Physician-Dean Puts His Mark on Public Health
By Robyn Alie, Manager, MMS Policy and Public Health
A committed, dynamic partnership between medicine and public health is vital for improving health outcomes at sustainable cost — but that partnership is not supported systemically. At Boston University School of Public Health, Physician-Dean Sandro Galea is aiming to change that, and is shaping the next generation of public health practitioners.
Sandro Galea, MD, MPH
An emergency physician and epidemiologist, Dr. Galea grew up in Malta, and studied medicine in Toronto where he volunteered with homeless populations. He has practiced rural medicine in Canada, and worked in Somalia with Doctors Without Borders. Vital Signs spoke with Sandro Galea, MD, MPH, DrPH, about the important roles social justice and addressing social inequities play in health — a core theme of Dr. Galea’s book published last year, Healthier: Fifty Thoughts on the Foundations of Population Health (Oxford University Press).
You’ve identified diversity and inclusion as core values at the BU School of Public Health. How important is diversity in medicine and medical training?
We have long underestimated the importance of diversity and inclusion for the profession. The profession has a responsibility to represent the population it serves, and there is abundant scientific evidence that diversity is a positive for creativity, innovation, and generating ideas. So, I think there is incontrovertible reason to believe that diversity should be central to all we do in health. Diversity means having everyone at the table, and inclusion means making sure everyone feels included. There is the element of making sure that the communities are not just represented by the people who are providing health care and those who are trying to promote the health of populations, but also that the diversity of community members are heard, and by those who are providing health care specifically.
When we talk about health equity and social determinants of health, we hear that “place matters.” How does Massachusetts matter?
Your zip code matters more than genes. There are plenty of data to suggest that quality of housing, parks, and environments, social connection, availability of transportation — these are ultimately the factors that create health. That matters as much in Massachusetts as in Mississippi or in Alaska or in Wyoming. Massachusetts has tremendous heterogeneity in its health, and a lot of that is geographically patterned just as it is in all other states.
Are there areas where we have opportunity for greater improvement here?
The production of health is ultimately a balance between health care and the social services that generate positive environments. Massachusetts is better on both of those axes than many other states. We have in many respects the densest, richest network of health care providers in the country. We also have had a generation of state leadership that has tried to invest in social services. Having said that, even in Massachusetts we weight our investment heavily on health care and underinvest in parks and recreation, mental health, public health services, justice, civil society, opportunities for social connections — the whole basket of services that ultimately generates health. This is the subject of my latest book.
Around the country, systems — ACOs, for example — are now paying attention to social determinants of health. Are we on the right track?
ACOs are a step in the right direction. They are a step toward having provision of health care done in a way that organizations are accountable for populations, not simply for patients. I think it’s going to take a shift toward blended payment models where there are clear incentives for physicians providing quality care but also incentives for keeping patients healthy, keeping people from becoming patients.
Is there a model that you have in mind?
There are systems in this country that do a reasonable job of this. Some of the large health provider systems, such as Kaiser, have invested quite a bit of money to keep their catchment population healthy. They have to contend with the fact they have little control over the context and are ultimately part of a very fragmented system. But I think to take what those systems do and to take it to scale and to cover everybody would achieve a tremendous difference in health in this country.
There are lessons from Canada reflected in the Medicare For All argument, most prominently proposed by Senator Sanders but [also] by many others. For countries that are less well-resourced, I think lessons lie in specific programs that make as their mission the promotion of health for a particular group of people.
Do these coordinated care models work in smaller communities?
Smaller communities, perhaps of necessity, have done a nice job of creating structures that look after the whole population. That involves a combination of physicians, nurses, and other practitioners working in close concert with municipal governments to generate healthy environments. Small communities in some respects can be a model for larger cities, states, and the whole country. That is what it is going to take to create health, the generation of a social, physical, and health care environment that all works together in creating a healthier world.
How can we better integrate physical and behavioral health needs and support?
Behavioral health — mental health and substance abuse — is undervalued in health and undervalued in medicine. We have long had an antiquated divide between physical health and mental health; all of health is health. We know that the line between physical health and mental health is artificial and arbitrary. We know that having mental illness predisposes you to physical illness, and vice versa. I would like simply to see us treat all health and all illness the same way.
Illness is a pathophysiological problem that medicine can help us solve, be that illness dependence on substances, be that illness major depression, be that illness post-traumatic stress disorder, be that illness arthritis, be that illness broken bones, be that illness hepatitis. I’m interested in keeping us away from hepatitis, the broken bone, arthritis, post-traumatic stress disorder, or substance dependence.
What is your vision for public health?
Public health is about creating the conditions that keep people healthy. Public health should aspire to creating a world where we have the right social conditions on multiple social axes — of housing, of income, of education, of child care, of elderly care — that ultimately keep us healthy. Medicine is a subset of that: we need good medicine, we need good health care, but we need medicine when we get sick. The job of doctors is to restore health once we get sick, but I think we all agree we’d rather stay healthy for as long as possible.
The metaphor that works is the one of a soccer team. You have 11 people on a soccer team and they try to get the ball to the other side and score. People who don’t understand soccer think the way to win is to have a very good goalkeeper, but anyone who plays soccer knows that no matter how good the goalkeeper is, when the ball gets close it’s a very big net and the ball is going to go in the net. So really you need to keep the ball away from the goalkeeper. The goalkeeper is medicine. Sometimes you are going to get sick and you want the goalkeeper to keep the ball out of the net. But you are going to win by having the other 10 players keep the ball away from the net. Those 10 players are sustainable income, childcare, excellent quality education, housing, opportunity for economic achievement, parks and recreation, safe neighborhoods, clean environments.
How do we get there?
I think we get to prevention by saying again and again that prevention matters. Would you rather have a world where there is a treatment for Alzheimer’s or a world where there is no Alzheimer’s to begin with? Then you look at our investment: is it in preventing Alzheimer’s or treating Alzheimer’s? The system privileges treatment over prevention. Doctors have a powerful voice in the health care debate. If doctors understand that there is a need for engagement in multiple sectors to keep us healthy, the voice of doctors can move the needle.
