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Sandro Galea: the Epidemiology of Consequence Sandro Galea Talks to Gary Humphreys About the Power of Epidemiology and the Need to Change the Way We Talk About Health

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Sandro Galea: the Epidemiology of Consequence Sandro Galea Talks to Gary Humphreys About the Power of Epidemiology and the Need to Change the Way We Talk About Health News Sandro Galea: the epidemiology of consequence Sandro Galea talks to Gary Humphreys about the power of epidemiology and the need to change the way we talk about health. Q: You started your career as a primary health care physician in northern Can- Sandro Galea has devoted the last 20 years to ada. How did you end up focusing on raising awareness and improving our understanding behavioural epidemiology? of the drivers of health and poor health through A: It might seem counter-intuitive, epidemiological studies, writing and teaching. He but I wanted to have more of an impact. is the dean and Robert A Knox Professor at Boston University School of Public Health. From 2010 to 2015, Q: Can you explain that? he was Gelman Professor and Chair of the Department A: Well, I always wanted to make a of Epidemiology at Columbia University. Before that he difference. Even when I was in medical Galea Courtesy of Sandro school, I was very interested in work- Sandro Galea was at the University of Michigan (2005-2010) and the ing in countries where the need for New York Academy of Medicine (2000-2005). His latest health-care professionals was acute. So, book targets a general audience: Well: what we need to talk about when we talk for example, during my training I spent about health. He is also one of the editors of Urban health, a recently published four months in Papua New Guinea and collection of essays. Galea holds a medical degree from the University of Toronto, a couple of months in Guatemala City at graduate degrees from Harvard University and Columbia University. This year he a time when there was considerable po- took over as chair of the board of the Association of Schools and Programs of litical upheaval there. After I graduated Public Health. He is a former president of the Society for Epidemiologic Research from medical school in Canada, I did and of the Interdisciplinary Association for Population Health Science and is an my residency in the town of Geraldton elected member of the National Academy of Medicine since 2012. Galea has in the north of the country. I was just received several lifetime achievement awards. one of three doctors in a town which was three hours from the nearest large urban area and a lot of my patients were from the First Nation population (indigenous I knew nothing about public health. I and psychiatric epidemiology. But once peoples of Canada). These people were knew nothing about prevention. again I realized that I did not know generally neglected and underserved by enough and I decided to do a doctor- the health system. So, I knew I was mak- Q: You did your master’s of public health ate at Columbia University, which has ing a difference, but I wanted to do more. at Harvard University. Was that your first a prestigious psychiatric epidemiology I always had this desire to see what it was encounter with epidemiology? programme. I started at Columbia in like to work in low-income settings and A: Absolutely. I actually applied 2000. So, in 2001, I was starting work so I applied to work with Médécins sans to do my master’s in Harvard’s health on my doctoral thesis and my ideas were Frontières in Somalia. policy programme, but half way through just forming when 9/11 happened – this the application process I realized that massive traumatic event, a violent event, Q: How did that get you to focus on what I really wanted to do was special- affecting large populations. As terrible as epidemiology? ize in epidemiology, and they were kind it was, it was an incredible opportunity A: In Somalia, I was the only doctor enough to accommodate me. to study the psychological impact of for about 350 000 people, so in many the event on people, up close and in respects I felt like I was doing as much real time. I ended up doing a lot more good clinically as I was ever going to work on the psychological epidemiol- be able to do, and yet it wasn't enough. There is great ogy of disasters and mass traumas. In I felt like I was pulling people out of a “power in numbers. fact, I spent a decade doing that kind of river, but I wasn't really understanding And when I say power, work, including work on mass shoot- how they were falling into the river in I mean power to effect ings and the broader epidemiology of the first place. And I couldn't help but change. gun violence. feel that once I left, nothing was going to change. So, I started to ask myself ” Q: You have argued in your articles and some fairly fundamental questions. books for an ‘epidemiology of conse- What is driving the burden of disease quence’. What do you mean by that? and death here? What is it, at the root, A: An epidemiology of consequence that makes people healthy? I realized Q: I understand that you went on to focus is an epidemiology that provides the that my medical school training had not on the epidemiology of behaviour and evidence-base to inform public health really prepared me to answer those ques- mental health, in particular. Can you action. Epidemiology should be at the tions. I was trained in medicine at the talk about that? heart of any public health thinking University of Toronto, which at the time A: At Harvard, I became very inter- and action, and should address issues was a fairly traditional medical school. ested in the intersection between social of consequence, such as gun control. 448 Bull World Health Organ 2019;97:448–449 | doi: http://dx.doi.org/10.2471/BLT.19.030719 News And, yes, I have written extensively on talk about the facts you are seeking to and choice. These forces determine that topic and have made a concerted establish there? whether we get sick or stay well, but effort to inject a sense of purpose into A: The facts I present relate to the they have tended to be neglected in the the field. Basically, my argument is for central argument, which is that as a health conversation. In order to change epidemiologists to quantify, to count society we tend to conflate the concept the conversation, I felt it appropriate to what matters, what will contribute to of health with the practice of medicine, address the widest audience possible. creating a healthier world. rather than seeing health as the product of broader determinants, such as poverty Q: Is changing the conversation enough Q: You have suggested that epidemi- and social injustice. In other words, the to bring about a change in health-care ologists should speak fearlessly, which forces that were affecting the people I outcomes? suggests that speaking out is not always was treating in Somalia. Needless to A: We will see. But I believe it can without consequences. Do you have say, I draw on a lot of data, but some of start a process that will lead to change. personal experience of hostile reactions the highlights include the fact that in Changes in politics and policy tend to to the evidence you present? the USA our health output per dollar follow a change in the broader conver- A: In truth I'm largely protected is worse than that of any other high- sation. Institutions change in response from the harsh realities that many activ- income country. One of the reasons to the broader conversation. And by ists face. But I have run afoul of different for this is that we are focusing on the the way, I consider optimism to be an groups at different times, including the wrong things. For about a decade we important form of social activism. National Rifle Association. have been consumed by discussions around health coverage and in particular Q: Do you have any indications that your Q: Why was that? the Affordable Care Act, the challenges message is being heard? A: They took exception to me chal- presented by its implementation and A: Most people I talk to say “Oh yes, lenging the prevailing national narrative more recently, by the attempts by the I get it. I see the point you're making”. on firearms. current administration to “repeal and The challenge becomes how to move replace” it. While it is clear that the act beyond platitudinous agreement to real Q: Challenging it in what way? was a long-needed step forward not engagement. But there is an appetite A: By presenting evidence regard- least for the provision of health insur- for change - of this I am certain. When ing the commercial interests behind the ance coverage for 20 million Americans, I talk in the USA and I say to audiences narrative, and by presenting the reality who were previously without coverage, it how many of you are aware of the fact of the gun violence epidemic itself – the probably will not have a huge impact on that there has been a downturn in life fact, for example, that in the United the country’s health indicators. expectancy in this country for the past States of America (USA) approximately three years, and that this is the first time 34 000 people have died from firearms that we have had a downturn in life ex- annually since 2000, and two to three pectancy since the 1918 flu pandemic, times that number are injured by guns. Epidemiology perhaps 5% of people hold up their Despite this simple and appalling fact, should“ be concerned hands.
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