Sandro Galea: Well, I have to say that I took me 20 years to write this book. That's not exactly accurate. But it really is a compilation of my thoughts of over 20 years in academic public health, there really was an effort to capture what I think it is that generates health in populations and to really move the conversation forward beyond a misconception that I think dominates how we think about health that we're in where we conflate health and medicine.


Amy Barrett: Right. And so what are the differences between the two terms?

SG: Well, I think medicine or health care is a very particular aspect of health when, when you are, when you are sick, we want to see a doctor and we would like to return back to health and that is all fine and good.

But medicine is one very particular aspect that we lean on when we are sick. Ideally, we do not want to be sick to begin with. Ideally, we'd like to stay healthy. So we as a society would do well to think about health and to think about what are the forces that generate health. And the book is about that. The book is about everything else that generates health and those everything else that that basket of everything else is much bigger than medicine itself, because it is about the world around us.

What generates health is about where you live, but the income you have, but what are you we're exposed to violence, about, where you went to primary school, about how you grew up and whether or not there were conditions for you to walk and exercise.

About the food you eat, whether it is calorie, dense, nutrient-poor, or whether it is healthy food. About whether or not you have a livable wage, about the conditions that allow you to age healthy.

These are all the forces that generate health. And really, as the book subtitle says, that is what we should be talking about when we talk about health.

AB: And who is it it's being failed by the current attitudes towards health?

SG: I think we all are, I think we are shortchanging ourselves in, because of our current attitudes about health. I think that is equally relevant to the United States as it is in the UK. And I think that the two countries are good examples because both countries have had a doubling down and greater investment in medicine and healthcare, to the detriment of investment in the other forces around us. So I actually think we collectively have far, that our health is far less good than it can be

To use the American example. The United States has had a downturn in life expectancy, year on year every year for the past three years, and that has not happened. We have not had a three year, year on year drop in life expectancy since the 1918 flu pandemic 100 years ago.

That is actually quite extraordinary when you think about it, that the United States right now is going through such a downturn in its health, and that is, of course, in a country, the United States, that spends far, far more on health per capita than any other country in the world.

More like this

Sometimes I worry that the United Kingdom follows the American example and things like this far more than it should when, in fact, America is perhaps the example that one should not follow, when it comes to health

AB: Do you know what's kind of causing this, this three-year decline?

SG: Well, the number of forces that are contributing to the tree are declining. The main factors from morbidity point of view and mortality point of view are increases in injuries that lead to suicide and a lot of those are due to guns, to the increase in deaths from neurodegenerative disorders like Alzheimer's, dementia, and deaths related to downstream consequences of opioid use.

Those are the three big causes of death at the end-stage because of that, but of course, the argument is that those are simple downstream consequences of much larger social-economic issues and that is ultimately, the, these larger social and economic issues what we, as a society have not paid attention to and what we are seeing now, this decline in life expectancy, is a reflection of longer-term processes.

AB: So, are there other countries that we should maybe be looking to as an example of better wellness, better health?

SG: Well, we just need to look at the health indicators and other high-income countries and many Western European countries have far better health indicators than does the US, than does the UK and the, the thread that unites them all is greater attention paid to investment in the social-economic resources that create better and healthier worlds.

And different countries do that differently and they focus on different aspects but to my mind, what unites them all, is a recognition, perhaps implicit, perhaps these countries have not explicitly wrapped their brain around it, but they act like they have, that generating a healthier population is inextricable from creating a healthier world around them.

AB: There are examples that you mentioned in the book of the kind of current attitudes that set up for failure, sets up people for failure in terms of their own health. I wonder, is there anything that we should be doing now to prevent the future unhealthy population that we're kind of establishing with our current society and our current attitudes?

SG: Yes, I make the point in the book that our health today, your health and my health today is much more a product of our life course of how we have lived and our experiences that we have had than anything we do today.

And we often make this mistake where predict in a clinical context, a physician sees a patient and she has a particular illness and the physician thinks about the illness and the patient today. But in fact that illness is a product of what she was doing, what she was smoking, where she was drinking, what food she was eating 10 years before. What her adolescence was like, what her childhood was like, and really what her in utero conditions were like.

