Dr. Sandro Galea: "Well: What We Need to Talk About [...]" | Talks at Google
Well. Thank you very much thank you very for being here and thank, you for joining both in person and on. In. The sites all over the world so, I let. Me just talk a little bit about myself by way of introduction then I'll talk about the book I'm. Mom physician, by training and then I did academic. Public health training as well as Chris. Mentioned and, it. Was sometimes I'm asked how long it, took, me to write this book and the answer is 20, years now I didn't I should take 20 years to write a book about it about six months but it, builds, on about 20 years worth of thoughts, and experience, in the field and, really. The, the earliest. Motivation, for this book came from where, I was working in Somalia which Chris, mentioned I was doing with other boarders and I, was very. Much, doing. Her hands-on clinical work day-to-day and, helping, people and helping people, on helping people and while I was there I. Couldn't. Help but feel like I was the proverbial guy. On decided River pulling somebody at a river as she's drowning and then jumping in pulling out somebody else because he's drowning and I'm jumping in pulling somebody else had River because she's drowning but. Never stopping, for a second and saying who, was throwing them in the river to begin with and. Recognizing. That I think I started my path down this road over the past 20 years trying. To better understand, what is it that really causes health how, is it that I can go upstream, and, understand, what drives health, so that we can keep people healthier for as long as possible and what. This book tries to do is it tries to say, what. Causes health and how do we change the conversation on, health so, that we can actually create, a healthier world because at the end of the day I talked, about units all the time blue audiences red audiences purple audiences and it's. Very clear that we all care about health we may disagree on on, any number of values but all over the world everybody would like to be healthy as possible would, like their children to be as healthy as possible and, would like to see their children grow up and get married and then, being healthy as possible so. The book is called well what needs talked about when we talk about health because I become convinced, that at, the end of the day we. Need a different conversation on, health and we need to talk about health differently, in such, a way that it changes, how we approach health so, I'm going to show you a couple of data. Slides that, frames, the issue starting. From the point of why. Our health is not as good as it should be now I'm going to make. This a a us, centered presentation, the first part of it just because I'm focusing. On us data but I'm happy to talk about it in the global context afterwards, but let me um then, move on to this first question which is really what, is wrong with our health like, if, I'm here telling you that we need to talk about our health differently, it's, reasonable to ask me well, there must be something wrong with our health otherwise the, way we're talking about our health is just fine so. Let me show you one simple. Slide that captures that which, is this so. This is death, from non communicable diseases, which is things like cancer and heart disease and what you see here is a number of high-income countries you have Japan Spain Italy Norway Sweden and the, United States is in red now this is one slide one data slide but I could show you I could spend the next half an hour showing. Use data slide after data slide that, makes this exact same point essentially, that health. Indicators, in the United States are worse, than they are in all other high-income countries it's consistent. On life expectancy constant. A mortality rate and it's, consistent, across, all age, groups just. To make that point so. What this graph is is you're, looking at age groups on the x-axis so you see you go from left to right you're starting with newborns, and infants and children, young. Adolescents. Older, adolescents, young adults older adults and you. See two things on this graph so first of all you see a u-shaped, curve that. And this is mortality, so the u-shaped curve makes sense because.
The Healthiest, years of life are young, adulthood so, late, adolescence young adulthood is when people die the least so that makes sense but, then I want you to look at the blue bar and the red bar the, blue bar is our, mortality, in, the US and the red bar is all other high-income countries and, what you see is that the blue bar is higher, than the red bar at every age group so in. The u.s. context, we are consistent. In that, we kill, more infants. Newborns. Infants children young children early adolescents, late adolescents, young, adults, middle aged adults at every age group so in some respects the. U.s. is consistent, that way in that it has worse health than all, its peer countries consistently. Now. I find. That, well informed, educated audiences. Tend to notice that, there, is a bit of a sense that American. Health is not all it's cracked up to be and in in in audiences, like this one which is sort of well read audiences you, typically, tend to have a sense of well we, understand, that this is actually becoming a challenge you, know high income countries and this, is this is a problem and we tend to approach is probably a bit of a shrug I find like, yeah which is not so good at health but, I, think. That approaches is incorrect, and we need. To be cognizant of something that is quite, important, which is it, was not always like this direction. In this, decrement. In health. Is, a relatively, recent phenomenon so this is a graph. Going back the past almost, 40 years now from 1980, on and this, is life expectancy so is how long people can expect to live and. What you see is the red dot is the US and the gray dots are other. High-income countries so, as recently as 1980, which is 35. To 40 years ago the. U.s. life expectancy, was actually in the top half of all, high-income countries and you see that over the past 35 years it, has drifted to the bottom so. The. What we can have come to accept with a bit of a shrug which, is that our health is. Worse. Than, other high-income countries that our health is not what it should be is, wasn't. Always like that and in fact it is a set of conditions, that we have created that has brought it here because I would ask you this what has changed in the past 40 years certainly our genetics have not changed so, it must be the rest of the set of conditions around us that ultimately, are driving, what's, making our health worse than, it was as, recently