I’m Sandro Galea, physician, epidemiologist, author and Dean at the Boston University School of Public Health. Ask me anything about health, wellness, and global public health.

1. What is the United States getting wrong about health, wellness, and healthcare? What could the government be doing differently? What could individuals do differently?
2. How can we change the perception of nutrition in the United States? So much could be avoided if people had a better idea of how nutrition really works.

1. We are investing in our money in medicine and healthcare, not in health. We need to be investing in the social, economic, and environmental conditions that affect health. So, we need to invest in transportation, housing, parks, and opportunities for a healthier life.
2. Yes, we need to understand that what we eat helps us and helps us get healthier. But equally well we need to understand that we need access to healthy foods in order to eat healthy. Without healthy food access we cannot eat healthy. So we need to create an environment where food is available that generates health.

Thank you again

Every few years it seems people start talking about bird flu epidemics.

Can you explain if you think a serious Spanish flu style pandemic is possible/ probable? If yes are the preparations being made adequate?

yes it is. Unfortunately we are not particularly well equipped to deal with potential epidemics and that is putting us at risk collectively. Preparations are being made from the point of view of the medical aspects of dealign with epidemics, but we have weak social and economic structures that would suffer, and quickly, if we had such epidemics. Bottom line: we need an investment in stable infrastructure that can withstand a global pandemic.

Wow. Cool. So what are the fundamental misunderstandings do we have about being healthy. What are the most important fundamental changes should we take?

The biggest misconception, to my mind, is that we think health is almost entirely a product of our individual choices. We believe if we can only eat right, get enough exercise, and avoid risky behaviors, we can assure our health. This is not the case. In fact, health is overwhelmingly generated by our context. If we live, say, in an unsafe neighborhood close to a pollution-spewing bus depot, there is only so much we can do to stay healthy. Inasmuch as health is generated by choice, it is shaped by the choices of high-level corporate and political actors, who are in a position to shape our shared context.

What are the 3 most important things you wish ordinary people knew about health?

1. Your health is linked to the world around you. Where you live, work, and play matter more to your health than your doctor
2. Genetics play a very small role in your health; where you live and how you live matter much more.
3. Your health and my health are interlinked and we cannot have one without the other.

Pharmaceutical companies have much to gain from constantly supplying us with drugs that make us feel well (whether the underlying problem is psychological, environmental or medical) but without actually curing us.

As more and more people are on constant anti depressive medication, pain relief, sleeping pills, dietary pills and so on how can the true scope of public (ill)-health ever be measured and what can be done to promote healthy living and preventative medicine with all the ad hoc solutions being so readily available and easily accessible to anyone who wants them?

The US spends more on health care than any other country in the world, yet our health is mediocre compared to peer countries. At core, these costs are driven by our failure to address the root causes of disease in society – the social, economic, and environmental conditions in which we live. We have not yet adequately addressed fundamental challenges like racism, poverty, climate change, and political disinvestment in the public goods that sustain health. Improving these conditions will not necessarily reduce the price of treatments, but it will reduce the need for treatments in the first place. Rather than spend more on health care, we need to spend more on health.

What’s your opinion of establishing “safe injection facilities” in Boston to combat the ongoing opioid epidemic?

I am on the record as being in support of supervised injection facility. They are a well established way to reduce harms associated with injection drug use and we should do everything we can and know how to do--including establishing SIFs--to reduce the consequences of injection drug use.

Are you Maltese?

Yes. Born and raised there. Immigrated to Canada as a teenager.

What do you predict will be the item we consume now that will, and should be, reviled as cigarettes?

guns

What are your thoughts on having marijuana recreationally available and its impacts on public health?

There are multiple thoughts on this. 1. The illegality of Marijuana over the years has resulted in an enormous burden of incarceration and its consequences being placed on minority communities, particularly young black men. Insofar as making marijuana legal reduces this burden that is a good thing. 2. Marijuana is not generally toxic and has relatively few long-term consequences. 3. There is emerging evidence though of psychosis linked to heavy marijuana use so I think the jury is still out on how this is going to affect population health

1. Is it worthwhile to eat organic vs non-organic foods?

2. Would you be concerned living in a residence in close proximity (.2 miles) to a cell tower?

1. Most foods purchased at mainstream stores are safe, whether organic or not. Organic foods are not infrequently more environmentally friendly which is a positive. So in that respect yes.
2. No, the science does not suggest problems to health with living near a cell tower.

