Sandro Galea, Physician

Why Changing The Script in Public Health is The Best Way Forward with Sandro Galea, Physician, Epidemiologist, and Public Health Dean at Boston University School of Public Health

: [00:00:01] Welcome to the Outcomes Rocket podcast where we inspire collaborative thinking improved outcomes and business success with today’s most successful and inspiring healthcare leaders and influencers. And now your host, Saul Marquez

Saul Marquez: [00:00:18] Outcomes rocket listeners welcome back once again to the outcomes rockets where we chat with today’s most successful and inspiring healthcare leaders. I invite you to go to our outcomesrocket.health to check out our podcast. Leave us a rating and review and let us know what you think about today’s guest. His name is Sandro Galea. He’s dean Sandra Galea. He’s a physician epidemiologist and public Dean of Health at the Boston University School of Public Health. He is very well known for many of his research papers he’s got over 700 papers out there all focused on population health. His work spans the majority of what we’re talking about here on every podcast. And so it’s really exciting to have him carve out some time for us and chat we had Will Wright who is with the Economic Development Partnership of Alabama who recommended this book to me and I was just floored by it. I loved it. It’s called healthier 50 thoughts on the foundations of population health. And this is one that I recommend to all the listeners if you have not read it yet. It’s an amazing way. If you’re busy person to get your dose of population health and understand it further. Each thought is between two and five pages and so there’s no need to feel guilty about diving into the content. And so there’s my little pitch for his book which I love and I recommend completely. But what I want to do is open up the microphone to Dean Galea and welcome him to the podcast. Welcome to the podcast, sir.

Sandro Galea: [00:01:49] Thanks for having me on.

Saul Marquez: [00:01:51] It is a pleasure and so you’ve had a really extensive road that has brought you to where you’re at today. Sandro what would you say was the spark that got you interested in health.

Sandro Galea: [00:02:01] I grew up in a small Mediterranean island of Malta where I grew up live. And then I left to go to university and I was always interested in health and as an immigrant when you’re interested in health. The only thing that you know you can do is be a doctor. So all throughout my my early childhood and adolescence I knew I was going to be a doctor because I knew I was interested in health. So I immigrated to Canada and went to medical school in Canada and they did residency and I became a doctor. Doctor became acute care doctors emergency medicine and primary care practice in some remote rural places and then I did some things working globally and some distance involved working really set up in New Guinea and working in places like the Philippines and I also in particular worked in Somalia and I spent a year on and off working with Doctors Without Borders MSF Frontier Corps. And I was the only doctor in around the region with 350000 people regional land and while I was there I was doing medicine acute care medicine every day and people would be coming and they were injured over three months to fix them. In many respects I was doing the epitome of medicine I was doing was trying to do helping people get better. I remember having this feeling that once I left nothing was going to change that I was doing some good and some good was helping people but once I left nothing was going to change because maybe there would be another doctor from the borders maybe not but essentially nothing fundamentally was changing that was causing people to get sick and thinking that must be a better way. Now the truth is I did not know a better way. I was trained at the University of Toronto medical school which was for classic medical training. I was trained to be a good doctor and to need people with who are sick to make them healthy again. But I had no understanding or no training and no perspective on how to keep people healthy to begin with. And I thought there must be a way of doing this. So I went back to school. I was a full fledged physician working and I set to go back to school when I went back into the Masters in Public Health and eventually the Ph.D. doctorate and then my career my career has really been in population health and it’s been in trying to understand how it is that we can create a healthier world. That’s been my journey.

Saul Marquez: [00:04:23] It’s a beautiful journey. So we went from the frontlines this passion for health frontline physician explored third world country medicine and just found this gravitational pull toward how can we make the foundations of health better. And so here you are today Dean Galea just as a thought leader in population health what would you say a hot topic that should be on every medical leaders agenda today.

Sandro Galea: [00:04:49] I think everybody who is in medicine and health today should be asking themselves the question how can we make sure that everybody dies healthy. Now what do I mean by that. Let’s assume for a second.

Saul Marquez: [00:05:03] That it’s a unique perspective. Everybody dies healthy.