esterified four years ago not to be optimistic from. A glass-half-full point, of view if. We've made our health worse in the past 35 40 years we, can certainly make it better if we understand, what makes our health worse and reverse it. As. This, has happened as the u.s. life expectancy, has sort of trundled, along many. Countries have passed us so this is shows Japan and Singapore and Chile and Costa, Rica have passed the US and life expectancy it's, for example not well understood in us that Slovenian, life expectancy, is higher than it is in the US not, just that in. Life expectancy in Slovenia, is actually higher than the life expectancy, of the state in the US with the highest life expectancy, which is by the way how I. Hawaii is the place you want to be if you want to live the longest don't know people on earth and Hawaii, who are watching this digitally but, even Hawaii has life expectancy, there's there's, less than Slovenian not to not to mention the states that are then in the lower half so, we. Have as a country. Created. Worse health than all. Other countries now. You might say well. Maybe we don't care about health you know I started, at the beginning by saying that health is a universal, value that, we care about health and it's reasonable, for you to say well. Maybe, we don't care so much about health maybe it's okay maybe it's okay that American health is doing worse and people are willing to accept that but, I would argue that the evidence suggests that's. Not true we actually were not willing to accept that because. We are more, and more begin to recognize, this this, is our life expectancy compared. To other countries and what you see is the blue bar is when. We were gaining one life expectancy, you see that until about the late 80s and the, red bars are we've been losing a life expectancy so we were gaining and now, we've been consistently. Losing, and. You, say well okay what's fine it's fine it's how it is and uh and you, know there are other things with other priorities. But. That's. Not what the data suggests this is the money that we throw at the problem so, the green bar is, our spending, on health the other. Grey lines that are very faint are other countries and the blue line is the average of, other, high-income countries so, what you see is we. Are, spending, 40%, more on the next closest competitor on health and the slope.
Of Change is steeper, than other countries so, right, now the u.s. health, economy. Is three point three trillion dollars one in eight Americans, work in health which, is a higher, ratio than any of these other countries so, we, are spending far. More money than. All other countries and we are getting much. Less out of it and sometimes, the challenge I pose audiences, which I'll pose to the audience both, here in person and digitally. Name. One other sector, where. We spend 40 percent more then, our next closest competitor and where. Our indicators. Are, worse let. Me ask you a question would any of you own a us-made. Smartphone. If, it cost 40 percent more and it performed, 40 percent less well. You would would, we own a car. Would you own a house like, we actually would not accept, that, kind of transaction, in anything else but somehow we. Accept it on how so. The argument, is you. Shouldn't accept us this is wrong this is simply wrong and it, should be unacceptable, and the. Reason it's not unacceptable. Which is the premise of the book is that we have not wrapped our brain around thinking, about health properly that, to make this unacceptable, we need to start thinking about health in the right way. This. Is one last slide to talk about the problem and comparing. The u.s. to other high-income countries and this slide is perhaps my favorite slide if you were to take anything. From this presentation and you. Want to take one slide and take it to a bar when you're talking to your friends to sort of start arguments there's this one slide and, there. Are two axes on the x-axis you have life expectancy, I apologize. You have two spending on the y-axis you have life expectancy, so what you see with all the gray bars is that, as we. Spend more you get more right you spend more higher life expectancy all the other countries followed that path but. Look at the u.s. u.s., falls off the curve because we spend more and we, get less out of it so I feel like this one this, one picture ultimately. Tells you what you need to know is that we are spending more and getting. Less and we're, doing that in a way that is in contrast, with everything, else every other sector in our economy and we. Seem to be doing it in the, sector of our economy which, matters the most at least from a sheer volume point, of view three. Point three trillion dollars a year one in eight Americans, work in this business that, delivers, less and costs. Us more so. Having. Said that and having made the argument, that we. Should be talking, about how differently, in order to deal with this problem the, thesis, of the book is what we need to talk about when, we talk about health and the book has twenty chapters in it they're all brief digestible, chapters and what. I wanted to do here is just talk about three of them I'm just going to tell you about three of the chapters and three, of the three of the things that we need to talk about when talk about health that I think can remedy this, sorry, state of affairs. Number. One number, one is, perhaps. The most important, one which. Is we need to be talking about health and not. Talking about health care now. I. Suspect. It's one of those statements that I'm making that everybody watching is, nodding, and thinking to themselves. Yeah. Okay I get it but. Before, I even tell you how to talk about it I'm going to pose a challenge to you all. Next. Time you have a dinner party or you're at a bar with friends. Start. A conversation about health you, can do anything one you can say I I went to a talk and I helped identify health and as, you do that take, out your watch so you can look at the time and see. How long it takes anybody. In the conversation, to, use the words health care instead. Of health and I, promise, you it'll, take less than five minutes always. Happens within, five minutes somebody will say health care when, instead they mean health and I'm, giving that that. Challenge. To, illustrate how much we conflate, it to how much we conflate health and healthcare, now, let, me explain why this matter, so much I'll. Start with this this is a story, of a bluesman for. Any of you who are while watching or in the audience who like. The Blues he'll recognize Blind Willie Johnson, playing really Johnson is recognized one of the blues greats we.
