
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And I think once we accept that,
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there's a lot more ground for agreement on what health is
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than there is, frankly, about almost anything else in our society.
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Let's build on that idea with another idea that you present that really resonated with me
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which is
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creating dignity as the ultimate goal of health,
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which I found really intriguing because,
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you know, thinking about it, given what,
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you know, we do over here at Healthier United in our day job,
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thinking about it as a political strategy —
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you know, there's been a lot of
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questions and consternation over
the past twenty, thirty years
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regarding, you know, why
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voters in many cases vote against their interests,
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for example. And Democrats will ask,
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"Well, I don't get it. You know,
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we gave them insurance subsidies in this bill.
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Why don't they support that bill, and/or me as a candidate?"
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And, you know, I think that a lot of it has to do with this idea of dignity,
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this idea of
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some people being skeptical, at least, that
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they're being treated in a way that's respectful and takes their dignity into account
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even if it doesn't line up with the literal policy proposals that
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a politician is presenting. The way in which
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these politicians communicate with voters
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falls short of indicating that they have respect
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and have that person's dignity in mind.
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Am I on the right track? What do you think?
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Yeah, I actually think you're completely on the right track.
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And I think this is why I wrote that chapter,
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and it's a thread throughout the book.
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And I see
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living a dignified life as being
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consistent with this thesis I'm making: that ultimately what health is about
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is that we can all live
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richly realized life. A richly realized life is a dignified life,
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and that is the goal. That is the goal.
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We want health
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to allow us to do that. And when you realize that,
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right, things fall out from it,
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meaning one should not be willing to accept medical interventions —
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using the term intentionally — that rob us of dignity,
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except in particular circumstances, under clearly circumscribed conditions,
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for a short period of time. Because the end is not otherwise justified.
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Otherwise, the end is not justifying the means.
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And the end is to be able to allow us to live fully realized,
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rich, dignified lives. And that,
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I think, if we can make that case,
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we will have a lot more agreement with the centrality
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of a pro-health agenda in this country than we have right now.
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And I think the disagreements we have are because
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we have not made this case clearly.
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Because when we say we disagree about health,
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we're not really disagreeing about health.
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What we're disagreeing on is particular disease-mitigation
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or disease-curative measures. And those are very specific,
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particular approaches. And we disagree about them, often, because
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we are uncomfortable with how they affect
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something more precious to us,
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which is living dignified lives.
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Right now we're working on a project that is trying to construct a better future for public health
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And to inform it,
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we interviewed folks from around the country:
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health secretaries, advocates,
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foundations, etc. One of the themes — it wasn't universal,
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but it was prominent — was that people felt that public health was trying
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to do too much. And one of the essays in your book is "Can We Deal with Everything
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All at Once?" What did you conclude?
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Well, my simple conclusion is no,
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we shouldn't be everything,
everywhere, all at once.
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And to tie it into this conversation,
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Jake, that you and I are having:
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we should, in fact, be only about one thing.
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And that one thing is creating the conditions so people can live richly realized,
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full, dignified lives, right? So,
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if you see it
that way, there's only one thing we're doing.
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The other things are all elements that get at that.
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And we need to have the wisdom to realize: when should we take on five elements?
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When should we take on twenty elements?
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When should we take on thirty elements?
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There are all sorts of elements that go toward creating a vision of
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the world that way, but it doesn't mean we have to do them all at the same time.
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And we need to have the wisdom to realize when we should take some things on,
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when the world is ready for us to take some things on,
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and when the world's not ready. And when we are, it's okay
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to let well enough be alone. You know,
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sometimes you hear from those of us who are in the business of health —
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and I'm using "health" here in a more traditional sense —
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"how could we ignore that thing,
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because it is hurting
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people's health?" Well, we ignore things all the time that
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are hurting people's health. I mean,
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for example, we tolerate speed limits that we know — were we able, were
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we lowering speed limits everywhere,
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we would have far fewer injuries and deaths.