So this argues for looking back and saying, how is it that we set up people for success or failure for a lifetime trajectory of good health or poor health? How is it that they are educated early in life? What are the environments they're exposed to? How much do they exercise early in life? What food do they eat early in life?

And that really sets us on these paths and these paths diverge over time for us to have in middle age and then later in life, health habits and health have nots.

AB: So does this mean changing the actions of a practising doctor, I'm thinking about, you know, here the NHS has already pushed past its limits. Does this mean that the practising doctors wanting to do more for their patients?

SG: Well, I am often asked this about doctors and my general feeling about doctors, and I am one, is that doctors job is to restore us to health when we are sick and what I want from my doctor is that they are excellent at doing that, because when I'm sick, I would like to get back to being healthy.

So in some respects, I think this is an issue that's bigger than doctors. I think, insofar as doctors can lend their voices to this issue, that becomes important because doctors have an important role to play in changing the public conversation.

But ultimately, this is not something that can be done in the clinic. This requires a broader political recognition of the essentiality of creating the pillars that generate health and that requires that we, as citizens, demanded requires that we as citizens, demand health and say it's not good enough that we're investing in more medicines, we actually also need to invest in parks and opportunities for healthy eating.

Because without that, we are just going to be leaning more and more on expensive medicines without ever achieving the kind of health that we have the potential to achieve.

AB: So, what changes, new ground-level changes do we need to make to promote a better and healthier society?

SG: I think we need to make sure that those of us who are in positions of authority between the public sector and the private sector who can, who are generating these structures that within which we live, recognise that health is a consequence of a whole range of decisions that we seldom think of is linked to health. That decisions about transportation, decisions about housing, decisions about income opportunities, decisions about gender equity; these all influence our health, and we need to make sure that when we make these decisions at a societal level in the private sector or public sector, we take health into account.

Now, why do I think health matters so much, I think, no matter so much, for a very simple reason, that health probably is the single most unifying shared value, and that we can disagree on political, political perspectives and a whole range of issues, but I have yet to meet people who do not agree with this statement 'we'd like to be as healthy as possible, and we would like our children to be as healthy as possible.'

So when you see it that way, health is a has the potential to be a real unifying force. And as a result, it strikes me as entirely reasonable to say, that health should inform the decisions we make about sectors that influence it.

AB: Absolutely. And in your book, you list sort of 20 different things that do impact our health from money and politics, humility values. When researching and writing a book, did you come across any factors that that really shocked you?

SG: I think where I ended up, which was perhaps different than where I thought I was going to end up, is how deeply I came to feel that our values and how we see the world informs what we do. I think I may have had a more analytical, dispassionate take on it, when I started, meaning that if only we invest more in housing in early childhood education and violence prevention, will generate health. But then I came to feel that issues that is said like kindness and love versus hate, and humility are important elements of us getting to the right place.

And the reason for that is because they can come to realise the more I researched and thought about it, that it is those values that create the conditions within which the decisions are made. And absent those values, absent a compassion for the state of humankind, absent a humility of understanding that the forces around us are complex and we have a responsibility to do the best we can by the people we are responsible for, absent a desire to promote love rather than hate in our speech and interaction, we will not make decisions that have these important downstream consequences for health.

So I think if there was one surprise it was that that I came to feel that these perhaps more abstract concepts, that philosophically abstract concepts like compassion and humility, are equally important to the very pragmatic nuts and bolts decisions about where we site our highway, in decisions we make about shared public transportation, decisions that are made about parks as public goods, decisions that are made about excellent early childhood education, because those decisions flow from a set of values, that prize creating a better world and improving the human condition above all.

AB: How has your own personal journey, how has that shaped your view and shaped your practise?

SG: Yeah, I suppose...

I suppose it has made me more contemplative. It has, it has made me recognise that one of the roles perhaps the most important role, that any of us with any leadership role in our universe, and as I think most of us have leadership roles in our various domains, have a responsibility to be thoughtful about what that means. Have a responsibility to invest that role with the right humility that says, 'the words I use, the actions I take, can influence how decisions are made around me, and those decisions are then going to influence our collective well being,' and that's, that's a real responsibility, and it strikes me that if we all embrace that responsibility would be a better world for all.

