If we had a better public health system in America, would the pandemic have been as bad? Would as many people have died? Was the real point of entry for the virus not just our bodies — but a system of public health that in a sense dared the pathogen to attack us?
With the omicron variant coming at us, this week on the WhoWhatWhy podcast we talk with Dr. Sandro Galea. He is the Robert A. Knox professor and dean of the Boston University School of Public Health, and has been named an “epidemiology innovator” and one of the “world’s most influential scientific minds.”
At the core of our problem, according to Galea, is that we don’t focus on real health care in America. Instead we have sick care. We spend more, almost 40 percent more, on medical care, and get less for it than any other industrial nation, with a lower life expectancy. This explains, says Galea, why we were sitting ducks for the COVID-19 virus.
If we had been a healthier nation to start with, he says, we would have had a very different pandemic. We are overinvested in treating conditions of aging in those over 70, and underinvested in the forces that keep us healthy from a young age.
Galea reminds us that the pandemic is not a singular event that exists in a vacuum. It has exploded, in part, because of 40-plus years of bad public health policy. Still, he thinks this could be a teachable moment.
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(As a service to our readers, we provide transcripts with our podcasts. We try to ensure that these transcripts do not include errors. However, due to a constraint of resources, we are not always able to proofread them as closely as we would like and hope that you will excuse any errors that slipped through.)
Jeff Schechtman: Welcome to the WhoWhatWhy Podcast. I’m your host, Jeff Schechtman. As divided as we are, as atomized as our culture and politics have made us, we might have expected that a common enemy like COVID-19 would have united us. Certainly, history tells us fighting a noble cause often unifies even the most divided of peoples. Instead, COVID has created new fault lines that we seem to be focused on every day.
But what if we’re looking in the wrong direction? What if the culture and political divisions that grew from the pandemic are themselves just the result of the bad politics and the social cleavage that helped create the problem in the first place? What if we need to be looking not for bats or lab leaks, but the system of public health that virtually dared the pathogen to attack us because it knew our weakness? That the real point of entry was not just our bodies, but in our society, that this might be a better definition of what public health really means.
We’re going to talk about this today with my guest, Sandro Galea. Galea is the dean and the Robert A. Knox Professor at the Boston University School of Public Health. He’s been named the epidemiology innovator and one of the world’s most influential scientific minds. He has served as a field physician for Doctors Without Borders and held academic positions at Columbia University of Michigan and the New York Academy of Medicine. It is my pleasure to welcome Sandro Galea here to talk about his new work, The Contagion Next Time.
Sandro, thanks so much for joining us.
Sandro Galea: Thank you for having me. It’s great to be here.
Jeff: It’s a delight to have you here. Is it safe to assume that had the world been a different place, had our society been different with respect to the way we looked at public health that we’d be talking about a very different result from the pandemic that we’ve just gone through?
Sandro: I think there are very few things that are safe to assume, given this pandemic, but I think that’s one is safe to assume, yes. But I think had we had a different world, a healthier world, had we been more prepared, we would have had a different pandemic.
Jeff: And when you talk about a healthier world, talk a little bit about what you mean by that, how you define it.
Sandro: Sure. There are all sorts of ways to define health, but if we just take very simple health metrics, things like life expectancy, how long we live, or our burden of disease, let’s say the burden of heart disease and lung disease and all that, so we as a country, the United States, live shorter, sicker lives than do all other high-income countries. That means when I’m comparing us to other countries, high-income European countries, Asian countries, et cetera.
Now what’s interesting about that is that we pay more for health than do all these other countries, so we pay more by a lot. We pay about 30%, 40% more than the next closest competitor, and we have lower life expectancy and more burden of disease. Just to be concrete, we have about five years less life expectancy than do the best performing other high-income countries. That means that we’re choosing to live five years less than they do, despite again, spending more on health than any of them do.
When you think about that, it is a funny state of affairs and one that we do not accept for anything else. I would actually challenge anybody listening to think of any other sector where we spend more and get less. If you take it to consumer goods, if I were to say your smartphone was going to cost you more, but it holds less data, is slower, has less screen resolution than a comparable smartphone, [unintelligible 00:03:41] you wouldn’t buy it.
But with health, we do that. With health, we spend more, we live less, and we live sicker lives. So that is really pretty incontrovertible, and that, of course, is what made us sitting ducks for the ravages of this terrible pandemic.