What would you say is the chief cause in the low health standards in the US as compared to other nations?

Our poor health as a country is linked to our disinvestment in the world around us, the world that causes health. We need to change what we talk about when we talk about health to talk about politics, money, power, place, transportation, housing, infrastructure, all of which generate health. My new book is about all of this. See: https://www.amazon.com/Well-What-Need-About-Health/dp/0190916834/ref=zg_bsnr_689676011_1?_encoding=UTF8&psc=1&refRID=HBA0S0810HA5YSAH14K2

What should be the first steps in transitioning from an unhealthy, sedentary lifestyle, to a more healthy and active lifestyle?

1. Recognize that is essential to health
2. Find places where one can exercise; you will not move an active lifestyle without such an environment
3. Make friends with people who are active; our social networks influence what we do.

Hi Sandro! Do you think vaccines should be mandatory for adults/teens? Why, why not, and why the difference if there is one?

Vaccines are one of the greatest scientific inventions that improve the health of populations. And they depend on all of us being vaccinated to increase herd immunity. We are seeing right now the consequences of low levels of vaccination in several measles outbreaks across the country. All to say that vaccines need to be mandatory to work, with the only exceptions being for medical indications (which are rare).

Hi Dr. Galea,

My question is related to one of the scientific approaches being researched in order to achieve a higher level of health and wellness globally.

I'm wondering if you have any comments on the potential ramifications that could arise through using gene drives in mosquitos in attempt to eradicate or reduce mosquito-borne diseases. In particular, is there a situation you foresee in which this all could go horribly wrong? And on the other side, if it goes well, could you foresee higher order ecological effects given the lower (or missing) population of mosquitos?

[After writing this question, I was able to find some more information on potential negative effects for myself (PubMed Table) --- could you comment on this? Where do you see this technology going in the health realm?]

Thanks for your time and input!

I worry about the ecological consequences that are possible when we disrupt systems with efforts like gene drives. Yes, it could go horribly wrong if we do not understand the unanticipated negative consequences of such moves. That does not mean that we do not perturb systems ever, it just means that we do so with caution and humility.

What type of healthcare system do you think the US should have?

I live in West Virginia, which is either at the bottom or close to the bottom of every health related list. What biggest changes to our state would you propose to help us?

The first step we should take is inform a shift in our national conversation about why we get sick and how we can stay well. We need to rethink our overwhelming focus on health care which too often neglects the broader socioeconomic forces that shape health, in favor of a health conversation that addresses factors like place, power, money, politics, and public goods, which are at the heart of population health. What we talk about eventually becomes our political priorities; our political priorities eventually become the policies that shape our lives. I subtitled my book “what we need to talk about when we talk about health,” because I truly believe this shift in the conversation is necessary if we are to move our policies, and ultimately our society, in a healthier direction.

Hey Sandro! Your work sounds incredibly inspiring! As someone who is interested in this field of work, I was wondering how you got your start in your career?

And what do you mean by our misperception of ‘being well’?

I am passionate about improving health for as many people as possible and if my work can contribute to that, I am happy about that. So, thank you. I mean by that that we do not adequately understand how it is that we generate health and that is in large part what my new book WELL is about. https://www.amazon.com/Well-What-Need-About-Health/dp/0190916834

Thank you, that is very kind. I am passionate about generating ideas that promote health and doing the science behind it. Insofar as that has fueled my career, I have been lucky about that. By misperception I mean that we misunderstand what it is that causes health and that is in large part what my new book is about: https://www.amazon.com/Well-What-Need-About-Health/dp/0190916834

What’s your favorite mathematical or statistical method for epidemiology?

Epidemiology is about telling stories, about describing the world. So my favorite approach is the simplest--using data to explain the world to us, finding truth in understanding health and what causes it.

Greetings.

I have read on the internet that Artic is the nest of many viruses. If those viruses spread on mankind, how are we supposed to deal with it, and can those viruse be deadly as cancer?

This is a bit outside the scope of my expertise!

Hi Dr. Galea, thanks for doing this AMA. What do you think the CDC and local public health departments can do to better inform and reach out to people about the dangers of high sugar and salt intake?