AB: It's quite a kind of crushing weight or responsibility though, don't you think?

SG: It is, but I think you near it, as do I.

AB: And how do the elements of our childhood, you mentioned even in utero, how do those elements influence our health as an adult and then in the wider population?

SG: Yeah, I mean, maybe I'll answer that by, by way of illustration. It's a story which I am, which I tell in the book and it's a story of blind Willie Johnson, who was a blues player from Texas.

He's an American blues player. He was born poor in Texas at the turn of the 20th Century, and he lost his vision when he was seven in a domestic violence incident, hence his, moniker Blind Willie Johnson. And when he was young, we had no money and he got married, lived in a small house, and that house burned down, but him and his wife didn't, they didn't have money, so they kept living in the burnt out house. And then when he was in his 40s, he developed malaria and his wife took him to hospital and he was turned away from hospital. And he died from his malaria.

And the question I asked is, well, what killed blind Willie Johnson, and obviously, medically what killed him was malaria. But when I tell a story like that, the notion is very clear that it wasn't just malaria that killed him, right. It was poor housing, it was racism, it was domestic violence. It was his poor, his poor fortune, his, his misfortune, to be born black and poor in Texas at the turn of the century.

So that's why in the book, there is a chapter on luck, something we, we don't talk about when we talk about our health, we have a very deterministic view of our health which says something like 'if you can just change your behaviour, you're going to be fine,' and before we get this overwhelming role of luck, of the good fortune of the circumstances of our birth and the conditions of our birth, and we don't like thinking about that, because it makes us uneasy.

But it is entirely true and it is important because once we recognise how much your and my good fortune today to be sitting here talking to each other is determined by luck, that's, that is undeserved, it makes us uneasy because it makes us feel anxious about well, what can I do to pay that back. And I think what we can do to pay it back is to live compassionately and to realise that health is a public good and that we owe it to each other to give back to the world better conditions that can advance those who do not have the same level of luck.

AB: Is it luck? Or is it privilege?

SG: Well, I think it's it's, it's a privilege to be lucky. And so I think the two tie in very much together. I think what we, what we tend to call privilege in today's conversation is an accumulation of lucky incidents that then become a set of privileges.

AB: And there's a chapter called Choice. Choice in health can be sort of misinterpreted, it can even be used against people, you read comments that, that say people are choosing to be obese, choosing to be unhealthy. Is that really the case?

SG: Yeah, the point I make is that that is far less the case than we think it is. And the example I use is the example of motor vehicle accidents, motor vehicle deaths, that, in all Western high-income countries motor vehicle deaths have dropped dramatically in the past hundred years, but by 100 folds, they've dropped dramatically. And the question is, is that because drivers have chosen to become better drivers? And the answer is absolutely not. Drivers are drivers. We're all human and perfect at navigating complex vehicles like cars.

The reason that motor vehicle fatality has dropped is because of safer roads, shoulders on the side of the road, airbags, seatbelts, shatterproof glass, laws that prevent drinking and driving. And that simple example illustrates that we tend to over privilege choice, we tend to think that if one chooses to be healthy, that one can be healthy, and we forget that actually, what it really takes to make us healthy is to create conditions around us that channel us in a healthy direction because we, we as humans, we're sort of terrible at making healthy choices. We just are and you know, there's been a lot written about sort of behavioural economic science of nudging people and even that and careful analysis doesn't look anywhere near as promising as soon as the, let's say the earlier discussion around it suggested

We, we need a structural world around us that gets us down a particular path. Now when I speak like that a criticism over the saying, well, you're asking for a nanny state, for a government to control what you do and my arguments is very simple, that, that those criticisms are misguided because we have, we have structures that are imposed on how we live in what we choose by the public sector, by government and by the private sector all the time.

There are all sorts of things that you cannot buy easily, that are determined by regulations and frankly, determined by what private sector actors are willing to produce and to sell you. So I don't think that this requires anything different. I think it's simply requires that those private and public sector decisions that shape the world we live are made with health in mind.

