At PRA, we work for well-being. Our work in the wellness and well-being space seeks to improve outcomes for individuals with behavioral health conditions. We understand that all populations we work to serve have unique needs, and improving well-being can enhance the overall quality of life and outcomes for these individuals, as well as for the organizations, systems, and communities serving them.
A number of staff members at PRA are highly active constituents of the American Public Health Association (APHA), which has the mission to improve the health of the public and achieve equity in health status. In addition to being a member of APHA, I was recently elected Section Councilor for the Mental Health Section, and am involved in the leadership of the Section’s Population Health Workgroup.
Each year, APHA holds an annual meeting—an intense multi-day event filled with powerful roundtables, oral presentations, poster sessions, exhibitors, and more. This year, the nearly 13,000 attendees at the APHA Annual Meeting in Philadelphia had the opportunity to hear from Dr. Sandro Galea, a physician, epidemiologist, and author, who serves as dean and is a Robert A. Knox Professor at Boston University School of Public Health, during the opening general session. Dr. Galea has been listed as one of the most widely cited scholars in the social sciences and aspires to change the conversation on health.
In the weeks following the Annual Meeting, I had the incredible opportunity to interview Dr. Galea on topics related to population health, mental health, and well-being.
Q: To start, for some, there is a degree of confusion about what population health is and how it differs from public health. From your perspective, how would you define population health and distinguish it from public health?
A: Population health is the science that informs public health practice. Public health is concerned with preventing disease among groups, with special focus on the health of the marginalized. Population health supports this mission through modeling and data, a granular focus on health within and among subgroups, and other innovations.
Q: Speaking through the lens of population health, my colleagues and I recently wrote a paper describing how it behooves us to focus more on community prevention efforts to improve health outcomes. Adverse health outcomes aren’t merely experiences to treat on an individual level, but they are seen on a community level and require prevention.[1] As you discuss in your new book, Well, our environments matter. These environments contribute to the outcomes of entire communities and populations. Community trauma and racism, for example, significantly impact community structure and well-being for whole groups of people. Is there anything we still need to change or communicate to encourage an acceptance and understanding of the need to take a public health approach to mental health?
A: Public health is mental health. There is no difference in the degree of importance between the health of our bodies and the health of our minds. The difference lies in what we choose to emphasize. For a long time, we have prioritized the health of our bodies at the expense of mental health. Changing this means changing the public conversation, by showing how the conditions in which we live affect mental, as well as physical, health. For example, consider the conversation about one of the sentinel trends of our new century, urbanization. This strikes me as an excellent example for changing the conversation about mental health. There are ample data on the mental health effects of living in urban environments. As we decide what the cities of the future should look like, we should take care that the mental health implications of urban design are every bit as talked about as bike lanes, noise reduction, and neighborhood walkability. This is one way to change the conversation, and we should keep finding others. Your work is an important part of that.
Q: It is important to be explicit about adverse community experiences, namely structural violence and community trauma. Dr. Howard Pinderhughes noted, “We have to engage in strategies that help heal communities from community trauma.”[2] This is not discussed extensively in the field; the larger, accepted discussion on social determinants is not explicit about structural violence, community trauma, power, privilege, and control of resources.[3] You help to further and normalize this dialogue through discussions of crucial topics like race, discrimination, and historical trauma. Why do you think these topics lack prominence in the conversation on health and well-being?
A: These are difficult conversations. They imply that if we really want a healthy world, we must fundamentally restructure society. Medicine alone cannot make us healthy. Doctors and hospitals alone cannot make us healthy. Even public health standbys like vaccination, sanitation, and campaigns to promote healthy behaviors are necessary but not sufficient for the kind of world we would like to see. What we need is social justice, gender equity, mitigation of economic inequality, a response to climate change commensurate with the scale of the crisis, an end to racism, and other structural reforms. This is the level at which we must operate. Accepting this requires us to also accept some degree of historical responsibility for present challenges, another factor which makes these conversations difficult. But public health is good at engaging in difficult conversations, and it is continuing to drive our national focus towards building the foundations of a healthier, more just world. So, I am hopeful.