Jeff: How much of that, as far as the US is concerned, comes from scale, from the pluralistic nature of the country, from the fact that, in scale, it is so much larger than other places that we’re bound to have different outcomes in different places?
Sandro: I think some of it comes from scale. That’s fine. I think it’s feasible to say someone comes from scale, but the vast majority of it does not come from scale. The vast majority of it comes from the fact that we underinvest in the forces that make us healthy. And I think to understand that, one needs to take a step back and say, “What’s causes health?” When we have a conversation about health, our reflexive answer is that health is about our doctors and about nurses, and it’s about medicine. Now it’s true that that is part of health, but it’s not really about health. It’s really about helping us recover from sickness.
What makes us healthy, Jeff, what makes you and I healthy is the fact that we live in safe housing, that we’re not victims of violence, the fact that we have lower risk of dying from an unanticipated accident, the fact that we have clean air, drinkable water, and safe and nutritious food, the fact that we have livable wages. That’s ultimately what makes us healthy. When I say we underinvest in what makes us healthy, we underinvest in all of those elements. And we spend all our money instead on the medicine side of the house, which is important, and gives us excellent clinical outcomes when we are in a hospital.
But of course, most of us do not want to and neither do we need to be in hospitals for the majority of our lives. So our imbalance is in what we spend our money on. We spend a lot of money, but we spend it all on sick care, and we spend much less of it on generating health.
Jeff: And talk about how taking that attitude towards public health and looking at those things that you’re talking about makes us more resilient to contagion.
Sandro: Maybe I’ll flip it on its head, and I’ll start by talking about how it made us vulnerable to this virus. So this virus hit, and one of the cardinal features of this pandemic, although it’s really true of any number of other pandemics, is that the people who are most at risk of severe infection and dying from the virus were those with underlying disease. And we knew this all the way from January, February of 2020 when the virus first hit China. In fact, one of the things I think wasn’t communicated well enough is that if you had no underlying disease, your chances of dying from coronavirus was actually very, very low.
So you have a virus that hits, and the people who are most at risk of dying from it are those who have underlying heart disease, lung disease, any number of diseases. If you have a country where the rates of those preventable illnesses are higher than a country where those are lower, you can see why the virus is going to hit the country where the rates of underlying disease are higher harder than the ones where they’re lower. So that’s how we were vulnerable.
Now to go to your exact question, how would we have been more resilient, had we had a country where we had better health, as a result, we were less likely to succumb to the virus, that in and of itself, separate and apart from other things which we can talk about, would have made us more resilient to this virus.
Jeff: How do we see that playing out in a similar fashion or differently around the world as we look at other Western countries, for example, in the way they were hit by the pandemic?
Sandro: Broadly speaking, we see it play out in the fact that we did worse than our other Western country peers, just like we do worse than they do in our health on any regular basis. I suppose the core argument here is, although we’re talking about the pandemic, and you introduced us about the pandemic, and the book that we’re talking about is about the pandemic, everything we’ve discussed right now, we could have been discussing in 2015 because these conditions were there long before the pandemic.
And it was equally true then that we were living sicker, shorter lives compared to other Western countries as it is now. It’s just now, we saw that most clearly because we had this crisis, and this crisis, of course, elevated health to the forefront and created this devastating tragedy with so many people dying. And when one delves into what happened and who died, it readily illustrates the underlying conditions and how they are both so unfair and how they hit particular groups much more than others.
Jeff: And did we see this come back to the same idea, as we look at other Western nations, did we see groups that were hit harder than others that fell into some of these categories?
Sandro: We did. And we saw in the United States that people of color, Black Americans in particular, but also Indigenous Americans, Latinx Americans, people who had low wages, people who are immigrants or marginalized in any way had, across the board, more infection and more lethal infection than other groups. The reason why that happened illustrates the fundamental problem. Let’s take, for example, the Black American versus White American comparison. Black Americans died more than twice the rate of white Americans, which is extraordinary when you think about it.
You may remember when the pandemic first hit, there was a lot of conversation, “The virus is going to affect all of us. The virus doesn’t discriminate.” The virus did discriminate. In fact, Black Americans died twice as higher rates than white Americans. Why is that? Two reasons. Number one, the people who are most at risk of getting the virus were those who could not lock themselves away from the virus, could not shift to working from home, could not, all of a sudden, pivot and stay in comfortable houses.