Sandro Galea: [00:05:08] No we are right. You and I Saul live as long as we can as healthy as we can and then one day pass on. So that it is a very different perspective than a perspective that says what we’re trying to do is catch people once they have disease and restore them to health and prolonged disease in a way that action moves to help. What we want to do is to create the healthiest possible world. Now when you say that to yourself you start thinking about health differently because hardly you realize that the locus of health is not me. It’s not you. The locus of health is the world around us. You realize that if we want to keep everyone as healthy as possible for as long as possible we need to create a world that generates health. And what does the look like. And it asks the question What does that look for. What are the politics that we need to put in place to generate health. What is the environment and the students health. What are the people relationships with that aren’t put in place. Turn it. What does the compassion wanting to make sure that we generate health and all of a sudden the locus shifts away from the individual to the world around us. I think that’s the hardest question that we face right now in health. And I would argue that’s the most important question and unfortunately it’s also the question that we pay least attention to.

Saul Marquez: [00:06:27] Yeah it’s a very insightful message that you shared there Sandro and as I think about that you know it definitely does create a shift in the way that that I think about healthcare to die healthy. And why do you think we have this challenge of not focusing on what you just mentioned.

Sandro Galea: [00:06:46] I think there is an American script about how we think of health. If by me I think it extends to dueling interviews because you have recently used the word health care. Yes. You said at the beginning the podcast is about healthcare and right now when you’re questioned me use the word health care and I’m sure you didn’t even think about it. That is because we are so used to thinking about healthcare as interchangeable with how the two are very different concepts. Health care is about what you and I both need. Once we sick right. We want to have great health care. Let us be clear about when we’re sick and we will be sick at some point in our lives. We want good healthcare. We want good medicine restores health. So in no way am I saying it’s not important. I don’t want to be misunderstood. I think medicine and curative care is very important. However the narrative is so dominated by medicine and curative care that the word health care slips in without even noticing. So we need to change the script and we need to set up a health. I would argue that your podcast is about health. You actually ultimately interest in general health and health care isn’t but one approach to the other. If you are interested in generating no need to think about place in nature anything about knowledge that will need to generate healthy have the humility to recognize that there are a lot of things we don’t know how generate help. We need to help people structured her choices better. We can be sure that we have the freedom to live in a healthy way to make sure that there is a fair and just environment and promote health. And we need to ultimately think about the values that promote health. As a public good that is what we need think about when we think about health care.

Saul Marquez: [00:08:22] That’s super interesting. DINGELL And so health versus health care and for the listeners they’re thinking through these profound thoughts that Dean Galea is sharing what is it that we can do whether you’re an industry executive or you’re a provider. To think about this in a bigger way health is different than care. And what can you do to start providing the resources the thoughtfulness the care the compassion to help people live healthier lives. A big problem that I see being led is just the way that the health system incentives are positioned their position today to drive that curative care that she mentioned rather than the preventative care. What are your thoughts on shifts there that need to happen.

Sandro Galea: [00:09:08] I think that’s an excellent question. Let me answer first by example May-Britt examples is what some hospitals have done to reduce their costs but also the burden of acute asthma attacks emerged. So some hospital around the country have had the forward looking vision to say we’re getting these acute asthma actually happened with vulnerable populations particularly when the weather is such. For example when it’s very hot and stifling in urban areas and they said we’re never going to change this. It’s costing us a lot of money. Unless we go out into the community into people’s homes and for example provide them with her conditions. Now I think you will agree and most listeners would agree that airconditioners providing her condition which is not really healthcare right. It is structuring the environment so that people do not get acute asthma attacks and that this has been published has been shown to reduce costs for all as well as people. So I do not think that the incentives needs to be misaligned as we think they are. Now having said that there is a real challenge with the incentives. There is a real challenge that many health care systems continue to be incentivized on a sick person basis and sending rice to restore people to health rather than to keep people healthy. And that will need to change over time and we are seeing movements towards that over time. Global payment models are ultimately move in that direction. CEOs and movement movements in this direction they remain small efforts in the big scheme of things but at the core I cannot help but feel that the appeal of this perspective is such that eventually it has to prevail.

Saul Marquez: [00:10:49] Yes and it’s fascinating the idea of an air conditioner and you pay you know whatever 400 dollars for an air conditioner and you can avoid a patient from really having those attacks and even the costs on the system. So the broadening of what can be paid for with Medicare Medicaid dollars is definitely a question that should be addressed over and now and Washington.