Don't Have any of his songs in about thirty six of his songs are recorded, he. Was born in Texas at. The turn of the 20th century which is 1900s. And. He was born he, was born sighted, and, the story is that when he was seven he, is stepmother. Through lie in his face in a domestic violence incident and he. Became blind and Blind, Willie Johnson. He. Grew. Up poor, black blind Texas, he learned how to play the guitar and he made a living busking, on street corners which. As he can imagine sounded pretty good living he. Got. Married him and his wife were living in a house the. House burned down and they. Didn't have any money so they actually when, the fire settled they went back and they lived in the husk of the burnt-out house. When. He was 40 he. Developed malaria which no were dealing with in 1940's, Texas malaria was not uncommon, he development area and his wife took him to hospital and. He. Was turned. Away from hospital and, then. He died it's. Not clear if he was turned away because he was poor because he was blind or because he was black. Now. I tell you the story to ask a very simple question. Which is what. Killed the Blind Willie Johnson. Well. What killed him was. Malaria, right. He went to hospital he, had malaria he did not get treated then he died so. What killed him was malaria had, he received treatment for his malaria he. Would have lived had to receive chloroquine, he would have lived but. The reason I tell that story is an extreme, story intentionally, is, because it's pretty clear that it, wasn't just malaria that killed blind blue Johnson right it was also homelessness, and poverty and racism, and access, to care and domestic violence all these, forces also killed Blind Willie Johnson and it's hard to avoid them when, you're faced with a story like that so. The difference between health, and healthcare is, health. Care is what. We do when, we get malaria it's treating our malaria and I want to be very clear this is not an anti, health care argument not at all this is not an anti medicine argument when I when, I have malaria I want to be treated properly when you have malaria you want to be treated properly this. Simply says that. Healthcare, treating, malaria is different. Than what causes health and what. Causes health is everything. Else it's, housing it's economic opportunity, it's education, it is domestic violence or lack thereof it is access, to care it is racism social. Supports that's ultimately what causes health and that's the difference between health, and healthcare and the. Reason the, fundamental. Reason why our health is terrible. Despite, our investment, is, because as I said we spent three point three trillion dollars and we're, spending that all on. Malaria. No not malaria per se a musical air is a metaphor we're. Spending it all on treating. People who are already sick rather. Than spending enough. Of it on the, other pillars, then, generate health so. The number one thing that we need to talk about is health. Not. Health care we, need to talk about how, it is that we. Generate health so, that we can collectively, invest, in what generates health not, just in healthcare not just in what cures disease. This. Is just a simple way now of showing this graphically, just with data the. Bar on the Left, shows. Roughly. What causes health the. Bar on the right shows what, we spend our money on so, if you look at the bar on the left the, green bar which is access, to care / medicine most, experts, suggested that causes about five to ten percent of our health genetics. Maybe. 20% our. Environments. Where we live our social interactions or physical environments, 20, 25 percent our. Behaviors, or. Eating or drinking or sleeping or, smoking no. 30 to 40 percent and the orange is sort of a bit of both a bit of everything else but the, key here is the. Mismatch between the, bar on the left and the, bar on the right all, our. Spending, is on, the green which. Is medicine and healthcare but. The Green causes. Five, to ten percent of Health so. Health. Care versus health is the fundamental. Tension that ultimately underlies, why, our health is, not as good as it should be and it, is at core if I were to be asked northen asked what's the one thing you would do it, is to change our national conversation so that we understand that, malaria matters but if we're only treating malaria Blind. Willie Johnson, is still going to die because he may be saved from his malaria today but, tomorrow he's. Going to have pneumonia, or the day after he's going to die from sepsis so. Treating the malaria alone doesn't, do it. Second. Argument. We. Choose to be healthy much, less than we think now. What are the counter arguments I get - the first one is okay health not healthcare fine I get, it I get that Housing, and Economic Opportunity and, poverty. And employment, I get that those things matter for health but, at the end of the day I, may. Be charitable and I might care for people who are disadvantaged, at Blind Willie Johnson had a hard life but you know what I can.
