In this issue we meet Prof. Sandro Galea, a Maltese export to the US who has contributed much to the medical field. A physician, epidemiologist and author, Prof. Galea is the dean at the Boston University School of Public Health, US.

You hail from Malta. From where exactly?

 

I was born in Sliema, and raised in St. Venera, close to Hamrun.

 

Tell me something about your family.

 

My parents were both teachers when we lived in Malta. This made the teachers strikes of the 1980s, and the broader political unrest of those years, very much part of our daily life. I remember teachers holding lessons in their homes during the strike, the knock of police at the door, and worrying about my father, who was often out at protests. These conditions would play a role in my family’s decision to leave Malta for Canada. They also shaped my thinking about how a country’s political dynamic shapes the physical and mental health of citizens. I saw the toll political instability took on my parents, the injuries suffered by protestors, and the how polarization could take hold even in a place as small as Malta, undermining quality of life. The fact that my first exposure to these challenges was witnessing their effect on my family is perhaps why the link between politics and health has remained core to my thinking to this day.

 

Why did you opt to go to the University of Toronto medical school?  

 

As far back as I can remember, I have always wanted to make people better, healthier. When I was younger, the most direct way of doing so seemed to be becoming a doctor. The University of Toronto was attractive for the quality of its program and for its proximity to where my family was living at the time, hence allowing me to honor my family’s wish to have me remain relatively close by – a fairly common wish for immigrant families.

 

At 48 years of age, you seem to pop out of a fiction book. You worked in New Guinea, the Philippines and also with Doctors Without Borders in Somalia. You have published a staggering 800 scientific journal papers and 18 books. Your work has been cited more than 50,000 times and you have been invited to present your work in 30 countries. Do you consider yourself to be a storyteller? Who is Blind Willie Johnson?

 

I think storytelling is necessary if we want to effect change that leads to a healthier world. We all tell ourselves a story about health. At the moment, the story in the United States is roughly this: to stay healthy, we must make good choices about what we eat, how much exercise we get, whether or not we engage in risky behaviour, etc. When we get unhealthy, it is generally because we have failed to make these good choices. We go to the doctor, who prescribes us medicine which makes us better. We then pay an astronomical fee for this treatment.

 

This story is wrong. The story we should be telling is that our health is shaped by the social, economic, and environmental conditions in which we live – by the food we eat, the water we drink, the air we breathe, our education level, neighbourhood safety, etc. Doctors and medicines treat us when we are sick, but these conditions decide whether or not we get sick to begin with. We should spend as much on improving them as we currently spend on treatment. The first step to doing so is changing our story about health.

 

This means talking about people like the blues singer Blind Willie Johnson. He was born in Texas in 1897. He lost his sight early, grew up poor and black in the American South, and eventually made his living playing music on street corners. One day his house burned down. With nowhere to go, he slept in the damp ruins, until he died from malaria after reportedly being turned away from the hospital because he was poor or because he was black (it is unclear which). Yet it was not really malaria that killed him. It was the conditions of his life – poverty, racism, injustice – which truly made him sick. We need to talk about these conditions when we tell the story of health.

 

Why study epidemiology?

 

Epidemiology is centrally concerned with the causes of disease in populations. By pointing towards the roots of what makes us sick or keeps us well, it helps us prevent disease from occurring. Its focus on populations reminds us that health is ultimately a collective concern. And it provides a scientific foundation for the practical steps we must take towards a healthier world. When epidemiology tells us, for example, that income inequality undermines health, this finding has political implications, opening the door to the high-level, structural changes that can improve our health.

 

You seem to prefer equity to efficiency. What are your allegiances? 

 

A core tenet of public health is that we are not healthy until we are ALL healthy. In the last century, life expectancy in the US rose from 47 to about 79, yet the lives of the poorest Americans are now 10 to 15 years shorter than those of the richest. Such health inequities persist despite the efficiency and technological promise of our age. Equity, the closing of such gaps, should be at the heart of our approach to health.  I am not sure I “prefer” equity to efficiency. I think both are very important and we should work hard not to sacrifice one for the other as much as possible.

 

You seem fixated with the idea of people dying healthy … what is the ‘Healthiest Goldfish’?

 

There is a story I often tell about a pet goldfish. Its owner wants it be healthy and live a long life. So, she feeds the goldfish nutritious food. She encourages the goldfish to exercise. She makes sure it receives special goldfish medication when it gets sick. Then one day, she wakes up and the goldfish is dead. Why? She forgot to change its water. The story is a metaphor for the conditions that shape health. Place, politics, the environment, the economy, community networks – these are the “water” of our daily lives. When we neglect these conditions, then, like the goldfish, we will get sick, regardless of the medicine we can access or our personal choices about health. When we improve these conditions, when we keep our “water” clean, we create a world where we can be healthy throughout life, rather than a world of constant sickness mediated by expensive drugs and treatments. This is the world we should invest in creating, a world where we can “die healthy,” rather than spend our money in a futile effort to live forever while ignoring the core drivers of health.

 

In what seems to stem from one of Prof. Edward De Bono’s books, you even advocate buying A/Cs by hospitals for installation in poor people’s homes to curb acute asthma attacks, and subsequent hospital admissions, in tropical climates. Can you explain further in view of the current healthcare payment models which we use?

 

We need to address poor health at the level of causes, while remaining pragmatic about changes we can make to improve health quickly in the near-term, prioritizing the goal of prevention over treatment. Ideally, we would prevent disease among the economically disadvantaged by creating an economy where income inequality, and the poor health it generates, is no longer endemic. This is a long-term goal. In the meantime, if we can prevent disease through smaller adjustments, such as installing A/Cs, we should do so. We should constantly aim for the best, without ever making it the enemy of the good.

 

You have been named one of TIME magazine’s epidemiology innovators in 2006 and Thomson Reuters listed you as one of the ‘World’s Most Influential Scientific Minds’ for the social sciences in 2015. What drives you to do all this?

 

I am driven by what, I think, drives us all: a desire to build a healthier world for ourselves and for future generations. Each day I work with talented, committed young people who are driven by a desire to do right by the world. I also have children who constantly inspire me with their instinctive embrace of creating a fairer, more just world. We owe it to the rising generation to be no less committed than they are to building this world, where all can live healthy.

 

Your latest book, Teaching Public Health, has been published by Johns Hopkins University Press in August 2019. Why should one read it?

 

I edited the book in partnership with Lisa Sullivan, Associate Dean for Education at the Boston University School of Public Health. Our aim was to address how public health education can respond to emerging trends in our field and create the best possible experience for students in the classroom and through curricula. The book features contributions from leading public health thinkers and teachers, and will, we hope, be useful to anyone interested in the future of public health.

 

Will you return to your roots, Malta?

 

My years in Malta were formative. They shaped who I am and much of how I see the world. I cannot imagine ever straying too far from their influence.

 

What advice would you give to the recently appointed Prime Minister, Dr Robert Abela?

 

I would advise him to stand for health. This means investing in creating structures that generate health, such as housing, education, public parks and places to exercise, and other factors that contribute to the “water” in which we live. Health is a public good sustained by collective investment, and politics is, at core, about how we allocate resources within a society. A leader who makes the resources necessary for health more accessible – particularly to people who have been historically marginalized or overlooked – is positioned to create truly transformative change.

 

Have you ever read The Synapse?

 

I confess I have never actually read it, but I look forward to doing so!