career as a doctor an immigrant and i was always interested in health immigrant interest and health the only thing i knew both was medicine so i went to medical school and went to medical school  became very interested in becoming the kind of physician who could really practice medicine anywhere who could serve marginalized and far away community so i did that i did that kind of residency that kind of training and then i practice medicine in remote parts in northern canada they slip up when you give me philippines and particularly in somalia working with doctors without borders so when i was in somalia i was the only physician for a population of a boat three hundred fifty thousand people and i was seeing a lot of people who were very sick and i was trained i was trained well and i like to think i was helping people i was helping people return to health and i think i was doing good was doing a lot of good for the individual patients were seen but doing this good had a paradoxical effect on me rather than saying i can do more i can do so much with my hands i begin thinking but there's something goes wrong with this because i'm here i'm doing good but i'm doing good in the short term eventually i'm going to leave and someone will come after me hopefully well trained as well but maybe not in there must be a better way there must be a way to keep people from becoming this sick to begin with from there and i would consider my calling really to be in this enterprise of creating health generating health maintaining health preserving health and really trying to be part of an enterprise that makes populations healthy now at this point the one question which i'm often asked is what is public health what does it mean to be part of an enterprise to make populations healthy and i suppose the best way not to answer that is by america and the story has it that the reason he was blind is because when he was three in an episode of domestic violence he had he had law a throne in his eyes and as a result he was blind so he grew up a peer group  black poor blind in a very poor part of the country he made his living essentially through his music through his blue singing and he was living in a in a fairly poor house and  he developed malaria in he died his wife at the time said that blind willie she took him to hospital and he was turned away from hospital and it's not clear whether he was turned away because he was poor or because he was is a concern but he didn't just die of malaria he also died of poverty he also died of racism he also died because he could not access health care those are all the concerns of public health and those should be the concerns of anyone who cares about making we care about health we care about health one should take my word for it but just based on the fact that we spend more money on health far more money and health than any other componentry usually thirty percent so you'd say we're putting our money where  it we care about some who spend money and there's nothing wrong with that but despite how much we spend on health we have far worse health outcomes than any other peer country no i'm not comparing us to very poor countries it's not a fair comparison but comparing us to other high income countries we are at the bottom of the barrel in terms of our health outcomes in terms of our health indicators now why is that when i come back to the story blindly johnson the reason that is because we do spend money but not on health we spend money on medicine mostly on curative medicine to go back to the story we care about the malaria but we forget that the malaria by itself is not what killed playing willy johnson the malaria killed him but so that his poverty so  race so that the violence and trauma he experienced in childhood so to create health we need to pay attention to the full range of factors we need to make sure that we spend money on the full range of factors and the data are very clear  interested in the business of generating health promoting health which is what i said i've been interested in since i shifted from the middle medicine to public health i think it needs to consider these factors one of the things that this has led me to is a concern with how we collectively spend their money and our focus as citing one of those for so recently has been precision medicine has been the enormous amount of effort spent on getting ever better at molecularly in genetically identifying specific diagnostic as well as treatment approaches and i am an enormous fan of position as it approaches i actually think this is has tremendous potential for discovery science and i'm very much supportive of the intellectual agenda behind precision medicine my concern is not that my concern has been a concern that if that is what all we're putting our resources in we are putting all  eggs in a curative basket and that that is ultimately not going to promote health that ultimately we need to pay attention to the breath of factors that promotes health and that and by we i mean those of us in the research those of us in education are funding research and at the national policy of when we think about health these kind of decisions like investing in procedure medicine at the expense of other factors reinforce a misconception that we have in our society and that misconception is that well if i am healthy if i look after myself i'm going to be fine i'm going to be ok and the answer is yes you're different going to be much better than if you don't exercise you can be much better than if you overeat but we forget that and violence are likely to affect us whether we're involved in the more not but ten percent of all pediatric motor vehicle deaths are not kids in cars they are innocent bystanders these are things that affect us whether we like it or not we have data not shows that our behavior for example where we overeat is determined as much by our networks as it is by ourselves patterns of things like alcohol drinking over drinking are determined by our network and by the availability of so unless you think you can wrap yourself in bubble wrap and insulate yourself from all social influences and from all potentially adverse influences in your social economic cultural environment we our health is all dependent on the world around  us i tell the story best through a metaphor i think which is a metaphor of a goldfish so much never goldfish in a bowl and you like the school fish and you want a goldfish to be healthy and you say to the goldfish in order to be healthy i want you to exercise and to swim ar kind of local as everyday and you see it as a goldfish when you get a little flaky food on top don't eat too much you don't get fat and you say to the goldfish if you have a goldfish companion make sure you have saved goldfish six and a goldfish get sick you get the best goldfish doctor and you do all these things and one day the goldfish still dies and you say well how could it be then he too much was careful with its relations with the other fish it exercise how could it still die and then you mississippi who really had no access to the resources that could create a healthy life it was only a matter of time before some pathology ended his life so for anyone who's interested in the in  care about marginalized populations that in and of themselves are vulnerable but also can change disease dynamics these are all forces that ultimately matter these are all the factors that we need to improve if we want to create healthy is called so one of the areas that i've done a fair bit of research on has been the consequences of trauma