Choose To, live a good life I pulled myself up by the bootstraps I, can choose to be healthy and as long as I choose to be healthy Shirley, I'm going to be okay and, this, is a mistake, that we make all the time and in fact if you go to a physical bookstore I know, he were here at Google which means so the physical, worlds thing of the past go to a digital book store you'll. Find the same thing there are two kinds, of books about, health there. Are shelves and shelves of books that, tell, you about how you can, choose to be healthy how you can choose to eat better to exercise more to sleep more and then, you have shelves and shelves of books that, tell you well if that doesn't, work here's. A mares a pill for you those, are roughly two kinds of books one is how. You can, choose to be healthy and you don't as well if that doesn't work let's, give you a pill let's give you a drug let's treat your malaria. That. Paradigm. Suggests. That. We think that we can choose to be healthy and that, ultimately, our choice, of health is within. Our hands now I know you're thinking well but isn't it so, let me let me just use a metaphor to illustrate how. It's not and I'll go to sort of a well-known now health. Movie. The Devil Wears Prada, so. Devil Wears Prada for those you who have not seen it is. A, movie about a fearsome, fashion editor, who's. Played in moved by Meryl Streep and the, intern was played by Anne Hathaway and. It's. A it's, a lovely story of a you, know old, couple who eventually come to understand, each other and all that but. There's a great scene which, is the scene which is on the right which. Is where, Andy. Is the, intern is wearing. A sweater, this. Sweater here and the scene is where. There. Is a conversation between her, and the editor around. Where. The editor is trying to choose one of two belts, and. Ended. The intern who thinks she's she's. Bigger than that laughs. At, the absurdity of the choice thing well the two belts look exactly the same and. The other term Miranda decides to soar take her down one a notch and says well. Look at the sweater you're wearing you. Think you chose that sweater didn't you but, what you don't know is. That that sweater is not turquoise it's not blue it's not lapis it's cerulean, and the. Reason you're wearing a cerulean sweater, is because. In 2002. Oscar. De la Renta showed, cerulean, on the runway a few. Years later Yves Saint Laurent you showed, cerulean. Military jackets in the, five years after multiple. The multiple designers. That are using cerulean, and then, that, eventually filter down into the. Sweaters from which you chose and, the. Value, of the team and I would encourage anybody to go on youtube and watch it is it. Makes it very clear that's. Something, that we tend to think of as personal, as much as what you're wearing you. Choose what you learn is, ultimately. Shaped by the world around you that Andy, choice of a cerulean sweater, yes. It was her choice but it was her choice from a very constrained, choice set that, was created, for her by, the world around her and this. Is the world that now we're beginning to dawn to it's a world of physical, choices made for us algorithmic choices, made for us and the. World's always been like that and the, world's always going to be like that and this is not an argument against that this is simply an argument that says once. We recognize, that, then. We should make sure that, our choices. Privilege. Health that, our choice set privileges, health and unless. We do that we, are bound for failure so the positive is once you recognize this let's, create choice it's that privilege health and if, we do not do that we, are going to have the kind of conditions, we have in the United States today now. We, have done this before and there, are good examples of, success, perhaps the biggest ones like example, success is, one of the biggest health triumphs, in this, country in the past century which, is our decline, in motor, vehicle deaths so. The blue line going, down is deaths. From car accidents the, green line is how much we drive we. Drive much more we die less per. Vehicle mile driven, we. Die about two hundred times less for every vehicle mile driven we, have earned for ourselves the. Freedom from dying unexpectedly, in our cars, now. How do we do that well. If choosing. People. To be healthy was the approach we. Would have done that by. Choosing. To create healthier, drivers, now. I'm from Boston I'm not from out here in the west coast so, I'm not sure what drivers are like in the west coast but I can tell you that in Boston people, are not better drivers than they were a hundred, years ago no.