Who are those people? Those are people who actually had lower wages and who were historically more marginalized and did not have those homes, and who work in jobs that don’t allow you to work from home. Who works in those jobs? Who has those living conditions? Those are people with low wages because low-wage jobs, you are less likely to be able to work from home, and people who have historically been kept out due to structural racism from wealth accumulation and homeownership. And that group is disproportionately Black Americans.
So reason A reflected our underlying economic structure, and that’s why Black Americans were more likely to have infection from the virus. Now, how about reason B? Once you have the virus, it may not be severe. Who gets severe infection with COVID? That’s what I discussed before. It’s people with underlying illness. And historically in this country, Black Americans already had about a four-year life expectancy less than white Americans because of greater underlying disease, greater exposure to illness, to violence, to heart disease, to lung disease, to diabetes, to hypertension. So that made Black Americans as a group more vulnerable to severe infection once they got it.
So the black-white difference in death from COVID is to my mind illustrative of these broader features that characterized why the virus hit us as hard as it did. Now of course, I’m simplifying black-white difference, but in fact, there were enormous deaths among white Americans, and we’re seeing rural-urban differences among white Americans. And certainly, from a sheer numbers point of view, most of the deaths in this country where white Americans just from the sheer numbers point of view.
And all of these deaths are tragic. Every death is somebody’s mother, father, aunt, uncle, cousin, lover. Every single one of these deaths. And then there were actually more than 700,000 of them. Because I think sometimes we get almost numb to the number like 700,000. That’s just a lot of human lives. And the argument is with a pandemic like this, was there a way to know that? No, there was no way. We were going to suffer from this, but we could have done so much better had we had a healthier country from point of view of health and had we had the economic and social structures that did not expose some groups to unnecessary disproportionate risk than others.
Jeff: Given the state of play in the country today, given how divided we are, given the political climate, is it not in some ways more problematic to be looking at public health through the lens of racial and socioeconomic disparity, even to the extent that it is absolutely true as a way into beginning to deal with the public health crisis we face? Playing into the divisions that already exist seems in some ways a more difficult way to approach it.
Sandro: Yes. I’m not sure I agree with that. I think acknowledging that there are differences and these differences rest on injustice points the way for good people who have good conscience of all colors to say that they want to be part of the solution. I think saying that Black Americans have historically been marginalized and as a result kept out from accumulating the assets that protect health is simply a clarion call for anybody in the country, be it Black American, white Americans, to say I want to be part of the solution.
In fact, that’s actually I think what has happened historically. The civil rights movement had substantial engagement of obviously led by Black Americans and special engagement of white Americans and people of all colors. And we see it today. We saw it with the Black Lives Matter civil unrest [unintelligible 00:13:19] civil unrest allowed people of all races to participate and to say, “We want to be part of the solution.”
I think there are ways in which one can look at injustice and say, “We together, all of us should find this injustice intolerable, and we together should be part of the solution.” It does not have to be divisive. And I think it’s a sad state on the politics of the moment, which you have alluded to, that these issues necessarily have to be divisive. In some respect, I actually think these issues can be uniting if we say together we want to build a country which isn’t characterized by these injustices, and together we value that, and together we will solve it.
Jeff: How should we define, how should we look at the business of public health today?
Sandro: I think there’s different ways of looking at business public health today. I think one way of looking at it is that there has been a surge of interest in public health like none we have seen in the past 100 years. I have the privilege of being a dean of the School of Public Health, which means I have this enormous joy every year of seeing young public health professionals there coming. They want to study public health. And we’ve had about a 20%, 30% increase in interest in public health in the past year, as have all other schools of public health.
So in many respects, that’s wonderful. We have a generation of younger people who are really motivated to be part of the solution of creating a healthier world and doing this for public health. That’s from one way of looking at it. Another way of looking at it is that we have the lowest number of people working in public health than we’ve had in the past decade because we have systematically cut back on our public staffing at the municipal, at the state, at the federal level.
We have systematically underinvested in public health. In most states, public health spending is less than $100 per person. In most states and in most municipalities, we spend much more on the police force than we do on public health. I think we’re at a point where public health is running on a shoestring. And of course, that’s part of also what happened during the pandemic, because the pandemic hit and we did not have the public health person power to mount basic public health efforts to push back on the virus, to mount the kind of testing, to mount the kind of screening and contact tracing and surveillance that we needed to have.