AB: So do you anticipate that this book could be used to educate those that are in that kind of, you know, level of policymaking?

SG: I hope so.

AB: And have you seen anything in the last sort of year that is made you optimistic for the future? Are changes happening?

SG: Yeah, I'm actually very optimistic for the future. I am. I've been involved in the past few years in any number of conversations with colleagues in the private sector who, that they talk about a recognition that what's typically called social determinants of health - which is a technical term that really reflects everything that we've been talking about in this podcast - and, and that corporations have a role in engaging with that and trying to figure out ways to generate context that generates health and private sector wasn't talking about this five years ago. They weren't talking about this 10 years ago.

So I think the world is changing. Perhaps the best compliment I've received about the book is when I have readers who stumble upon it and read it for, for whatever reason, they say well, everything you're saying here is obvious. And I like that. I think they're right, it is obvious. And my job is to, is to elevate this and make it clear to all of us.

AB: So much of the book and the examples in it are focused on the US, so what can the rest of the world learn from what's going on in the US?

SG: Well, yeah, focuses on the US simply because that's where I live, and it's a context with which I feel comfortable. And also, I feel like it's perhaps prudent to always reflect back on once environment not to have the hubris to talk about other environments. But I think that these lessons apply everywhere. I think they're universal lessons and they apply to all over the world.

And let me use one, one other analogy which I talked about in the book, which perhaps resonates with an English audience, which is in the analogy of the football team, by football I mean actual football played in, in mostly in Europe. which in the US we call soccer. And the analogy is as follows that in football, you have 11 players and a goalie. And of course the goalkeeper can use his arms and legs and his whole body to stop the ball from entering the net. And somebody who doesn't know the game of football, will say, well, as long as you have the best possible goalkeeper, you're always going to win. But people who know the game recognise that a good goalkeeper is never enough. What you need is a team to push the ball forward at all times.

And that's the perfect analogy for health. The goalkeeper is medicine. If you're, if the ball is going to get close to the net, if you're going to get sick, you want the good goalkeeper, you want a good doctor to restore you to health. But really what it takes to keep us healthy as a winning team is the other 10 players. Those 10 players are, where we live, where we go to school, the families in which we're raised, our being protected from violence or making sure that we actually have good nurturing environments, us having access to healthy food. Those are the other 10 players. And it's that same ratio, that 10 to one ratio that I think should inform how we think about health, that health is 10 times as much determined by the world around us, as it is determined by medicine, that keeps us from getting sick.

AB: Because a lot of what we do is, like you say, treating as when we are sick, rather than focusing on kind of preventing people getting unwell. Is that right?

SG: That's correct. That's correct. And it of course, is problematic in terms of how we spend our money. When we spend our money on, when, when the political discussion circles around spending one's money on health, it almost always is about spending money on medicine. And those are not the same thing.

And in fact, if we spend on medicine, to the detriment of spending on the forces that generate health, we are going to be creating exactly the kind of world that we have now, where our health in high-income countries, is receding and that is a real shame.

AB: There's a line in the book that really shocked me. You say that the influence of the conditions of where we live can suggest our zip code, or here our postcode, is a better predictor of our health than is our genetic code. How does where we live determine our health so dramatically.

SG: I think where we live determines everything about our health. It determines whether you have access to grocery stores with healthy food, that determines whether or not there are parks where you're likely to play and exercise and run. It determines the quality of schools you go to which then go on to determining your opportunity set throughout your life. Also, schools that teach you right from wrong held behaviour. It determines the friends you have and their behaviours influence your behaviour. It determines how likely you are to get a job that is stable, keeps us stably employed, and then opens up opportunities for resources that keep you healthy.

So, where you live is everything about how you're going to live, and how you're going to live is then what, what becomes imprinted in you as your health.

AB: So is it that you know, you can't once you're an adult you can then backtrack, you can't rectify the mistakes, or you're unlucky, you're misfortuned when you were a child.