But Everybody knows how we've done this we've, done this through agreeing. On seatbelts, and airbags and, shatterproof glass and against, incentives, against driving, while, under the influence of alcohol that's, how we've done it so we have created, a world where. The, choice set of healthy. Driving, is now. Constrained. In the direction of not hurting, each other that's. How we've done it and that really has. To be the. Metaphor, for how we create, health in all aspects. Point. Three. If. You really buy this argument and and perhaps the comment that I'm faced most often since I've done this book when, I talk to different audiences is well. This argument you making it's kind of obvious, and I actually really I really enjoyed this comment because I feel, like the arguments obvious it means that's intuitive, which means we can actually act on it, we. Need to understand. That. It's the world around, us that, generates. Health and in order for us to be healthy we need to actually invest in the world around us and I want to tell you a story to explain. That and this, is a picture. Of what. A couple years ago was the best soccer team in United States which is the u.s. women's national soccer team that won the World Cup now. Soccer. Is the only sport I care about so this is a it's a very personal story um. But I understand that people, in the audience may may, or may not notice and other people from outside the US who call it football which is this real name but, for those who don't know the sport it's very simple you have eleven people on one side living on the other side and they sort, of kick the ball with their feet hence it's football and try to get the ball to the other neck that's. How the game works it's, a very simple game which is why it's the most popular game in the world now. If you don't know. The game justly understand the 10 players in blue they can only see their feet the, one player in red she can use all parts of her body to stop the ball from going to the net so. If you don't play soccer, sometimes. The mistake that we make is to say well if you have the world's best goalie you're, always going to win because she can stop any ball from going to the net but if, you watch a professional soccer game what. You'll see what it was so so we were, to see here with Hope Solo she's, now retired the. Goalie prowls. Her area for the entire game and she's yelling at the other players you. Know what she's yelling at them to do just saying, keep the ball away from me because. The good goalie knows that. The, net is big it doesn't, matter how good she is a fast. Ball coming at the net is going to go in now. Why am I telling you this I'm. Telling you this because you want a good going but. A good goalie by herself, does not win the game the. Goalie is medicine the goalie is health care the, goalie is what we have to, look after us if. We. Get sick and we want a good going right as I said the beginning I want to be treated for my malaria I want to be trained from my heart attack but. The goalie by herself is not going to the game you, need the other 10 players and the other 10 players are the, places we live the air we breathe the water we drink the food we eat they. Are whether, the environment around us encourage us to smoke, new substances, the houses, we live in the, parts that we have for recreation, the education, that we have that teaches, us and puts us on a path towards healthier living the, economic opportunities we have whether, or not there are is violence, that we're exposed to whether or not there is equity, between genders those are the pillars that ultimately generate health and that's, what creates the soccer team that wins at health and. One, of those pillars here's examples, early childhood education, we, can spend five dollars we. Know that we save five dollars for every dollar we spend oral education we reduce crime child. Maltreatment teen, pregnancy we know this. Public. Transportation, we know that, in a city of a million people a forty percent expansion of public transit has, an animal health benefit of more than two hundred million dollars and, incomes. We know that, things like earn income tax credits, increasing. Earned income tax credits for low-income families by ten percent, reduces. Infant mortality, by twenty three per hundred thousand or put another way another, way is it. Saves twenty three infant deaths for every hundred thousand infants born so, we know this I'm just showing you three concrete examples, and these. Are data you can find on the web you can surely go on the CDC website you'll find these data these are all from the CDC itself and.
We. Know are. That. Investment. In these other ten pillars ultimately. Generate health, and, what, we keep forgetting, is that, investing in these outer temple doors is non-discretionary, we actually have no choice but to invest, in them if you want to generate health as is perhaps evident. By the, abysmal state of health in this country despite. The extraordinary investment, that we make because, all that investment is going on just one of the players namely. The goalie. So. The bottom line so here's the bottom line here's the takeaway from this, presentation and really take away from the book I I. Would, urge us, all, to. Remember three, things. Tradings, are as follows number one what. Killed Blind Willie Johnson, what. Choices we are really making and why. We need to invest in more than the goalie what. Killed Blind Willie Johnson, was. The, combination, of certain in his life degenerative, health who, was housing. Its. Poverty racism, domestic. Violence poor access to care the. Choices we are really making we. Think that, we are choosing those, healthy, are healthy, behaviors but in fact our, behaviors, are constrained, by the same world around us that ultimately killed when Willie Johnson and, number, three if, you want to create health need to invest in much more demille area much more than, the goalie once. We understand, that I think it fundamentally, changes. How we talk about health and it puts us on a path towards. A much healthier world and. I will start with just one last slide and then I'll. Take questions this, is sort of what the book this is um what, the book is trying to get at and uh really. The, point of the book is the subtype which is what we need to talk about when, we talk about health because what I'm trying to do with the book is, I, am, trying to say we, need to change our conversation. On health once we change your conversation on health a lot, of other things follow and our fundamental, problem right now is that we do not understand, Blind, Willie Johnson story we do not understand Devil Wears Prada we, do not understand how software is played and how sock could actually help us win at health, that's. It I'll stop there I will take questions comments, thank you very much. Thank. You very much dr.. Kalia, um I, think in your book you also touched, on how. Come. How unique, the, American, culture, is around individualism. And about individual, choice and you just touched on it as well during your presentation. Are. Those, is, health. And this. Fixation. On the individual, choice of individualism. Fundamentally. Contradictory. Because, I think. It. Seems, like there is some kind of. Yes. Fundamental, assessment, that we have to do, amongst. Ourselves yeah. That's a terrific question the, answer is I, don't. Think they are at all I don't think Americans are any different, and then the Irish the Italians the Swedish does ambience I think, at core Americans. Want to be healthy I think, we mistake, and we make a mistake in. The American conversation, in this, notion of we want freedom it's. Part of the national conversation right freedom, freedom is a core part of what it is to be American but. When, you look carefully at. The canonical texts, at what started the country, and. There are different kinds of freedoms there's. Freedom to, do things and there's, freedom from, things and in. The past thirty four years we, have privileged, freedom, to over, freedom from and. You, want, freedom from. Dying. Unexpectedly. When you leave this building that. Is a freedom you. Want freedom from, getting, obese without, thinking about it because you're constantly eating calorie. Dense nutrient-poor. Foods that. Are there because, of, subsidies. For, products that are unhealthy and. That is also freedom so, I do not think it's in contradiction, I actually think that, we. Have allowed, ourselves to, get into a place where, we privilege one type of freedom over another and I think it's simply a mistake in our national conversation I.