Sandro Galea: [00:11:12] It certainly should be. But it is a complicated question there’s no question in large part it’s competitive because we have it we already have a system where the system is set up. There are incentives there is momentum. There are ways in which we do things and anytime you work your existence it involves a lot of people and a lot of particular interests but this is why I come to the notion that we need a change in the script. The change in language of changing conversation around health care is at the core of things that have emerged in the past several years is a fundamental mismatch in this country and the mismatch is as follows We spend more on health and pausing when they see the word health. But isn’t going to get to. Not really. But it going more than any other country in the world. All your listeners know this about the third and we’re not just a little bit more a lot more. But we also have worse health indicators than other high income countries. Now I’m not comparing of low income countries nor fair comparison right here where poor countries we have worse health indicators. So there is this mismatch. We spend more and get less and arguably we would not accept that mismatch in any other sector and in fact there is no other sector you can think of that has the same example. So the question is Why is that what’s going on. Why are we spending so much and getting so little. Is there something national American soldier isn’t. The answer is very simple. The answer is that we spend on curative care. We spend on curative care and we do not spend on this. That is that ultimately we need to invest and to keep people healthy as well as spending on curative care to restore our health. When we get sick so we have this enormous mismatch. How do you fix that mismatch. Well you make sure you generate the science to support that and you make sure the community get to communicate it so that we can change the language and focus on health.

Saul Marquez: [00:12:57] Absolutely. And what are the things that’s a theme here that you’ve mentioned Sandro is. This thought of changing the script. It’s something that that I think about in my day to day as an individual just going. What’s the script. What’s my story. How is that affecting what I’m doing with my family with my work. But there’s also a thing that you do really well and that I captured from from reading your book is just this amazing ability to to capture society sort of as a body in itself and society. American society also has a script and changing that script is the opportunity for anybody in public health as well as at a hospital. What would you say is the way that we can do that. How do we change the script.

Sandro Galea: [00:13:40] Different ways of getting a script in the two ways that come to my mind. Number one is by telling stories that illustrate live events. And number two is by producing the right evidence. So let me start with a story when we tell a story if you don’t mind yes please. We like stories. Okay good. So the story is over is of a blues man a blind willie johnson language and the Blues many can even find his work out there and blindly denounce his latest claim to fame was that one of his songs was included in the golden disc that was sent off into space on one of the spacecraft that went out is never going to come back. In case aliens encounter us and they came here Sanha but its language was not Beverly Johnson was born at the turn of the 20th century in Texas. The story is that he was blinded by having lye thrown in his face when he was three in a domestic violence incident. So he grew up blind and poor in Texas he learned how to play. He made a living busking very good living that made a living. He got married. He was living in a fairly ramshackle house which burned down and his wife had no money so he kept living in the burned out shell of his house. In his early 40s Blanco Johnson with malaria his wife took him to hospital and the story is that he was turned away from them. Now it’s unclear whether he was turned away because he was poor because he was black because he was blind. And then he died. Now suppose for a second that there was an effective pill that he could have taken was malaria right away or shot that could have taken it could have cured him. Everybody listening to this will realize that Willie Johnson was going to die sooner or later and something was going to get him. It wasn’t just malaria that language said it wasn’t malaria but it was also poverty. It was domestic violence. It was racism. It was homelessness. All of those factors also killed language arts. And when you tell that story I think most rational people realize we should do something malaria but we should also do something about domestic violence about racism but homelessness but access to care and that is what it means to create healthier work that you don’t ignore. You don’t ignore them or their treatment but you also realize that unless we can also deal with these accumulating risks we are never going to create a truly outward. So we asked them what can we do. Number one is I think we tell the stories of what it requires to create health issues. And the second thing I think is we need to focus our science on generating this evidence to focus our science on showing the public transportation implemented on a large scale. We’ll end up saving lives and saving money. We need to generate more and more evidence that shows that the Earned Income Tax Credit will result in saving mothers and children’s lives. We need to create the data that shows that creating affordable housing can double people’s quality of life and assessments of their own health. These are all examples on which there are data. There are many many other aspects of treating the world on which we do not have there. So telling the stories their. That’s what I did.

Saul Marquez: [00:16:47] That’s such a beautiful response. And I think a wonderful way of doing it. And so you’re exposed to a lot of these things in your role with what you do. Dean Galea. a lot of the people that are in the frontline like you were at one point just don’t get that exposure. What would you say the best way to share these stories and to figure out what the possibilities are is because your wealth of knowledge. How do we connect what you do with the implementers in the frontlines are doing.

Sandro Galea: [00:17:18] I think that’s what you’re doing and that’s why you have a podcast that you have me on. So my job is to tell the story and your job is to make sure that everyone listen up.