and violence mostly on large scales in terms of war and after large scale traumatic events like disasters a war that conflict and drama that ultimately it has enormous human cost that large scale traumatic events be a human made like we were natural disasters result in in vast numbers of people who are injured in the short term and that's what we tend to think about but even more people who then end up having mental health consequences of the trauma and of that war and that is to my mind one of the great unspoken tragedies of any conversations about war so i actually talk about war in my book but not because of something that happens every day mercifully but because it is such an extreme example of when we neglect to focus on the core there is no one thing that causes the health of populations it requires a whole set of factors and at the level of concept in some respects it's not so hard it becomes even harder though at the level of analysis how does one rep one's brain around this analytical y within one's research and scholarship it's to that end that i did this other book called system size and population health which really is about saying how can we take a system science approach to solving these issues how can we use system sense approaches which is a full range of of approaches to take into account system heterogeneity interrelationships dynamics feedbacks discontinuity face shifts all characteristics of complex systems but also all characteristics of populations how can we take those factors into account analytically through a particular analytic approach and i think system science methods give us an opportunity to do that and it's not so much the method although there are particular methods things like  modeling or discrete stuff as to models but as much as the perspective as much as the lens the thinking about and recognising that these are complex systems only to take into account the full range of factors so we can understand what are the key manipulable factors that can make a difference i think there are two key conceptual perspectives that really inform how we can think about how health produced one of them is called a multi level perspective what that means is that my health is determined not just by me but also by the people around me and the health of all of us is determined by where we live and health of where we live is the time but the policies of the place where we live and the policies are determined by the national cultural and economy and politics so just to give a concrete example i may get lung cancer because i smoke but i smoke because my friends mark who we smoke because we live in a marginalized neighborhood which frankly no other source of pleasure we live in such a neighborhood because of policies that enshrined gaps in income and that happens because that is the value that we accept at our society's word that the nested multiple levels of influence the other perspectives called the life course perspective which is that my health as an adult at this point is a product of my life all the way from from our perinatal conception even preconception as well as intergenerational and perhaps the best way of thinking about that is is by thinking about the circumstances of your birth that i understand in the american conversation which privileges this notion of autonomy and the fact that we can determine our own fate their own health i get that but it's hard to argue that we any of us have done anything to deserve where we are born or reborn as a matter of luck and where we're born and how we're born in the circumstances of our birth matter enormously for health at a very simple reductionist level if we are born in a context where our our mother was exposed to perinatal toxins and we're born with a deformity that is going to set the course for our health for our entire life at a much subtler levels being born in the environment where one one's parents are stretched and as a result there is trauma or violence in the household which we know is deeply if perfected of subsequent mental disorder and mental health over the life course that matters tremendously in terms of shaping our health so our health to day one's health as an adult is not a snapshot of just what i did today it is an accumulation of forces that i've experienced over the course this is why for example things like flint matters so much because when you have children who are exposed to toxins that's going to matter throughout their life course this is why if i were to have a choice of one particular investment one particular investment that i would make it would be to ensure as healthy as possible early childhood development because that is going to yield more return investment for society than anything else i can think of in the science of resilience that result is by definition is you're exposed to traumatic events you're exposed to hardship and then you bounce back is actually quite a rich and deep that comes from engineering both materials that are resilient to stressors but it's been applied now to humans quite a bit and we know that some people are resilient some people in the do bounce back but we also know that not everybody does in the key factor in bouncing back as far as i'm concerned is the burden of the trauma experienced in that in that the people who experience trauma throughout their life have a harder and harder time passing because frankly they're shifting ever away from the norm so yes we can bounce back and i often feel in the public narrative we make a real virtue out of saying oh look at this particular example she had such a tough a life and then she was still ok but we have to remember that these are the exceptions that for most humans the more trauma is experienced the harder it is for them to bounce back and to get back to normal children who have experience malnutrition for example or children experience perinatal toxins some of them can bounce back it depends it depends on the amo the pens on the malnutrition and some of them will have latent health affects throughout their life of course when they're adults there is no question that genetics plays a role in the term eamonn health no question what i think has been a misconception is that we think the genetics is everything is not everything it is just one very small piece of the puzzle it's not a blueprint on which we build the building it is rather a rough guide and the expression of our genes to determine very much by our experiences all the way through our life all the way to our and of life so the mistake if there is any mistake that we've made in genetics is that thinking that it's everything in this is not the fault of geneticists or people is that it genetics because their genetics are very sophisticated about these things and me understand that this is just one piece of a larger puzzle but i think we have failed in the translation of this and in the public conversation genetics frequently is portrayed as the blueprint on which we build everything far from the case genetics is just one piece just as much as  point point is that saying that our obesity is due to our genes is like saying that our the reason we drown is because of genetic factors of course we drown because we don't have kills but we don't of course we draw because we are in the water in conditions to don't let us win but do genes matter of course they play a role but they are just a very small part of the bigger picture and we need to keep that in mind we keep in mind that yes genetics can result some widespread ready availability of cheap nutrient poor calorie dense food