Am. Curious to hear your views on like drug, decriminalization, in. Light, of what, you said about choice sets and. Things. To motivate behavior yeah, the I. Think. The moves towards drug decriminalization are. Um. Enormous. Li long overdue the the. Criminalization of drugs, in this, country has had such, a disproportionate. Effect on. Particularly. People of color particularly young black men that, it has created a whole. Wave. Of, incarceration. And downstream consequences that. I actually think that we are still. Haven't fully come to grips with the full scale, of, the. Physical, mental health consequences, of incarceration. Which is directly linked to, criminalization. Of drugs so I think decriminalization. Is long overdue I also, think that, decriminalization. Leaving aside now the the. Burden. That criminalization, was has, imposed, upon a particular group. Decriminalization. Creates. An opportunity for, regulation, it creates an opportunity for, drugs. To, be, purchased. And sold in. A way that controls, them it creates an opportunity for. This. For us to create a system where. The ingestion of those drugs happen, such a way that people are not hurting themselves. And that of course is something we can never do if drugs are are, criminalized, now the argument often about the criminalization is well people can still buy drugs illegally, that's. True but, there's ample historical, precedent. To show that most people most of the time would. Rather do things that are legal than two things that are illegal once you decriminalize, drugs people will be buying those, substances through, legal, means, so. Thank you good question. I'm. Gonna, paraphrase. A. Virtual. Dory question, um so. This person saying that a similar approach needs to be used, regarding, our justice system in mass incarceration. Also. Contributor, mortality. Health we focus on eradicating crime, aka, disease rather, than creating strong safe communities, a gay health. So. I guess I wanted to kind, of phrase them more in a question of, what. Role does it, should, community, take. A broader, role or do you think it's really just. Converse. Just, like a shaping, the conversation, shaping, the national like, rhetoric. Yeah I know it's an excellent question the, III. I think the the, answer I should give is to say the community you should take a role but uh I want to be careful when I say it I think it's just too easy an answer. To paraphrase Margaret Thatcher of. All people it's um, no it's a market I just said, she. Meant it differently obviously but sure there's no such thing as community there are only people and, I, I actually think that there is some cynical. Wisdom to that because, community. Is us the. Community populations, are collections, of people that have their own emergent, properties that behave differently than individuals, do but, they, do remain, collections, of people so I do think, that, communities. Behave in a way that its, constituent. Citizens, us. Push. The, conversation forward, you know that there is um a, recent. Set of papers that talk about what. Percent, of people. In a given country do you need to, create real change and they the. Science seems to be heading direction this year if you have more, than three point five percent of people who. Would. Demand real change change always happens the three point five percent the u.s. is 10 billion people's not that many people, so I do think that this, rests, on a, national. Conversation shift. And, a global. Conversation shift for those who are following from other countries who are feeling smug about it it's. Probably not so wise because unfortunately there. Are abundant, examples. National examples in other countries that are following hello, the path that the US has has. Paved on this and the u.s. path is is definitely, not immutable, so I do think that it comes down to people, comes, down to citizens comes on citizens demanding, health and citizens understanding. Health and demanding. Health by. Demanding. That we build the structures to generate health a. Lot. Of people sometimes, are skeptical. Of experts, like you because they there. Has been a lot of. Distrust. Of experts, and a facts, and uh because. Because I think a lot of people, presently. In poor health and import. Situations, can only help but you that essentially. People who at or in positions of power failed. Us and I, fail. To trust people, who. Spell, knowledge. And expertise, I'm, sure I'm sure that's part of the reason why there, are many parents who refuse to vaccinate, their children so.