Saul Marquez: [00:17:29] Man that’s such a great call out and this is exactly why we started outcomes rocket and it’s a really great idea and I love what you’ve gone into here. And so the thought is maybe we create some sort of forum where people can go and hear stories of what it is that actually works. And changing the script that’s just something that really resonates with me Sandro. And I’m going to think about how we implement this even further to empower those in the frontlines listening to this podcast to make decisions that are going to work best for the populations but also them as people and individuals.

Sandro Galea: [00:18:05] I mean to help you let me know.

Saul Marquez: [00:18:07] Thank you so much. I’m going to take you up on it. So Sandra can you give us an example of potentially a population health effort that has gone awry and what was learned from it. Because a lot of the listeners are working hard and they’re working a lot of hours to dive deeper and provide solutions in population health. Can you give an example of a mistake that you’ve seen and what they could learn from it so they don’t repeat it.

Sandro Galea: [00:18:35] Yeah I can give you a big picture and I think the big picture are many efforts at population health group and that fail and the ones that fail. My estimation looking at these are typically efforts that aim to tell people how to behave. The data are clear telling people will be better. Thou shalt not eat high fat food. Thou shalt not smoke, thou shalt not drink. They just do not work. In fact they might work for a short while and then they stop working. So what regional efforts that that are they would call extorted worthy of telling people finger ranking. Yes. That is not the right way to improve population health. If we would like people to have healthier behaviors and to change the structures I’ll give an example the best example of that is the incredible success story of the reduction in deaths from car accidents in the past hundred years people die per vehicle mile driven 220 times less than needed 100 years. That was an amazing success. Amazing. Now I ask you this question are people today better drivers than they were a hundred years later pretty clear. You know I live in Boston I can tell you that there are not accidental collisions and myself and that probably but we have had enormous success. We had success because we carried airbags and seatbelts and shatterproof glass and ways for people to pull over and make sure that people don’t drink and drive through religious issue. That’s how we change. So public health efforts. Imagine if 100 years ago someone said look we have a problem with car accidents. We need to do is we need a full of effort spent the number of years just teaching people to drive better. We would not have notched our car fatality maybe Bajram a little or nearly 225 fold reduction that we have not. So I think public population efforts fail if they simply try to target individual behavior because we humans we you and me Wellingtons be free I’ll speak for myself. We’re imperfect we do bad things to ourselves. Yes it’s a matter of changing the world around us so that our choices can be healthy. So it’s number one. The second mistake that can go of additional efforts is something a little bit more subtle but I think equally important which is we can aim to improve the health of whole populations and in so doing we create health gaps within populations. So let me give a complete example supposing you are responsible for the health of the population. Supposing you say well what are the things I want to do is I want to increase the rate of and people were 50 BroadVision get regular colonoscopies reduce the incidence of cold Africans. So you see the colonoscopy rate in this community is 60 percent. And when you get up to 80 percent how do you think will be the person. Well the easiest way to do that is I’m going to go to everybody who is rich and well how’s this community and take up their close to 100 percent by doing that. My average is going to go to eight. But of course you ignore everybody else and everybody else’s colonoscopy drops to 50 percent. So you’ve succeeded in improving the average but you’ve now widened the gap. And I think that is the real challenge of population health efforts face. And I think there’s no easy solution for that. I think there’s a tension between equity and efficiency which is achieving a lot of stuff from the utilitarian question about which of these do you most prefer. And I don’t think there’s a right answer. I think it’s a pretty it’s a value question. It’s a complex question but I think it’s something that anybody interested population health needs to have in her mind because we need to make sure that we balance the health of the many with the health of the few and that is intrinsic that is intrinsic to the imperatives. We have to create healthy populations and not to make populations more naked.

Saul Marquez: [00:22:11] Yeah these are some great lessons. And listeners take these thoughts into consideration as you as you look to implement population health programs where you’re at and if you’re a company looking to somehow partner with the providers to do this just keep these thoughts in mind some really great points of wisdom there. And I’ve taken a lot of notes here. I know that you have to but don’t worry if you haven’t if you’re driving or you’re working out and you could dive into outcomesrocket.health/Sandro that’s outcomesrocket.health/Sandro and you’ll be able to get the details here of what we’ve been talking about. So Dean Galea this has been a really really interesting part of what we do in the podcast here as we’re getting close to the end is we build a syllabus on what it takes to be successful in medicine today. It’s the 101 or the ABC of Sandro Galea in this case. So I’ve got four questions for you. They’re going to be lightning round style and then we’ll finish with a book that you recommend to the listeners. You ready.

Sandro Galea: [00:23:13] I’m ready.

