arranging to host the series here at the earth's atmosphere some planetary sciences department and also to helen hill here for the web page for the series our topic tonight is the issue of public health and we are honored to prison dr sandro the robert knox professor and dean of the school of public health at boston university dr  leader worldwide in the effort to connect health and context as he says health is more than just medicine more than just eating our veggies and getting exercise we must consider the relationship between health and environment politics economics and other factors that impact physical and mental wellbeing as a physician and epidemiologist dr galileo has focused especially on the consequences of mass trauma in many parts of the world and you're familiar with quite a bit of that going on today dr bellair has dealt first hand with catastrophe in his past service to doctors without borders and in his research he's worked on a brave broad range of issues including mental health and substance abuse major crises here today he's the author of numerous books and he will talk about his most recent one tonight healthier fifty thoughts on the foundations of population health that book is must reading and very readable even the way it's put together it will change the way you think about things in public health and i promise it will change the way we think about health and we need it it's not a minute to relate and the you thank you vonne and thank you everybody for being here so i am going to talk a little bit about the subject from a book i wrote called health here which of all mentioned and really to shift to this idea of what is it that we should be to talk about when we talk about health and to ask how is it that we should be thinking about health and why is it that would be thinking about health all wrong and i'll start to the fundamental premise of of this conversation really is that we care about health and we care about health the top of the list stuff before the head of unemployment terrorism gratian cetera so premise a is that americans care about health and we have to care about health a lot now before i move on to why it is that i'm making an argument that we should be talking about health differently that we don't talk about health i do want to start off by pointing out that this is a good time this is actually a good time for health and i want to start by talking about the good this is the longest time series that exists life expectancy in the world which is the united kingdom what you see is that life expectancy trundled along around forty four really centuries until about one hundred fifty years ago when we notice and we've gained about another forty years we've doubled our life expectancy in the past one hundred fifty years and it's actually hard to rep your brain around what it means to have a life expectancy of forty but most people who i speak to in the audiences in the universities  would say well i probably spend less time in school if i knew that my life expectancy was going to end their own forty but this is a dramatically different time to live than it was living in the eighteen hundreds just one hundred fifty to two hundred years ago and he's never lost ration this is global child mortality that this change is ultimately wrought by our medical system and how we go about intersecting with health today and the thesis of my argument really is that that's not the case but illustrate that let me start off by pointing out what is and this is a year just in the past thirty five years the red dot is the united states the great dots are all the other high income countries and i want you to see is that we were in the top half as recently as nine hundred eighty and what happens is nine hundred eighty is we've continued to gain life expectancy but we've been gaining a much lower rate in everybody else until we have landed ourselves right at the very bottom of the life expectancy the bad news is that we have done this to ourselves in the past thirty five years the good news is that we've done this to ourselves and buster to five years which means we can undo it as a life expectancy has been going up at a very slow rate and in fact we're seeing a dip in life expectancy in the past year many other countries if over the past have verse or past us overcome is the united states singapore japan costa rica chile all now have higher life expectancy than the united states so what's going on what's the picture wise or life expectancy so low well our of expectancy is low and it's consistently low at all age groups so i want to show you life expectancy the mortality of mortality rates actually by age group the blue bar is the united states the red bar is all the median of all the other high income countries so we see countries so this is age group this is under one year one to fourteen years etc first of all you see this you shaped curve which is very standard that mortality is lowest in the teenage years and early adult years mortality as high as it is in childhood and then goes back up again later in life but what i want you to see is that the blue bar is higher than the red bar at all ages so mortality is higher under age of one higher in any time twenty five twenty nine thirty thirty four we essentially killed more people at all age groups than other high income countries all the and mortality in the other countries is higher than it is in the united states so we have higher mortality at all ages until age seventy five and but then over seventy five we have a higher mortality in other countries it's a great country to live in as long as  age seventy five because then you live forever so why is that the reason that is is because all our focus in health something that we care very much about has been on medicine and on curative approaches and the benefit of those approaches a cruise at towards the end of life when we can gain not very much but we gain a little bit giving us a mortality advantage at the end of life in fact if you look at our ranking as a country how