Could. You pretend is is this potentially, related could you speak on this because I think there would be a lot of people who would say well they're. Just trying to tell me how to live my life yeah. So, I think, um. It. Seems to me appropriate to be a suitably, skeptical, of experts that's fine but it isn't, reasonable I, I. Think. Taking. The American lens for a second the. American. Woeful. Underperformance, on health has. Had deep. And devastating, consequences, for. The. National. Political scene and by that I don't mean as a partisan comment, I mean, it in terms of fracturing, the, national political conversation, so, I could show you data, which. I, have, my laptop and I'm not showing it here that. Looks. At the, counties, in the US that. Lost life expectancy. Up, to, 2016, and you. Could correlate, to stay down, with the counties in the US there were likely as to vote for Donald Trump and. It. Is a dose-response, as a straight line the counties that lost life expectancy, were, more likely to vote for Donald Trump now if. You think about it and I, hope this is not taken as a partisan comment you, had two candidates running in the last US election. One. Candidate who, was the party of the incumbent who, essentially said we're. Doing well and we're going to do better. Another. Candidate who said I'm. Not a politician I don't. Like anything that's happening I'm going to change all that and throw everything out now leaving. Aside how, you feel about both candidates leaving aside their personal characteristics it, seems to me that, if. You are living in a county where, you've seen your life expectancy go down. It. Is not unreasonable to, vote for the kennedy who says everything, is going to hell in a handbasket i'm, going to change all of that what are you, believe that he can actually do it or not he's actually done it is it, relevant so, the point I'm making is that. Our health, underperformance. Has, had. Seismic. Impact on the. American conversation. And many, respects this trickle down to the global conversation so I do think, that there, is help. To pay for the fact that we have let this the. Way we have let this, sneak. Upon us and and we are I should, be clear today in a. Worse position than we're in when I started write this book so I'm. Not sure how many viewers.
Will Notice but in. 2018. 2017. 2016. And, there was a decrease in life expectancy in, u.s. there, was the first time we had a year, on year three year decrease in life expectancy. Since, the 1918, flu pandemic so. For a hundred years we, have not had the, poor, health indicators that we're having now so it is reasonable it is very reasonable for. People. To say I don't, trust experts, this, is where they got us too we are in a not a good place on health, having. Said that the, reason we're not a good place is because we. Collectively, are not talking about how the right way. Thank. You for coming to speak dr. Claire I had, a question regarding the. Bar charts that you had comparing, the. Contributing, factors to our health outcomes and the amount of spending and that we have on health care I, believe, the largest recruiting, factor was personal, health choices in. Terms of health outcomes my. Question for you there is one how did you determine that that was the largest contributor and, where. That overall chart overall and. Secondly what, do you think are the obstacles or what is hindering people in. Terms of finding the information they need to make better personal, health choices yeah so the the. Calculation, of those percentage is always very difficult it's a attribute fraction calculation, which, ultimately. It. Ultimately blurs the fact, that these, are multiple causes that all occur, and all contribute at the same time so, we have to be careful about being too, rigid and saying it's 30% 32%. It's some I would. Think of it more as a as, a way to organize our thinking about what the major what the major contributors, to health are the. Because. Ultimately personal choices I've indicated are nested, within the environments, with which we're in so saying, that, you choose to eat healthy, food is. Ultimately directly. Driven by the fact that you're surrounded by healthy food right so the two are not separable the. Information. I think, is critical, in terms, of health behavior, but. It is. Necessary. But nowhere near sufficient, and I, think one of the mistakes we make in our. Digital. Conversation. And in our being. And raptured by all things digital is that we think that information, by itself is sufficient it's, simply not and there's abundant, data on that I'm making show you for example data that. There's, been this a wave of personal a genetic testing and one, of the premises of it is that well, if I know what, I'm what, my genotype is and what I'm more at risk for I'm going to change my health behavior data. Break here doesn't happen actually I do not change my health behavior so information is necessary but. Nowhere near sufficient, so this, is again, it's a bit of an end argument, so an argument against, information, there's an argument that says we, need structures. That, create. Stable. Healthy, behavior sets versus information at all I think, we need both by the information by itself it's not enough. Mister, you're right to think I. Had. To. Thanks, for the wonderful talk I had two questions one, is I was curious how, the bar charts might appear in other countries, that are doing sort. Of better on, a smaller. Map portion of their. Expenses. Yeah, the, contributing. Factors to help don't change they really are they're they're human Universal what, what, does changes is what countries spend, their money on so I've, said in this talk consistently, that we spend more on health in other countries it. Would be reasonable for you to say that that's wrong, we actually don't spend more on health we, spend more on health care when, you look at our spending on these other pillars that I'm talking about which, is the house in the education, your kind of opportunities, when you look at that spending we've. Far under spend our peers so when you add those two if you take my soccer metaphor and, you say what are we spending on the whole team we.