I think the CDC and local health departments do a very good job of communicating. It is a big job to educate populations about health and it is the job of all of us--myself included--in the field to do this. I have boundless respect for my colleagues in public health practice--they do hard work and do it well. In part such conversations like this AMA are efforts to improve the health conversation, to supplement efforts like those of the CDC and health departments.

Thank you for the AMA, Dr Galea.

I am a practicing veterinarian with strong interest in pursuing my future career in public health - especially in the field of zoonotic diseases.

1. What do you think about the concept of One Health? What role can a veterinarian play in this?

2. In your opinion, what is the best way for a clinician (veterinary or medical) to step in to the field of public health?

Thanks again for your time.

My thoughts

1. I think that our approach needs to be to understand health as a product of the universe around us, that our health is interlinked, and that we want our world to be one that facilitates health at every step.
2. I think clinicians play an important role in saying this and you should feel emboldened to explain how the clinician has a role in generating health beyond their clinical purview. I wrote about this in JAMA. See: https://www.ncbi.nlm.nih.gov/pubmed/30548080

Hi! I see such a lack of knowledge amongst the general population when it comes to health. Whether it's not knowing what a good blood pressure is or what the numbers even mean to what OTC meds to use for the common cold to some ingrained belief that every little cold, ache and pain needs antibiotics. How does this ever change? What do you see for our future once antibiotic resistance is much more of a problem than it is currently? Thanks!

This comes from a misunderstanding of health and what causes health. It is in part why I do AMAs like this. So that we can better understand health. Health is a product of the world around us--the places we live, the air we breathe, the water we drink. That is what makes us healthy. It will change once we understand that.

Do you think the ways we measure the overall health and wellness of a community are influenced by cultural and epistemological norms? Is it possible to have a standardised way of measuring how healthy a person is that holistically considers how different we all are?

The WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." On the whole, our culture is inclined to miss the first part of this definition, in its focus on simply curing disease and calling it health. This is seen in our preoccupation with extending life indefinitely. But since we cannot live forever, we must ask ourselves: what is health for? I would argue health is a means to an end, and that end is being able to enjoy a rich, full life, doing what we enjoy in the presence of those we care about. Our definition of health should take this into account.

Your opinion on cholesterol's perceived evil, and the clinical the jump to statins for those with high cholesterol would be appreciated.

​

I recently had my blood work done and my cholesterol was 230, but my HDL was good. My doctor luckily didn't jump to statins but recommended fish oil. Im 42 and do not have any family history of heart issues.

​

To tie in, your thoughts on keto/paleo, which is my go to when i want to drop a few pounds.. It obviously comes with it's cholesterol. Does dropping the high sugar/processed grain benefit outweigh cholesterol increase for someone with higher cholesterol? Can sugar affect the circulatory?

​

Thanks for dropping in!

Unhealthy eating is driven far more by structural causes than by lack of will power. Regular consumers of such food tend to eat it because it is the cheapest, most available option. It is also important to remember that portion sizes in American restaurants have more than doubled over the last twenty years. So while unhealthy food can be enjoyable - facts must be faced, after all – the reason they are now fueling a health crisis in this country has less to do with the seductive power of a chocolate bar and more to do with the fact that chocolate bars are everywhere and cheap, while better fare is, for many, out of reach.

two questions:

- What changes, on a societal scale, would be most effective at increasing life expectancy and improving health/ quality of life through out?

- What could help reverse the shortening of life expectancy for some Americans, and reduce lifespan (and health) inequality?

edit: two Qs

Among the many factors that enforce health gaps between Americans, one of the most striking is the gap between those at the very top of the economic ladder and those at the very bottom—a full fifteen years. As economic inequality widens, this gap is likely to grow (see our team’s work on this: https://www.ncbi.nlm.nih.gov/pubmed/28402829). For this reason, health, and specifically the mitigation of life expectancy gaps, is inextricably tied to economic justice, which is, in turn, tied to political policy. So, it is important to remember, especially as the economic debate unfolds during the 2020 presidential campaign, that when we talk about tax policy, the minimum wage, etc. we are also talking about health.