do we rank for mortality a different age groups this is a rank graph there are two lines men and women they behave the same way you see we are seventeen this is the rank don't want to seventeen we rank seventeenth at all age groups essentially here one to sixteen all the way to seventy five and then we jump to number one rank after age seventy five that is what we have wrought in terms of how we think about health today and in fact a lot of this has emerged in the past thirty years it wasn't always like this just as i showed you before here is a recent grafter thing makes a very nice case of showing this this is called american exceptionalism and it's the difference between american life expectancy and the average life expectancy in o e c d countries that are high income countries and what you see is until about nine hundred ninety three the u in the blue our life expectancy was higher then you see what happened here ninety nine when we flipped then we flipped and now our life expectancy is getting progressively worse compared to the other high income countries so i have called this phenomenon this this is an unhealthy mismatches from paper i published a few months ago and the mismatches this follows the mismatch is that we care about health we care about health a lot but our achievement in health is much less that how much we care about how we care about health and that outweighs what our achievement is now the question of course is why is that why is that and the reason it is i think is twofold one is our scholarship that we are producing evidence that is not helping us overcome this and the other one is our national health conversation that when we talk about health we talk about the wrong things now i'm actually going to talk about a scholarship at all today that's the subject of a different topic but i want to talk about the national health conversation i want to talk about how it is that we are misunderstanding what health is and what it is that we should be talking about when we talk about health before i do that let me go back to the initial slide they showed they show the slide about the polls and but what americans care about when they talk about health and i just go back to this live this is a very mature member beginning emersed care about health more than anything else the blue here superimposes actually what the media talks about so this is of course what americans care about in the blues what the media talks about is a particular snapshot point in that the polls were actually not talking about health they were talking specifically about health care so it's actually not about health it's about health care even in the conversation it's as we care about health we are specifically talking about health care so this factors that i think we should be talking about when we talk about health minister were the first one the first one is that i think we talk about help we need to be talking about the actual causes of health now what do i mean because he recorded some songs that have lived on but as you can imagine it was a very good living not particularly good living he got married he was living in a house or a shack really the house burned down and him and his wife they had nowhere the money to go elsewhere so they kept living in the burned down house in his early forty's blindly johnson got malaria his wife took at the hospital and he was turned away from hospital and it's not clear where he was turned away because he was black because he was poor because he was blind but then he died so there is i tell the stories because the question comes up what killed blind willie johnson what caused his death now from a path of physiologic point of view what was his malaria i mean we can all agree on that but i think we can also all agree that if malaria did not kill blindly johnson something else was going to kill that ultimately his his domestic violence the poverty the racism the homelessness that he was experiencing we're going to get him sooner or later from malaria if there was pill or a shot to get it malaria something else was going to kill him to next day and i am still the story to illustrate that whatever the cause of that what killed by and willie what were the cause of his health the causes of it was malaria but it was also homelessness poverty racism domestic violence and those are the forces there's a sampling of the forces that ultimately cause health or cause death and those are the forces that we cannot avoid if we want to create a healthier world in the data they showed about how we are not doing anywhere near as well on health as we should be doing ultimately reflects our mis spending now are we are spending money and in fact this graph shows this is life expectancy here in this is spend on health which is all the other countries right they spend more and their life expectancy goes up they're all clustered together but we are spending more but life expectancy is not gaining we're like off the chart we're going off the chart and why is that that is because what we're spending we're spending wrong with responding is ultimately on medicine on curing us and that is why we have the advantage in mortality after each seventy five you know i have a disadvantage at all other age groups because ultimately what causes health is a combination yes it's medicine medicine probably causes five to ten percent of health care  percent but our genes maybe twenty percent are our physical environment or social norms twenty thirty percent are behaviors thirty to forty percent and interaction among a bunch of these things but that green bar which is medicine is what we spend ninety percent of our money on so we have a mismatch between what we spend and what we should be spending on now the stock is being given massachusetts with the privilege of living in massachusetts which has some of the best health indicators in the country and sometimes i get the comment well sure that it's not like this in massachusetts but it actually is like this in massachusetts this is a strange and spending in