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But we tolerate speed limits being at 55 miles per hour on various highways
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all the time. So we actually tolerate all manner of things that we could optimize.
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But sometimes we make the mistake of thinking
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we must tackle everything, everywhere, all at once.
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And I suppose I'm arguing: no,
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we must not. Because if we do,
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we lose the larger picture. The larger picture is, our job is to,
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as much as possible, create the conditions so everyone can live fully realized,
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dignified lives. And that is what we should not compromise on.
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As I speak, we have a poll in the field in Michigan, and among the questions
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we ask is one about how public health agencies can do a better job.
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And one of the options, for example,
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is to be more transparent with their processes,
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including regarding mistakes. And I was thinking about that poll question when
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I was reading a chapter on the potential and limits of science, and
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how difficult it is to communicate clearly to the public and, you know, follow
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a rigorous scientific process.
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I guess I'd put my question like this:
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how does public health reconcile the biases and imperfections
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of the scientific process with the need to communicate clearly
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and perhaps confidently to the public?
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Well, I think, like many hard things,
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we do it by being careful and intentional about how we do it.
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We have had the misconception that the public needs
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us to communicate with certitude.
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And I wrote in the book, and in other places, that I think that's false.
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The data are, to my mind, relatively clear that
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the public responds to communication that is honest and is able
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to handle uncertainty, as long as the uncertainty is explained.
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Science is the most wonderful thing we can do as a species to ennoble
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and elevate ourselves. Generation after generation,
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we do ever better science, which observes nature so we can learn from it
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to the end of improving ourselves.
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It is a wonderful gift that we, as a species, give to ourselves over and over
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and over again.
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But science is imperfect, it's fallible,
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it is dealing with all sorts of unsolved questions at all times.
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And we can both celebrate science and recognize its limits.
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In my observation, we have had a hard time with that sometimes.
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We have found ourselves being pushed into a corner where,
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if you're criticizing science,
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then somehow you're anti-science.
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And if you're pro-science, somehow you need to say that science should trump
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all other social values. I disagree with both of those extremes.
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I think science makes an enormous contribution to the human condition.
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But what emerges from science has to live alongside other aspects
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of the human condition — the aspects that give us joy and pleasure,
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what gives us grief and sorrow.
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And those are all inputs that we, as a society, must weigh to make decisions going forward.
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And, tying this back to health,
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you realize now how the whole picture comes together.
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Because that is also what we think about when we think about health.
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It is a compound set of social decisions
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that are driven by many inputs:
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some from science, some from values and beliefs.
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And we, as a society, must negotiate and navigate that space to
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get to a place where we elevate health that serves most of us, most of the time.
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You were in public health academia before the pandemic, and now here you are
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as a dean of a public health school.
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I have persisted.
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You've persisted.
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I'm wondering now: are the students in your courses —
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are their attitudes or regard for public health different than they were back when
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you had students before the pandemic?
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And, if so, how?
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I think students today in public health are more thoughtful.
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I think the pandemic moment has pushed anyone in the field —
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be they a student, be they a professional —
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who is being deliberate and careful about it,
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to reflect more deeply about what is our role.
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What is our role in public health?
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How is it that we intersect with these competing
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social values? And I think students are much more open to having these conversations today.
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We are seeing more people who could be students being afraid of engaging
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in public health, because the moment has, in its sort of didactic binaryism,
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has told people to be afraid of public health, because there's danger
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in these challenging issues. And we're gonna get over that, because
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the world is going to need public health for as long as you and I
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are around, and many, many generations hence.
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But, as a result, the students who are in public health, I think,
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are even more thoughtful and even more deliberate about how they engage
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with these questions. Which brings me back to my saying I'm an optimist, because I think
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I have seen the future. The future is the students,
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and they are
(Mm-hmm.)
better than they were.
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I noticed that you included an anticipatory, or even preemptive,
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chapter in the book on disagreements,
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in which you write,
(Yes.)