I've had all my vaccinations, including six measles shots, but I'm still not immune to measles according to titers (my doc says I'm a "non-responder" to the measles vaccine). What should I do if there's an outbreak of measles in my city?

You should see your health care provider about whether you could benefit from another booster if there is an outbreak.

Hi.

What do you think is the worst thing that people do regularly and routinely which negatively affects their health in the long run?

Also, should I completely stop fast food?

Yes, you probably should stop eating fast food. Ok, every once in a while it is fine, but in general eating healthier food means eating food where you know the ingredients and can control the calorie count.

And to be healthy in the long term eat healthy, exercise every day, get sleep (as much as you can), live in a safe environment.

Hi Dr. Galea, thank you for taking the time to answer questions.

The United States has a significant shortage of physicians, particularly primary care in rural areas. As such, one major barrier to health care access is distance. Do you think telemedicine will play an increasing role in healthcare? Additionally, what do you think would be the benefits and consequences if so?

Yes I do and in some respects I would be surprised if telemedicine did not play a bigger role going forward. The benefits are clear--broader access for more people. The disadvantages include potentially widening digital gaps (we know that some groups have less access to technology than others say) and also we need to recognize that for elements of therapeutic interaction, digital remains a poor substitute for human contact.

What basic education (school system) initiatives would you endorse, with a mind toward preventative medicine?

What public education (public service announcements, media campaigns, etc like we had for smoking) would you endorse, again with the outcome being improved preventative medicine?

I would argue (and, in fact, have: https://www.bu.edu/sph/2016/05/08/a-good-education-the-best-prevention/) that the best form of prevention is education itself, and the earlier the better. Universal pre-k, robust, well-funded public schools - these help us to grow, flourish, make better health decisions, access good jobs, and make enough money to afford all the other resources that generate physical and mental health – from nice homes in safe neighborhoods, to quality food, to family vacations, to the simple peace of mind that comes with having money in the bank. All of this comes down to education, which is likely why there is a life expectancy gap of about nine years between people with a college degree and people who do not graduate high school. Investing in education as a public good is at the heart of preventing disease and promoting health throughout the life course.

John Feinblatt, President of Everytown for Gun Safety, said, in his blurb for my new book, “civic engagement is the closest thing we have to a miracle drug.” I agree – health is not only linked to politics, health, in a deep sense, IS politics. The social, economic, and environmental conditions that shape health are themselves shaped by the choices made by political actors. Participating in the political process is therefore one of the most important steps we can take for better health. For this reason, I would love to see a public education campaign about how not voting is bad for our health.

Is alcohol a problem in global public health? If so how much of a problem? And does it affect the poor more than the middle class and wealthy?

It is an enormous problem and one that led to about 88, 000 deaths from 2006-2010 in the US. See: https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm It does affect those with lower socioeconomic status than those with higher status, as is often the case.

Alcohol is indeed an enormous problem. It caused 88,000 deaths in the US between 2006-2010 alone. And yes, unfortunately it is linked to socioeconomic position. See the CDC on this: https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm

Does the nutrition problem in the US reflect personal choice or structural problems to a greater degree? As in, do people eat unhealthy because they can't afford better food, or because they like eating unhealthy food?

Also, what effect do diet/health trends have on nutrition? Are trends like paleo, cleanses, gluten free diets (when not medically indicated) a net negative, and where can people get better informed if so?

Thanks for educating us!

Unhealthy eating is driven far more by structural causes than by lack of will power. Regular consumers of such food tend to eat it because it is the cheapest, most available option. It is also important to remember that portion sizes in American restaurants have more than doubled over the last twenty years. So while unhealthy food can be enjoyable - facts must be faced, after all – the reason they are now fueling a health crisis in this country has less to do with the seductive power of a chocolate bar and more to do with the fact that chocolate bars are everywhere and cheap, while better fare is, for many, out of reach.

What is causing the mental health, suicide and opiod crisis and what can be done about it?

These diseases have been called "diseases of despair" with good reason. They are linked to poor underlying socioeconomic conditions and an approach to them must involve grappling with poverty, homelessness, inequality, and the range of conditions that threaten health throughout the country and world.

These are complex issues that are associated with a broad range of factors. They have been called "diseases of despair" because they are linked to underling social and economic forces that have been negative for large numbers of people in the US for quite some time. I do think that underlying structural issues--poverty, economic inequality, poor housing, limited opportunities--drive these phenomena.