massachusetts over the past fifteen years and this shows we've increased our spending on health care by about eighty percent well we've kept the same or decrease their spending on primary public safety mental health public health higher education early shelter education and vironment and recreation so all the other forces that ultimately produce health we're underspending on well we're spending more and more on curative medicine even  so what should we be talking about without the health but the real cause of help and we should be talking about efforts to improve health for example at first like early childhood education we know that early childhood education is associate with a benefit cost ratio but five dollars to one for every dollar we spend early childhood education we get back five dollars because reduced crime rate child maltreatment teen pregnancy and we improve academic achievement that is what we should be talking about we talk about so point one we should be talking about the actual cause of health points to we should be talking about emerging pathologies we should be talking about the conditions that are emerging that we know are emerging that are ultimately causing us to lose life ninety's early oughts and we paid very little attention to it until until several papers started showing that it's actually white men that were being affected by opioids and this is actually from a fairly classic paper now showing are emerging next what should bring attention when we know this we actually know what we should be paying attention to and here is a recent paper just came out and the way to read this is these are conditions where we are doing better so we are gaining life expectancy versus conditions on the left where we're doing worse where we're losing life expectancy so just to focus heart disease in the cancers you see the big bar on the right here is actually we're doing better on those we're gaining life expectancy the question is what are we losing life expectancy on here's what it is we're losing life expectancy on injuries you see are there also drug poisonings and opiates of all poisoning so really a whole basket of injuries and also suicides so this basket of accidental death or intentional self harm a lot of which is driven by guns expanding access to clean syringes expanding accidently syringes we know return almost eight dollars for every dollar spent but clean syringes remains a politically charged issue there remains an issue that is highly sensitive and  restrict even though the data are very clear that this is an emerging pathology discount to becoming the next second thing should be about emerging pathologies third thing we should talk about we should be talking about prevention we should be talking about not about curing disease we should be talking about preventing disease before it happens now i often ask audiences this question which kind of world would you rather live in with rather live in a world where there is treatment for your alzheimer's after you've had it for a couple of years  would you rather live in a world where you don't get alzheimer's to begin with everybody says they would love to live in a world where they don't get alzheimer's to begin with but is there really what we spend our money on is the really what we do in the a perhaps the best way of looking at this is but looking at trends in medicine and medical research in the past few years one of the biggest trends has been our fascination with our dedication to our investment in personalized medicine personalized medicine very promising approach to discovery science where we focus on genetic m of disease and in fact our spending on genetics this from national says of health has been going up and only very clear that the fact their funding their spending has been going up is a good thing this is good this is good for discovery science and a big fan of brain molecular targeting the point is not that the point is that we know therefore to prevent disease there are many other factors that have changed and matter much more than our genetic factor haven't changed in the past thirty years and we know we've been doing very poorly in health in the past thirty years we do worse than ever what has changed well here things have changed for example our diet a bagel twenty years ago had hundred forty calories a day has turned fifty calories french fries at two hundred ten now they have industry funding and what you see is private insurer funding is consolidated in short survival in short term survival drugs in fact there's less and less industry funding for drugs that go towards helping us survive longer our industry funding really is focused on things that cure things quickly so what should we talk about prevention here is something that is important to know your risk of cavities increased by fifty percent if you don't drink florida water and today one hundred million americans one third of the country do not drink water that's not sufficient authority which means they have entirely preventable increased risk of cavities i always ask audiences the question do you know if your water is sufficient authority that most people don't know those people have never checked it out one should probably check it out so point three we should talk a prevention point for we cannot talk about health without talking about the underlying social conditions that cause health now obviously this is echoes of what i talked about with blindly johnson there is no stronger relationship than wish between income and health and income and health wealth and health and here's just one simple example how does income drive health the way to read this is the way you go down here you have more income so what happens well the more income you have you work you have paid sick leave you get paid vacation leave your pension retirement contributions you live in neighborhoods with sidewalks parks playgrounds recreation centers you have your report you have excellent a very good health which means you have better mental health is all flow from