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We should look at healthcare through the lens of love

Public health expert Sandro Galea on why public health should be more founded in compassion

One core set of concepts in public health make up the social determinants of health. The Centers for Disease Control and Prevention breaks these into five broad categories: access to health care, education, social and community context, economic stability, and neighborhood and built environment.  These outside forces consider where you were born, where you go to school, the food and water you consume, and the social support surrounding you. They are key in deciding individual health outcomes. Some estimates place these factors outside of a direct clinical setting to account for 89 percent of our overall health.

It is not uncommon to think about an person's health as simply the sum of individual choices, but social determinants of health flip this common fallacy on its head. For example, it is difficult to eat a good balance of fruits and vegetables if you live in a food desert, or to access preventative medicine if you live in a rural area without a car or public transit. Social determinants of health are an important because they shift the blame of health outcomes from the individual to larger, systemic inequities, such as high costs of health care, contaminated water, environmental pollution, or food deserts.

Such inequities have been highlighted by the COVID-19 outbreak. For example, people of lower socioeconomic standing have a higher likelihood of risk factors like diabetes or COPD, they may be less able to stockpile supplies, and their lower wage jobs in the retail and service industries require in-person hours — limiting their ability to maintain social distancing. Theses inequities are driving differences in which populations COVID-19 affects the most. For example, infection and mortality rates were three to six times higher in predominantly Black counties in the US, according to a study last year in The Lancet Respiratory Medicine. Such horrifying statistics are both a result and reinforcer of systemic racism — another key social determinant of health.

Social determinants of health are undeniably important, but what about moral determinants of health? In his 2020 TEDMED talk, Sandro Galea, the Dean and Robert A. Knox Professor at Boston University School of Public Health challenged the US to envision a healthcare landscape through the lens of love, where health, by default, becomes a public good. "Our health should be founded in compassion and shared humanity," said Galea.

Galea's worldview has been strongly influenced by his experience as an immigrant and his work in rural, remote health care settings. A key experience for Galea was his time working with Doctors without Borders in Somalia. Galea explained that he often felt like a man standing on the side of a river saving individual people from drowning, but that before long he wanted to know why people were ending up in the river in the first place. His efforts began to feel futile, and it became came clear to him that there were limits to what any one physician could achieve. He recounted: "I think I went into medicine thinking I wanted to do population health, but then I got to medicine and then I realized it wasn't about that at all." He went on to pursue an masters and doctorate in public health to get at those root causes of health and disease.

Of particular interest to Galea are the effects of hate and trauma on health. Some estimates suggest that at least 70 percent of adults in the developed world have experienced at least one traumatic event. Galea stated, "When we choose to hate and demonize, we are poisoning our public health and our public discourse." This was apparent for Arab Americans living in the US after 9/11 and has been equally problematic for Asians in the wake of COVID-19 where misnomers like "Chinese virus" have led to increased hate crimes and acts of violence.

Galea admitted that he had some reservations about using the word "love" in his talk. But while he doesn't want to be perceived as overly sentimental or naïve, he still believes that values like "acceptance, compassion, respect, community, justice, and the equitable distribution of resources" will help us get to a place where health becomes a collective investment — another key piece of the global commons.

"We've come to see health as a private commodity," Galea said. He suggests that next steps are not necessarily more research or randomized controlled trials, but rather adjusting health care and adjacent systems to remove conflicting incentives — in effect, changing systems to incentivize compassion.

Paraphrasing Jeffrey Vickers, Galea said that "the real job of public health is to take the acceptable and make it unacceptable." Galea suggests that the question we should be asking ourselves is, "Why should there be any preventable deaths?" Like deaths from smoking or not wearing seatbelts, how can we make the thought of preventable deaths unacceptable? Compassion is not a blueprint all by itself, but it is certainly the place to start.