SG: Yes, it's much harder. It's much harder to do so and in some respects, I suppose my, my argument is an argument for better health for our children, but that, that's probably how it should be, isn't it? Now that doesn't mean that adults listening to this should despair, because a. there are things that we can do and agitate for and ask for in the world around us to help our health but it also means that I think we as adults, as with any generation, have a responsibility - there's that word again - to invest in creating a word a world that's better for those who come after us and perhaps in part, it's what this book tries to do, it's a play on an investment in a future better world

AB: And the next generation are already more aware than the last...

SG: They are. Oh, they are they really are. My, my children are much more aware of these issues than, than I was when I was their age. And you asked me if I'm optimistic and the answer is yes, I am. And I also prefer to be optimistic because it's much better than the alternative.

AB: Obviously, now, you know, us and younger generations are able to see what's going on all through social media, there's more knowledge out there for children to access and I wonder how, how does media and pop culture influence our health?

SG: I think it influences what we talk about, influences what we talk about when we talk about health and as a result, this is sort of why I am, I am happy to talk to you and in context of that you are part of what's shaping the conversation that people have in shaping the conversation around health. And I want to make sure that these ideas are part of a broader conversation that is heard by adults, which then trickles down to or up to how we're going to look at it, to children and young adults and their conversation. Because the conversation 20 years from now will be very different. And I think it'll be a more positive conversation where a number of these issues will have moved forward.

AB: And you mentioned that, you know right at the beginning, you said this book kind of has, has been building over the last 20 years, what's your career been like over the last 20 years?

SG: Well, I'm trained initially as a doctor and I, then I, I went back to school to get a masters and a doctorate in public health. And so for the last 20 years I have been teaching, writing in public health. A lot of my work has been around mental health and the forces that generate mental health. And I have had a succession of different academic leadership positions.

So I feel like I've gone from doing primary care medicine where one very much feels on a day to day basis, the forces that inform the health of one's patients, to thinking about this at a more academic level and trying to do the science that teases apart the forces that, these forces that generate health, articulating them providing evidence and now translating that evidence to a broader audience.

AB: Do you ever worry sometimes that scientific research can be used in perhaps a negative way, that it by not being communicated accurately or confidently, it can actually misinform the public?

SG: Worried but I worry about a lot of things. I worry about that too. I think we all probably should. But I would like to, I would like to believe at the end of the day that, that most people have good intentions. And at the end of the day, most people when they understand what the right thing to do is will actually do the right thing. And in part, this book is an effort towards nudging us towards what the right thing to do is around health.

AB: How can the good health of one person affect the life of another? You mentioned in the book that it's in all of our interests to, you know, help other populations achieve higher status of health, but why is it so important?

SG: Well, I think the obvious example of that would be something like infectious diseases where if health systems crumble in West Africa, you have transmission of Ebola to high-income countries where both those are non-native. That's something that has really grabbed headlines and a little bit more prosaic example. If, if you choose not to vaccinate your children, it increases the likelihood that measles will spread and that my children may get measles, even if my children are, are immunised.

And separate apart from infectious diseases we know from the science very well that my likelihood of being overweight or obese is influenced by whether or not my friends are likely to be overweight or obese. Another example is that we tend to think of car accidents and risks of children dying in car accidents as though it's only a passenger in a car problem. But in fact, a substantial proportion of children who are killed by cars every year have nothing to do with the with the car and there's simply struck by other people driving poorly.

So our health is intertwined, whether we like it or not, unless you can sort of wrap yourself in a, in a bubble and protect yourself from other people, your health and my health are intertwined whether we like it or not.

AB: So on an individual level, what can a person do to be healthier themselves, but also to contribute to the health of the wider population?

SG: I think that if every person listening to this podcast understood this message, and acted in terms of their engagement with private sector, public sector, to insist on the conditions that generate health, I think we will slowly change the conversation on health, it will slowly change what we need to talk about when talking about health. And that's, I think there will be a positive for all of us.

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Amy ArthurEditorial Assistant, BBC Science Focus

Amy is the Editorial Assistant at BBC Science Focus. Her BA degree specialised in science publishing and she has been working as a journalist since graduating in 2018. In 2020, Amy was named Editorial Assistant of the Year by the British Society of Magazine Editors. She looks after all things books, culture and media. Her interests range from natural history and wildlife, to women in STEM and accessibility tech.