And you’ll remember, at the beginning of the pandemic, there was a lot of scrambling about creating ways to actually do that. And of course, it was too little too late because we were essentially not prepared. So I think our public health workforce right now, we’re at the state where public health infrastructure is far worse than it should be for a country of the stature and the wealth of this country. Now I’m hopeful as I see the next generation wanting to be part of public health that we collectively are going to invest in public health and reinvest in public health, so when the next pandemic hits, we will not be in this state of public health disarray.
Jeff: Do we need to approach it in a more national way? Right now and part of the problem that we face during the pandemic was that public health varied so much from community to community, from state to state. Do we need to be taking a stronger national approach to public health?
Sandro: I suppose I’m agnostic about that question. I think it depends. I’ve been part of groups that have written policy reports in the past year recommending different approaches that we can take to building up our public health infrastructure. I do think we need a stronger national presence, but I also think we need a stronger state level and local presence, to be honest. I think there are many states where the local public health infrastructure is poorly organized and could benefit from a consolidation and from a reorganization.
Similarly, we would all benefit from having similar standards that are brought about nationally and where we bring about national coordination. I actually think we need action at all levels. I’m not sure I would characterize it as more nationalization as much as action at all levels.
Jeff: Are there places in the world we should be looking with respect to best practices?
Sandro: I think there are a number of places in the world where we can learn bits and pieces from. I’m always reluctant to say we should be more like country X because– this goes back to the very first question you asked me is that we as a country, it’s hard to compare us. For example, it’s hard to compare us to a place like Sweden which is a much smaller and much more homogeneous country. I think the best approach is to take bits and pieces from what other countries are doing and figure out how to apply them to this country. We are blessed with no shortage of smart, motivated people who can do that, given the resources.
And what I’m hoping is that this moment, this pandemic moment, is a teachable moment that forces us to pay attention to these issues in a way that we just haven’t for decades because there’s no way to redeem the tragedy that has been COVID 19. But surely, it will be even more tragic if we do not use the moment to learn. So what I’m trying to do is to say we should be learning. We should be paying attention to see what happened and learning to do better.
Jeff: Is there a danger that we take away the wrong lessons? Certainly, when we look at the way some of this has been politicized, there’s a lot of bad lessons in here.
Sandro: Yes, there are. Let’s stay away from politics for a second, and we’ll come to politics. Let’s start with the lessons that we may take about how we can go about preventing the next pandemic. And you mentioned some of this in your introduction. The reason I wrote this book is because I wanted us to have as part of our conversation these fundamental truths about social and economic structures that set the stage for what we experienced in the pandemic. If all we take from this pandemic is that we need better vaccines, better surveillance systems, better treatments, then we’re missing the point.
I’m not arguing that we don’t need better vaccines and better treatments and better surveillance. We do need all that, but that by itself is necessary but not sufficient. We actually need that. Plus, we need to pay attention to the world that made us so vulnerable to this virus. I do think, for example, it would be a mistake if what we took from this is saying that all we need is better treatments.
Now let’s come to politics because I’ve had many people who say to me, really, the problem was all about the politics. We should be honest with ourselves that the politics and particularly the partisanship perhaps more than the politics that in March of 2020 were horrible. They were a perfect storm of terrible partisanship that led to chaos in terms of how to deal with the pandemic. And so we should be clear in our mindset that’s the case.
Having said that, to my mind if all we take from this is that it will chaotic politics that was the cause of our problem, again, we are taking away the wrong lesson because even if the politics aligned as well as can be and the federal government clicked into place and did everything possible, we still would have had devastating consequences of this pandemic because of our underlying vulnerabilities to this virus.
Jeff: There is this mythology that exists, and you touched on it earlier about the state of healthcare in this country, the state of medicine. And the mythology tends to make things seem a lot better than they really are. And you addressed it in the context of life expectancy, et cetera. One of the things you point out is that a lot of increase where it’s happened in life expectancy has more to do with better hygiene, better water, better education, more money than with the state of healthcare itself. Talk about that.
Sandro: It’s pretty clear to anybody who studied these things that the improvement in our collective health over the past 150 years is largely due to improvement in living conditions, not improvements in medicine. But just to concretize this, life expectancy for humans for tens and hundreds of thousands of years for the human species was about 40 until about 1850 or so, so about 150 years ago when life expectancy jumped from 40 to what it is now about 80.