How does the definition of wellness change when the society is consumerist based rather than something else? And it's that definition more or less healthy?

That is a good question and a complicated one. An unchecked market-based society does tend to shift our thinking in particular ways that privilege individual achievement and consumption and away from investment in goods that create public goods that can make us all healthier and better. So the definition of wellness changes insofar as in an individualist society we prize wellness only as it affects us without appreciating that our wellness is interlinked.

Why does BU need 3 (arguably more like 6) Green Line stops?

Ummm, the University stretches a long way on commonwealth and the stops serve everyone along the route? ...

Good Afternoon and thanks for the AMA Dr. Galea!!

I just want to know your opinion on vapor products and the "epidemic" of teen use. Do you believe vapor products are a less harmful alternative and do you think the USA is doing a fair job of evaluating their policies on vapor products?

Thanks again!!

I think the evidence is pretty clear that vapor products are less harmful than combustible cigarettes and in that regard they can be a harm reduction tool, an adjunct to just quitting combustible tobacco altogether. The challenge is that there is evidence that e-cigarette use may lead to combustible cigarette use and if the former become a gateway to the latter among those who were naive to combustible cigarettes to begins with, this could be creating and amplifying a problem rather than solving it.

Do you eat your eggs boiled or fried? Does it make a significant difference in terms of general health?

I eat my eggs scrambled. Fried food of course includes more fat than boiled food so the latter is healthier than the former. But all in moderation and a bit of butter with scrambled eggs is not at all a detriment to living healthy as long as one does not have too much of it.

How can individuals change actions and behaviors to achieve a more effective health and wellness lifestyle?

I think the extent to which individuals can change their behavior is overstated. We are creators of our context and environment and to the extent that our health is determined by the world around us, we change less than we think we do. So, we need to create a world that helps us generate health. The example of this is car accidents---we have much less motor vehicle injury now not because of better drivers, but because we have healthier cars (seatbelts, airbags etc)

What is your opinion on BMI being used as a population health indicator?

BMI is a measure that has utility, but like many such measures it has weaknesses. See the work of Andrew Stokes on this: https://www.ncbi.nlm.nih.gov/pubmed/28886964

How do you think field epidemiology will change over the coming years with the increasing burden of NCDs?

I think epidemiology is an exciting field that is only going to grow, and NCDs present an opportunity for epidemiology to discover and works on new approaches and methods. I have written a bit on the future of epidemiology as I see it in academic papers. See for example: https://www.ncbi.nlm.nih.gov/pubmed/28938753

Greetings from a junior clerk who has dabbled with some research into Global Health. What will according to you and current trends in public health research be the next big paradigm shift in the national understanding of public wellness?

Thanks for providing the opportunity for this AMA!

I think the next best thing we can do to understand health is to understand the health of populations, to understand the factors that shape population health to have as many people be as healthy as possible. If interested take a look at my book Population Health Science: https://global.oup.com/academic/product/population-health-science-9780190459376?cc=us&lang=en&

Hi Dean Galea,

I am actually an incoming first-year MPH student at BUSPH, and a lot of my classmates are either involved are want to get involved in public health service and jobs while getting their Masters. What advice or recommendations would you make to college-aged students who want to make an impact on public health that might not necessarily be pursuing a public health-related degree?

Thank you in advance!

We are delighted you will be joining our community! To your question: one of the reasons the study of health is so constantly fascinating is that it is, in a sense, the study of everything. Health is shaped by politics, culture, economics, architecture, labor laws, community networks, and much more. The study of any of these topics can inform and enrich the study of health, creating new perspectives from which to tackle the health challenges we face. We look forward to welcoming your perspective to our school.

[deleted]

A biosocial approach to health means an approach to health that takes into account individual biology, behavior, and context, that recognizes that the world in which we live is inextricable from our health and that says that we have to tend to context and the individual to improve health. So a "regular Joe" needs to recognize this and make sure that they argue for a healthier world, agitate for health in all decisions we make, and make sure we generate health in the public and private sector.