Q: In your opening session presentation at the APHA Annual Meeting, you discussed the consequences of slavery and material disadvantage experienced by Black people and how these experiences impact disparities in mortality rates today. Are there any specific policy recommendations you might suggest for improving health outcomes for communities of color?
A: We need to implement policies that address the legacy of racism and slavery in the US, while continuing a conversation about the history of black populations in this country, and how this history has shaped health across generations. This means addressing residential segregation, disparities in education, maternal mortality, the health gaps that exist between white Americans and communities of color, and more. To build the political will for these solutions, we must communicate—as public health, I think, uniquely can—the link between history and health. When it comes to the challenges that undermine the health of black Americans, it is not enough to act like we are dealing with discrete, isolated issues, rather than core injustice. We must make the moral case for addressing this injustice, a case informed by data, thoughtful activism, and what Martin Luther King Jr. called, “the fierce urgency of now.”
Q: Of course, when I say “health,” I include “mental health” in that term. Mental health is health, and is therefore a matter of public health. Why do you think we are still making the case for including mental health in the larger health conversation?
A: One of the obstacles to a healthier world, and this has long been the case, is stigma. In public health, we often encounter situations when feelings of shame or taboo around certain diseases hinders our efforts. I think mental health falls into this category. Anxiety, depression, addiction, PTSD, suicide—these are health challenges, diseases, which we have convinced ourselves are personal failings, to be ignored or suppressed. Changing these attitudes takes time, but it is happening. Public health can help move this along, by generating data that show the true nature of these diseases, and by talking about them in a frank and honest way, to chip away at stigma and increase our comfort with discussing mental health.
Q: I am so grateful for all the work you do, and for your contributions to the field. I am honored to have this opportunity to interview you and connect on issues related to health and well-being. Is there anything else you’d like to add?
A: Public health is fundamentally about telling a story. It is a story of how social, economic, and environmental forces shape health. Now, people are fascinated by stories about health. They cannot seem to get enough of the many films, TV shows, and books about the world of doctors and medicine. But health is not doctors and medicine. Health is not what takes care of us when we are sick. Health is not getting sick to begin with. And that means living in a world that generates health. We have already come a long way towards building such a world. We are far healthier now, for example, than we were at the turn of the 20th century. This is because we have built a world which, while still deeply imperfect, is also fairer, more just, more equitable than it was just one hundred years ago. Telling the story of this progress helps us to advance it even further. So the next time a conversation turns to health, make sure it is also turns to justice, neighborhoods, money, the environment, racism, community networks, and the sweep of history. Imagine what our national health conversation could be like if it kept these forces at its heart. We should all do our part to help put them there.
Biography
Sandro Galea, a physician, epidemiologist, and author, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. He has published extensively in the peer-reviewed literature and is a regular contributor to a range of public media, about the social causes of health, mental health, and the consequences of trauma. He has been listed as one of the most widely cited scholars in the social sciences. He is chair of the board of the Association of Schools and Programs of Public Health and past president of the Society for Epidemiologic Research and of the Interdisciplinary Association for Population Health Science. He is an elected member of the National Academy of Medicine. Galea has received several lifetime achievement awards. Galea holds a medical degree from the University of Toronto, graduate degrees from Harvard University and Columbia University, and an honorary doctorate from the University of Glasgow.
References
[1] Crystal L. Brandow, Jasmin S. Brandow, & Cathy Cave. “A Wellness First Approach: A Lens for Improving Mental Health and Well-Being. Ethical Human Psychology and Psychiatry 21, no. 1 (In press).
[2] Prevention Institute, “Adverse Community Experiences and Resilience: Understanding, Addressing and Preventing Community Trauma.” https://www.preventioninstitute.org/projects/adverse-community-experiences-and-resilience-understanding-addressing-and-preventing.
[3] I am working on a manuscript with Dr. Ron Manderscheid that furthers this conversation. Please direct any inquiries to cbrandow@prainc.com.