"I suspect that readers who note that I am asking us to rethink
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our fundamental philosophical approach to health may worry that
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I am empowering those who wish to undermine the work of health."
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I'm wondering why you included this chapter, and if there's any relationship
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to feedback that you received
on your last book, or not.
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Yes, there is. You know,
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we are all a sum of our priors, and I'm no exception.
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You know, I think there is an argument in the field about: is this a moment
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in time to challenge from within the family?
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And I think it is. I think it is.
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I think the field is strong enough to withstand
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disagreement — disagreement that is hopefully thoughtful,
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that is careful, that is responsible,
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and that challenges all of us
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to get better in what we think about when we think about health.
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I also expect that some will disagree —
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and some have disagreed — and said that, in this moment when public health is challenged,
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and we should be upfront about this.
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When public health is being challenged by the executive branch.
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I mean, it is — you know, the president, he has been challenging public health
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in his first term, is challenging public health in his second term,
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and that's difficult. That's a difficult moment to be in.
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But I don't think that that moment means that
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we do not do the hard work of improving who we are, and improving who we are as a field.
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And I am trying to push us to reflection.
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And I think now — it's not just as good a time as any to reflect;
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I think it is a better time than any to reflect, because it is a moment when we're
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under pressure, and it is a moment when there is an opportunity
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for reinvention and reimagination within public health.
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And that is the right moment for reflection.
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What did the rise of the MAHA movement indicate to you?
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And how would you regard the movement going forward, in terms
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of a potential partnership or a threat?
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First of all, I'm always jealous
of the movement name.
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I mean, what a great name:
Make America Healthy.
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This is a wonderful way to capture the imagination.
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But I think the emergence of the MAHA movement as a challenge
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to mainstream health thinking
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reflects, to my mind, a real problem with mainstream health thinking:
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that we could not hold this plurality of perspectives within the tent,
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that the people who were behind the MAHA movement felt they had to
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go outside the tent and then challenge the establishment from the outside.
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I think that is a failure of a big-tent thinking about health.
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And that pains me.
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Now, do I think it's a threat? I think the MAHA movement serves an important function.
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It articulates an alternative perspective on many issues.
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Do I think the MAHA movement has achieved the intellectual clarity
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and coherence that a
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different perspective needs? No,
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I don't think so. I think there is a collection of inputs that have become
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the MAHA movement that don't necessarily hold together as well as they could be.
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I think some of those approaches are valid and important.
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The observation that corporate influence plays an undue role
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in shaping the circumstances that keep us healthy,
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which is one of the core pillars of the MAHA movement,
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is a really important observation, and it is something that I am delighted
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to see forces advancing and pushing us to reckon with.
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The observation that we should allow space for heterodox perspectives within health,
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also that are tied to the MAHA movement,
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I applaud, and think we should be absorbed wholesale into anybody's thinking about health.
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The casting of doubt on
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vaccines that we have known for close to a century are efficacious
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and save the lives of children,
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is a really unfortunate addition to the MAHA movement,
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because that is
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literally threatening the lives of children and the next generation.
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So I think there are different pieces of the MAHA movement.
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It is not a monolith.
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I think there are elements that we can learn from.
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And if one were to rise above the individual tactical elements
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to the larger existence of such a movement,
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I think it is good to have movements that challenge
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the orthodoxy, that challenge the received wisdom.
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And I think those movements also have a responsibility to make sure that,
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in so doing, they are not hurting people.
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Well, Dr. Galea, I want to thank you for challenging orthodoxy with this new book
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I thoroughly enjoyed it,
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and thanks for your time here today.
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Jake, always a pleasure talking.
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Thank you for having me on.
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Thanks for listening, and I hope you guys appreciate our new logo and
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kind of look and feel to the website.
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Check us out online if you haven't already.
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You can also watch us on YouTube if you're not already,
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and always like and subscribe to help us get the word out.