Many thanks for doing this Dr. Galea

With the ongoing digitization of health care do you think there is room for single and aggregate n-of-1 studies in clinical care and clinical research? It’s a model that has gained a “cult” following over the past couple decades but has yielded minimal real world value and I’m curious as to whether or not this is due to lack of value in the actual n-of-1 trial model or if it is due to the cost and logistical obstacles that still exist in creating and running these studies.

I think it depends on the question. There is nothing wrong conceptually with n of 1 studies. I would argue though that many of these studies are about questions that are not of the most important consequence for us and that is probably why you note that they have yielded minimal real world value. Having said that there is value to discovery science, and as part of a scholarship of consequence that involves many other kinds of science, discovery science plays a very important role.

Currently making my way into medicine. Epidemiology is something I’m considering in specialising in. Just curious what made you choose this speciality? What’s your day to day like? What sort of patients are you seeing? What’s the most interesting case you’ve worked on?

Thanks in advance!

Epidemiology is about understanding the causes of health and disease so that we may improve them. it is a research field and involves math and science. I do not see patients in my day to day but deal with data from real people of course. You can find the papers I have published by going on PUBMED and typing in my name.

I feel like in today’s society we push a dichotomy of health equals medicine/medical care and vice versa. While this is partly true I believe health is at an intersection of biopsychosocial factors. Would you agree with this? If so how can we as a society move away towards health equaling medicine and take a more holistic approach to being healthier as a nation?

I agree and see no reason why medicine cannot take on a role in understanding health as the product of multiple forces across levels of influence, beyond the individual. How do we move towards this? I think it is through having this kind of conversation, through shifting how we think about the role of medicine, to see it as central to generating health, through building a healthier world.

Hi Dr. Galea,

This may not be a top of the list issue, but should we be worried about prion diseases in the long run?

Maybe not top of list but certainly prion diseases have affect people in particular outbreaks of course. will this grow over time? I do not know really. But it is a good area indeed to have discovery science about.

1. What are the three most critical things everyone should be doing for better health?
2. Parkinson's is considered a Pandemic? Any thoughts on why the increasing numbers?

1. Demand health, not just from yourself but from the world around you. Make sure that all decisions are made with health in mind, be that food, exercise, zoning, choice of transportation, investment in housing, infrastructure.
2. Yes. It is increasing likely due to a combination of population aging and increased sensitivity in diagnosis, and also changes in lifestyle that have adversely affected the risk of disease. See this paper on this: https://jamanetwork.com/journals/jamaneurology/fullarticle/2529538

Hi Dr. Galea, thank you for doing this.

As someone who is about to enter residency for a primary care field, I realize that mental health and the social stigma surrounding it is still having a large impact on people’s overall health. Steps are being made in the right direction, but what things can we as health providers do to help the process? Do you think this is something that can be feasibly be addressed in the next ten or twenty years?

I think that all health providers can play an enormous role in destigmatizing conditions by being careful how the talk about them and showing compassion for all they deal with. I also think the public conversation can do well to speak about mental illness as an illness like all others, like physical illness, and accord to the persons who have these illnesses the dignity that all of us deserve, whether we are healthy or sick.

What is wellness to you and what would you want to see shift on a world level regarding awareness?

Health, as defined by the World Health Organization (WHO), is "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." I think that is a great definition for wellness. I do think we need a shift away from thinking that my wellness is driven only by my genes and my behaviors to understanding that the world I live in, my context, is equally important to determining my wellness.

[deleted]

No it is not and it might suggest Depression that can be helped by a health care professional. You should see a health care provider and talk to them about that, really, do.

What is you current thoughts on telemedicine in terms of its impact on healthcare disparities?

it seems to me clear that telemedicine will be coming and play an increasing role in the health delivery landscape. In so doing it will help increase access to care, narrowing some disparities. It is not, of course, a panacea, and the human element of many therapeutic interactions cannot be underestimated.

Sandro can i use your lab to test a sample of the charles river so i can drink it?

I do not run an environmental science laboratory, but I would not suggest drinking from the Charles River anyway--why not drink tap water that has already been screened and ensured safe by the good folks working at the city.

I do not run an environmental science laboratory, but I would not suggest drinking from the Charles River anyway--why not drink tap water that has already been screened and ensured safe by the good folks working at the city.

Does washing hands really do anything, and how many people actively wash their hands for the appropriate amount of time? Does washing hands only impact bacteria levels? What about viruses?