Saul Marquez: [00:23:14] Awesome. What’s the best way to improve health outcomes.

Sandro Galea: [00:23:17] Investing in all the structures around the key to healthy.

Saul Marquez: [00:23:20] What is the biggest mistake or pitfalls to avoid.

Sandro Galea: [00:23:23] The biggest mistake for people to avoid is to think that I find myself in my self-help the that we can make is by thinking as long as I have enough money to go to the best possible doctor I’m going to be healthy because that is where most of you realise why not investing in health systems in West Africa also. When convertible indexes the next day the real mistake is to think it’s all about me and the right answers to realize that our health collectively whether we like it or not is interlinked and we have no choice but to invest in reading and looking at health as a public good. That’s the mystery.

Saul Marquez: [00:23:58] I love that and listeners. If you want to dive a little bit deeper into this thought I’ll put a link here to Dean Galea’s talk on Ted med. He really dives deep into this thought of me versus we and the impacts of that in health care. So go to the show notes and you’ll be able to find that. How do you stay relevant as an organization. Despite constant change.

Sandro Galea: [00:24:21] The organizations stay relevant by following the Gretzky Maxim you don’t go to puckers or the puck is going to be of course it’s tricky to know where the puck is going to be but in the context of health there is little question in my mind that the puck is going to be in a place of keeping people healthy for as long as possible in organizations that health care organizations that continue to focus strictly on restoring people to health are on the losing side of history.

Saul Marquez: [00:24:50] Love it. What is one area of focus that should drive everything else in your organization.

Sandro Galea: [00:24:55] I think humanity has created organizations as a way of generating human capital. I think organizations are all about the people inside them and at the end of the day organizations are only as strong as the people who make up that organization. So here your focus ultimately needs to be on the developing unionization or those people with those people can do the best job you can help the new organization cheeps mission.

Saul Marquez: [00:25:20] And finally at Dinga lay out what book would you recommend to the listeners on this syllabus.

Sandro Galea: [00:25:25] I would recommend the recently released book by Walt Whitman which was called mainly health and training to teach the science of sound and beautiful body which Wolke which was culled from writings of world with more than a hundred years where he talked about many of the things that you are doing right now.

Saul Marquez: [00:25:42] That’s amazing. OK that’s a really great recommendation. And listeners take that one down. But also in that list Dr. Galea he’s very humble man. But I also want to recommend his book which was very inspiring and I know that you’ll find inspiring especially if you’re a busy person trying to learn about population health that’s called healthier. If the thoughts and the foundations of population health take that one up and also the Walt Whitman on health care was the name of that one again the queen’s name it’s called manly health and strangely manly health and training. And this is the timeless principles of what works right. That’s correct. Love it so you’ll find links to this listeners in it just go to the show notes at outcomesrocket.health/Sandro and so we’re here to the end Dean Galea. This has been so much fun. I’d love if you could just share a closing thought with the listeners and the best place that they could follow you or get a hold of you.

Sandro Galea: [00:26:36] Let me close with one more story or you know as a dean of a school of public health I don’t have much time for pets but I have pet goldfish. OK. I love my physical strength. You’re wondering where it is going and going to. So I tell my pet goldfish. I want you to be healthy. So every day I want you to swim around your bowl and things clockwise counterclockwise sees the. And when it feels a little flaky stuff on top don’t eat too much you don’t get fat. And when you get sick goldfish I’m going to get the best goldfish doctor. Now one day I walk into my living room and my goldfish were all dead. Could this be a exercise that eat too much and it stopped her and then realized Ah I forgot to change the water. And if you don’t change the gold fish water doesn’t matter what else you do goes fish will not. And we are tickled. And when we focus only on medicine the same thing happens. So we ultimately need to create their health by thinking about water and the water is where we live the cities around us. The environments are known as the air we breathe the water we drink. The food we eat the politics and policies to shape those conditions that ultimately was great. That’s my last thought. Now to follow me on Twitter. @sandrogalea one where and I didn’t publish in very different places but I always pushed things out on Twitter scroll easiest way.

Saul Marquez: [00:27:57] Oh wonderful. A powerful way to end this. This interview. This has been amazing. I really appreciate you carving out the time for us and looking forward to keeping up with your work. Thank you so much for being on the podcast.

: [00:28:09] Thank you for having me, Saul.

: [00:28:14] Thanks for listening to the outcomes rocket podcast. Be sure to visit us on the web at www.outcomesrocket.health for the show notes, resources, inspiration and so much more.