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interviews

We Saw The Limits

by Dr. Sandro Galea
April 2, 2020

This interview with Dr. Sandro Galea, a professor and Dean of Boston University School of Public Health, was conducted and condensed by frank news. Follow him on Twitter: @sandrogalea.

We spoke with a doctor [Dr. Michael Brumage] earlier this week working in West Virginia – he described what was happening now as evidence of a societal failing and undervaluing of public health. 

I couldn’t agree more.

When we say public health, what do we mean?

I think we mean two things here. I think we mean the functional, operational mechanics of the public health infrastructure. By that I mean how city, state, and federal agencies work and interact together – and have suffered from decades of underinvestment.

With this crisis, we saw the limits of our public health infrastructure that we have underinvested in for decades. 

The second part of it is public health is about health, and the health of the world around us. It's about your health and how that might help our health collectively. And it's about creating a world that generates health to build a world where we have safe housing, good schools, clean air, drinkable water, livable wages, fair economies, gender equity. These are all forces that ultimately drive health. And we have deprioritized these forces because we have focused our health thinking on a very individualized biomedical approach. This failure shows our disengagement and disinvestment from public health at both these levels, both the more mechanical core functions of public health, and the creating a healthier world aspect of public health.

Right. We need to look beyond healthcare and healthcare institutions.

Exactly. 

You mentioned the coordination between hospitals, state, local, and national. How is responsibility managed and tasked both in and out of crisis? How do you help those in charge at every level?

Collectively, we need to keep reinforcing the messages of public health. Public health should be about all of us paying close attention to the foundations that generate health.

Public health should be about a relentless focus on the importance of health for all. 

I think the way to do that is by being clear about the message. This is not a one off pandemic. There will be other pandemics. The only thing we don't know is when and where, but there will be others. There have been others in the past, and there will be others in the future. If this is not a wake up call for us to create a healthier world, I'm not sure what it is.

What do we know for sure we need to do to take care of the most vulnerable populations? 

There's a lot to do for the care of a lot of our most vulnerable populations. We need to make sure we are paying attention to the homeless, to the low income populations, those who have unreliable sources of income, those who are in prison, and our immigrant population. And each population requires different solutions. The health equity approach means not doing the same thing for everybody, but actually paying particular attention to what needs to be done for those who are most vulnerable.

Right. This virus has made it exceedingly clear that we are only as healthy as our least healthy populations or people.

Exactly. I think that this teaches us that there is no such thing as health for one, without health for all. Health ultimately is a public good, whether we like it or not. Seeing health as a private commodity, as something that you can buy and sell, fails. Because what you can buy is healthcare, and healthcare can only help us if we're already sick. We need to move to a health system, not the sick care system. To do that, we need to invest in the infrastructure that builds health.

Do you think that the stimulus bill that was just passed does what it needs to do?

I think it's a good first step. It has provisions for individuals, for small businesses to keep people employed, and for unemployment insurance. A lot of these provisions will depend on how they're implemented. However, the stimulus bill doesn't at all affect those who are living on the margins. For example, the unemployment insurance does not affect those who do not file tax returns. Twenty percent of Americans don't file tax returns. It doesn’t do anything for you if you're an immigrant living in this country and you're undocumented. I understand why that is the case from a political perspective, but we should be clear that this is a first step. It’s a good first step from where we need to be, but it’s a first step. 

I mean, 3.3 million people filed for unemployment yesterday. That was an extraordinary order of magnitude, higher than the highest at the peak of unemployment during The Great Recession. This shows that the people who are losing their jobs are low income people who already had no savings. These are people who were already living on the margins, and these will be the people who are going to be affected hardest by this.

I read something you wrote recently that addressed the mental health component of all of this. You wrote, “first it's important to disseminate accurate up to date information on COVID19 to counter the misinformation that can lead to undue fear.” What pieces of information right now are critical? Beyond what I feel is necessary, I’m also consuming a lot of information that might not be. When is it enough?

I think it's important to try to keep yourself informed, but I also think there's been a lot of information, much of it inaccurate.

People need to be sure they are listening to sources they trust, and sources that are reliable. It is up to the individual in some respects to identify sources that they consider to be reliable. But I would encourage people to, as much as possible, not filter through information, to go to sources whose biases they understand, and who they think are reliable and who are trying to help educate the public through a combination of science and reason, with a very clear moral purpose to generate health for all. 

Do you have recommendations on an individual level for mitigating the difficult mental health components that come with this?

Yes, absolutely. I think that, number one, people need to stay connected in this time of physically and socially distancing as much as possible. People need to maintain a community of their friends, their loved ones, and their workplaces. Number two, people need to be educated and realize that symptoms of depression and anxiety are common at a time like this. We need to be educated and aware of the challenges that those symptoms can pose. Number three, people need to be able to go to a health provider to get help if their symptoms start to impair their ability to get on with their life. Number four, I think people need to maintain healthy routines. People need to continue to exercise, to continue to maintain daily routines. 

You spend your life in public health, do you see a way out of this? I think a lot of the anxiety is that it's all indefinite. 

I mean, by the grace of God we will emerge from this and we will survive. I think that the key question is how we deal with the long term consequences of this. The long term consequences are going to be very much consequences of the economic slowdown and the people who are affected by that. Number two, how do we make sure that when the next pandemic hits, and it's good to remember that there will be a next pandemic, right? There will be. The question will be have we learned our lesson and built a world that's better able to handle a crisis. 

I would go back to these two pillars that spoke about at the beginning of this interview. One is the, the actual public health mechanics of dealing with the pandmeic. And number two is creating a world that is resilient that has the pieces in place so that we are healthier. Those are the questions.

Right. And you're hopeful?

I prefer optimism. I think optimism is a form of resistance in the face of dark times. So yes, I am optimistic.