income  linked to health i can show i can spend an hour talking about the relation between them how can you spend many hours talking about it here's another example this is an economic mobility in us cities which is the likelihood of people doing better than the previous generation and infant mortality mortality and they think it's to recognize about underlying social conditions is that their role in determining health is getting ever more they are determining health ever more in that our gaps in health between those who have more social resources and those who are fewer is widening and this is not well appreciated let me show you one slide to make that point so sixty so they're now in their fifty's they have a twelve year life expectancy gap while men born in one thousand thirties have a five year life expectancy gap so the gap is widening between health for those who have a social haves versus social have not met a wrinkle in this point about the underlying social conditions is that we have a misconception that we can always spend more money on medicine and buy our way out of this issue and the sad situation is it's not true we actually can't let me illustrate that by focusing on a disease where medicine makes a difference the stick cystic fibrosis  which is a silly motility disease used to be a death sentence for four people mostly is mostly men of those not all men for says what process mom in their teenage years early twenty's drugs and medicine makes an enormous difference life expectancy five u s and canada same survival look what's happened in the past thirty years this is gap now there's a ten year gap in life expectancy this is actually difference in life expectancy ninety nine five zero zero twenty fifty it's but ten years there is now a ten year gap in life expectancy for a disease where drugs matter and why is that is because drugs by themselves are never enough they're never going to be enough the underlying social conditions matter and they're always going between health haves and health have nots because unless we dress these gaps it keeps all our health down and i would be very careful about this point because the danger with this point is that it makes one think well as long as i'm a health have i have to worry about everybody else or maybe i will if i'm charitable from a good person but the point is that the gaps between health haves and health have nots hold us all back so what are these gaps well we have persistent deeply persistent racial gaps in this country we have all this is life expectancy by race that's white that's black we're both going up but we still have about a five six year life expectancy gap between black and white we have enormous life expectancy gaps by socioeconomic status by income by wealth and i will show you a slide with women on it st half as much on spring street same line two miles apart elder avenue in one thousand nine hundred ten thirty six street their sixth avenue seventeen to fall gaps one to two miles apart despite the fact that these subway stops i'm showing you are all around there all around the world class medical facilities the people from all over the world come to to receive care because it really has nothing to do with medical facilities it has everything to do with the  verco was one of the fathers of microbiology who said that politics is nothing but medicine on the grand scale and i agree with him except for the fact some really medicine is actually health health is about politics and it's about politics in the definition of politics and politics ultimately is about the process by which we allocate resources in society by which we decide what we what matters to us and by what and by that by which we then prioritize what matters so we can promote it and i argue at the beginning there with a mismatch we care about health but we don't prioritize it enough what we prioritize as medicine curative medicine we care about preventing disease but we do not prioritize that we prioritize curing disease and that means that we are gaining all the advantage at the end of life without realizing a vision for a healthier society the with much more consistent with what we actually think we want but the other point about politics is that health has real change candidate why would you want your change can be a particular one if you don't know what he's going to do well you might vote for him if you feel like you have no other option because your health has been getting worse in the past couple of decades despite the fact that the world around is getting better despite the fact that people like me stand up here and say we're the healthiest time ever in human history but my husband works well let's look at this this is simple graph this is change in life expectancy this is women but the same thing applies for men in the past get your health getting worse over the past thirty years it strikes me as entirely reasonable to say i'm just going to vote for this person who's not a politician who is going to change everything because hopefully i'll get better because frankly what they have to lose in this i think brings us back to the central importance of health central importance of health as a force that ultimately determines everything around us not only about our own life but the life of our society is evidence in the last election fellow players and what she telling of them out she's telling them to keep the ball away from me because she knows that no matter how good she is if the ball comes at the net she's going to lose and ball and goals can be scored now what's the matter for the goalie is medicine when we're sick we all want to have a great doctor we do we want to have a great doctor who can cure of pneumonia if your heart disease we can cure a cancer we want but what we really want is not to be sick to begin with that's what the other ten players are the other two players our income their employment their housing their absence of racism that's what the other ten players are and those are the forces that from the keep the ball away from the