Hand washing is one of the single biggest advances in health over centuries and is in part responsible for an enormous increase in life expectancy over the past century. So, yes, please wash your hands, do not stop, and do it better than ever. Some people do not wash their hands well, we know that, and they should do better!

Do you have an opinion on what is causing the increase in autism rates? Do you believe it’s just bring better diagnosed, that there is a rise or a combination of the two?

Probably a combination of the two. There are many who have written well about this. See for example the work of Peter Bearman https://www.incite.columbia.edu/understanding-autism at Columbia.

How are the aspects of “food deserts”!and “food swamps” able to change the health disparities of neighborhoods. What are some of the key strategies in fixing these disparities?

The limited availability of food is one of the challenges of the oft invocation to "eat healthy". It is hard to eat healthy when you do not have healthy food available. So, to my mind food swamps and deserts really matter and are an important contributor to health disparities. There is a scientific literature to back this up. In some ways we need incentive structures to make sure that purveyors of healthy foods are located in all neighborhoods--that could be a structural solution to a local problem.

Thanks for doing this.

Bill Gates has stated he thinks we face a real danger of a pandemic. Have you thought about this, and if so, what are your thoughts?

I agree. We are in real danger of this and we will be for a long time unless we create a more stable and healthy world, one that can withstand such events. That means an investment in economies, infrastructure, parks, safe workplaces, less violence and the full set of factors that generate a healthy world.

Why did you become a physician? Was it worth it? What's more important to you? Getting free stuff from pharmaceutical companies, or getting kick backs from insurance companies? Because screw the patients, cash is king, right?

I became a doctor because I was interested in helping people be healthier. It was worth it and still is. I disagree strongly with your characterization of kick backs and cash as the main motivator for me or for other physicians. Medical school is a lot of work and there are easier ways to make money. I strongly believe that nearly all doctors are doing it for exactly the right reason--to help people be healthier. Thank you for asking.

There are many advocates pushing for healthcare reform in the US - attemping to improve access and availability to a broad array of services, including those that address whole-person needs and social determinants of health. There is also a fair amount of activity in pursuing alternative payment models at local and state levels, some funded by CMS. However, at the national level we see a sharp contrast in the conversation, with growing interest in Medicare for All versus continued attempts to repeal the Affordable Care Act. What do you think will be the next big national healthcare policy movement, and what do you think will be the major factors that precipitate it?

This week, we hosted an event here at the BU School of Public Health on this very topic (video here: https://www.bu.edu/sph/news-events/sph-live/). The evolution of the US health care debate - from initial skepticism, if not antipathy, towards the ACA becoming an impassioned defense of the law when faced with its potential repeal - represents the awakening of a demand for health among Americans. It is heartening to see the debate seems to have shifted from a question of whether we should have universal health care in this country to how we can best institute such a system. As this debate unfolds, we need to broaden our understanding of which policies shape health, and realize that the health care debate is actually a subset of the broader issue of promoting health at the political level, which we can do by pursuing health in all policies, not just those related to health care.

I’m working on my bachelors degree in public health with a focus in epidemiology. I’ll be getting my masters degree after. What advice would you have in where to look for a career? I’m very interested in community outreach and global health.

Good, congratulations. That sounds like a great path. I would suggest choosing a school of public health for your master's that matches your aspirations. Obviously I would recommend our school that prepares people very well I think for both community outreach and global health. See our website: http://www.bu.edu/sph/ but there are many the excellent schools of course.

How do you motivate patients to change bad habits? Ie quitting smoking, eating healthier, getting exercise.

I would caution us against thinking that we can change bad habits simply by telling people to live healthier, to eat better, exercise more. In fact our ability to influence people's behaviors is quite limited. The way to create healthier behaviors is to create a system that encourages them, to create a system that makes it easier to eat healthier than not, that provides parks and neighborhoods that are safe and pleasant to walk in, that makes it expensive to smoke and nudges us to use that money to buy other things that do not harm our health. In other words, nudges, incentives, and contexts that generate health.

Thanks for doing this Are you in favour of mandatory vaccination?

See my other reply, but yes.

[removed]

Here is the proof link: https://twitter.com/BUexperts/status/1123997121877770240