That increase in life expectancy had very little to do with medicine, had very little to do with antibiotics. It had everything to do with the fact that we moved to cleaning up cities that had become polluted in the industrialized world, that we created better opportunities for hygiene, that we created cleaner airs, safer water, that we reduced violence, that we reduced chances of accidental deaths, that more and more people had livable wages, more and more people have better living conditions. That doubled our life expectancy in the past 150 years as a world, which was this extraordinary transformation of the world.
Humans could expect to live to about 40, and now, they could expect in high-income countries to live into late 70s and 80s. And that is the misconception that somehow we have gotten in our heads. We have gotten this misconception in our heads that our advances in health are due to advances in medicine. Advances in medicine are critical to help us get better once we’re already sick. And that’s why we as a country have the healthiest metrics once you’re over age 75 because over age 75 is when you start relying more and more on medicine and care.
So we do very well in life expectancy once you hit age 75. We do terrible in life expectancy until age 75 because that depends on the state of the world around you. And we just need to be very clear on that. And in fact, Jeff, when you ask me the question, you asked me to comment on the healthcare, but I think what you meant to ask me was to comment on health. And we often use these words interchangeably. And I think we shouldn’t because we should be very clear that healthcare is important. When I have a heart attack, I want the best possible doctor, the best possible nurse to look after me, as do you. That’s healthcare. But I would rather not get a heart attack, to begin with. That’s health.
Jeff: We have this tendency though, which may be human nature or just may be our nature as a country, as a society to look for the magic bullet, the magic pill. We see it now in terms of this fascination with, and it’s great that it’s been developed, this pill that Pfizer and other companies have developed to treat COVID. And there seems to be this amazing acceptance of it even among people who have been resistant to prevention, resistant to the vaccine. So it just plays into this idea that we just want a pill to solve everything.
Sandro: We do. It is part of our narrative. And look, I also want a pill to solve everything.
Jeff: Absolutely, we all. [chuckles]
Sandro: I think it’s okay to want a pill to solve everything at the same time as saying, “Well, let’s be grown up about it,” and realize there’s no pill to solve everything. Ultimately, the answer lies in the hard, hard work of improving the world we live in. And I’m okay with the fantasy of the pill as long as we realize it’s just a fantasy. And again, the pill that’s now being approved to this treatment for COVID is terrific, it’s excellent. But I would rather people not get to COVID, to begin with.
Jeff: In listening to the debate about this, I’m not sure there isn’t that understanding. You hear out there, and it’s reflective of some of these problems that you’re talking about, “I don’t have to worry about the vaccine now because there’s a pill.”
Sandro: I think you talk about the debate out there, and I tend to characterize this as the public conversation on health. To go to the proverbial kitchen tables conversation, you’re sitting around the kitchen table and you say to a real relative, and you say, “What matters most for health?” And your relative is likely to say, “Well, my doctor,” and I have a good doctor or I don’t have a good doctor.
What I would like that relative to say, instinctively is to say, “The fact that I have a roof over my head and I live in a safe house, and the fact that I have a reasonable income that allows me to actually be in a neighborhood where I can exercise and I’m not afraid of violence and I have clean water to drink, and I have air that’s not polluted that I can breathe.” Once we’re at the proverbial dinner table when we talk about health start saying that, it will change how we see health, because then, of course, politicians will follow. Politicians will be having debates, and they will be discussing whether or not their policies around housing and transportation are going to affect health.
When there is a conversation about urban development, the politician will be asked, “How is that going to affect the health of residents in the neighborhood? And is that effect on health the price we’re willing to pay?” Until we’re actually having those conversations, we are going to keep misthinking about health. I suppose the reason I fundamentally write a book like this is specifically to get this conversation going, to make sure this conversation is out there. And that’s why I’m grateful to you for actually having the conversation because I think this is how these ideas move forward.
Jeff: Sandro Galea, the book is The Contagion Next Time. Sandro, I thank you so much for spending time with us.
Sandro: Thank you for a great conversation. Thank you, Jeff.
Jeff: Thank you. And thank you for listening and joining us here on the WhoWhatWhy podcast. I hope you join us next week for another radio, WhoWhatWhy podcast. I’m Jeff Schechtman. If you like this podcast, please feel free to share and help others find it by rating and reviewing it on iTunes. You can also support this podcast and all the work we do by going to whowhatwhy.org/donate.