Are Spending. Substantially. Less on the whole team compared. To countries that do much better than we do on health so in some respects the spending, in the outcome is well. Matched so, on on the left side that would have been unchanged. Relative, to the the rights other countries the right side correct, they would have had more, than instead. Of just 5%, on the bottom on other factors, that would have been higher correct, my second, thing I was curious about is to what extent do you find it useful and informative to. Break down the u.s. into, different say. Socio-economic. Categories, or something, and how do the curves look if you, do that does does that is. That useful yeah it doesn't, change it, doesn't change very much now there. Are many different so she can always across, the country and the fact there should be some papers that have been done dividing. Up the u.s. into eight different groupings. Of kind of states, there's, many different ways which we can divide up the country but, the things that don't change are as follows number one is in. Terms of those two bars you're referring to what. Causes health doesn't change and what, we spend, on health does not change become. I live in Boston and Massachusetts. Boston. Is the city, in the country which has the highest doctor population, ratio it is a city where health is the primary is the, primary employer so. Sometimes, I give this a talk like this in Boston and I, get challenged on that side well surely, Boston, is different and, I can show data in Massachusetts. This shows in the past 15 years we. Have increased our spending on medical care by about 80, and. We have kept the same or decrease our, spending on, parks and recreation on mental health and Public Health efforts on criminal, justice domestic, violence all of that's gone down or stay the same so even in Massachusetts, which by the way if I mentioned Hawaii is the healthiest, state Massachusetts, the second healthiest state so even in Massachusetts, we, are underperforming. This set of factors which explains, why. Even. Hawaiian Massachusetts, have worse health indicators. Then say Slovenia, and all, the countries about Slovenia. Thanks. Very much thank you I. Have. A question about. For. Each individual, should reach out all. The trending, diets. And health advices, flowing. Around in the internet such as keto, diet or, should we just stick to the, most basic, less, is more concept just be, stable, I think. John I. Think. You should stick to the most basic, because. The. Truth about all these diets is some. Will work some won't some will make a difference some. Won't but the difference in is around the edges what really matters what, really matters is, ultimately, the choice. Set and the individual, doing eating.
Healthy, Consistently. Over a lifetime so, going. To the keto diet or the Atkins, diet or whatever it's. Sort of irrelevant what really matters is that you eat, a variety. Of things you get enough nutrients you, eat in moderation and. You do that consistently throughout a lifetime and most. Humans, have, a really, hard time doing that in, a large part because we do not surround them with healthy, foods consistently, over a lifetime so, I would say ignore, all that eat. Reasonably, eat, broadly, over like. That that's what you needed. And. Then to just kind of bring you, know the question home here at Google so, in your research how have you found technological. Advancements playing a part as your as. Your, bar chart to increase or decrease how, have you seen that I am. I like. Technology think, technology zone has. Brought some wonderful things - um - to our changing, our life although we. Never changes our life as quickly as we think it does that, always would be driving, around and flying cars today I. Think. The mistake that we make is, into thinking that technology. Is a. Solution, for fundamental problems, and this goes a little bit to my answer I gave about some information. Being necessary but not sufficient I think technology is a. Is. A terrific adjunct. To, improving. Our quality of life towards, creating opportunities, for us to live healthy for as long as possible, and but. It, is by itself it is, not sufficient and the mistake that we make is if, we think that technology, is going to be the only solution and there's. Plenty people sort of written about this and and and, I think it requires humility. On the part of all of us that um that, technology, is simply, part of the solution many of the day technology isn't going to deal with domestic violence and I'll be at home without, with housing Sunday they would all economic, operation I'm going to deal with our with gender equity it's not going to deal with early childhood education, it's an adjunct to all of those but, by itself is not enough so I do think that uh me, to make sure that we, see, technology as in, its, place and you know go back to my soccer metaphor, I think, technological, advances, and, developments.
That, Create, opportunities, for. Let's. Call it a more, sophisticated, form of living that allows us to do more is, one of the players on the soccer team and I'm ok with that and I think it's important that one of there's a soccer team as long as we don't make the mistake thinking, that if we invest everything, in in player number seven they're number seven beam technology we're, going to win the game because we're not so. You believe more in technological. Aids rather than solutions I think, what, the PI's watching by solutions, if by solutions, but, my argument is not what our second largest solution or not my argument is whether it is a sufficient. Solution, so, I will stick with my soccer metaphor, I think player, seven can score that, she's not gonna win by herself she. Needs the other ten players and technology is one of the ten players. I, guess, to ask, one final question which is kind of a good final. Question um this. Person, wants to know what, we ended, at the individual, level can do to help change the system in the environment, is it you, know next time we got to a bar like start. The conversation, yes that's, that's great so I I will, um I will. Give three things number. One, yes. Go, to a bar go, to dinner and tell. Ten people about, this talk if. Everybody tells ten people and tell them to tell ten people there. We'll get us to ten million people who understand, the orders of his number one there's number number two, number. Two. Vote. For, candidates. Who, understand. This vote. For people for, positions, of authority in the public sector who, understand, what it is that it takes to generate self and that, could be at local level at, the municipal level at the state level at the federal level number. Three. Be. A part, of and. Support. And encourage. The, private sector that. Is willing to generate, the conditions, that generate health, so. I think those three change, the conversation, vote. For people in public. Office who understand this and number three create, conditions, in the private sector by, supporting, Elmo so the private sector to understand, this discussion. With. Thank you to Google for allowing me to present that message. Thank. You very much for giving your wonderful. Lecture. You.