In a session from our 2024 Symposium, our panel of experts examines how the field of public health is prepared to address emerging risks and social inequities that affect health outcomes while drawing on past lessons and opportunities to strengthen trust in our institutions. Moderator Cathy J. Bradley (Dean, Colorado School of Public Health and Deputy Director, University of Colorado Cancer Center), speaks with Georges C. Benjamin MD (Executive Director, American Public Health Association), and Sandro Galea (Dean and Robert A. Knox Professor, Boston University School of Public Health). The panel is introduced by Kristan Uhlenbrock, Executive Director of the Institute for Science & Policy.

Watch a video of the panel discussion on our YouTube channel.

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Symposium 2024: The Future of Public Health

KRISTAN UHLENBROCK: Thank you again for joining us today for our annual Institute for Science and Policy symposium. This year's theme is “The Future of Science Policy,” and I am thrilled for today's panel with our very esteemed guests. We'll be talking about the future of public health.  

My name is Kristen Uhlenbrock. I'm the executive director of the Institute for Science and Policy, and I'm really grateful to be able to listen to today's conversation. I know I'm going to hear a lot of thought provoking ideas and discussion as we talk about the future of public health. 

We have about an hour and a half for today's conversation So we have plenty of time to cover a lot of ground, although this is a pretty big topic. When we talk about the future of public health today, we're going to be talking about emerging risks as well as social inequities, which affect health outcomes for many individuals. 

We're going to spend time drawing on some past lessons. You can't talk about the future without thinking about our history and where we are today. What systems do we need to build and strengthen our institutions, particularly public health, into the future? What is the relationship between public health, trust and the deep politicization of science?  

How do we build  bridges to make sure everyone has the health outcomes that we want? So I'm really thrilled to have three very great guests. I have had the chance to work with all three of these people in various ways in the past, and it's nice to bring them all together.  

So we have Dr. Georges Benjamin. He currently serves as the executive director of the American Public Health Association (APHA). He's been there since 2002. He has been leading the association's push to make America the healthiest country in the world. Prior to joining APHA, he served as the Secretary of the Maryland Department of Health and Mental Hygiene. 

He has many publications and  authorships. He also has a book that I felt was relevant to today's conversation: Public Health Under Siege: Improving Policy in Turbulent Times. Thank you for being with us today. Georges, how are you?  

GEORGES BENJAMIN: Thanks for having me. I'm excited about being here.   

KRISTAN: Thanks for being here. We also have Dr. Sandro Galea. Sandro is the Dean and the Robert A. Knox Professor at Boston University School of Public Health. He has been named an Epidemiology Innovator by TIME Magazine. He's a top voice in healthcare according to LinkedIn. He's one of the more cited social scientists in the public health space that we've seen. You may have seen him in various TED Talks. He's often quoted in the major news outlets as well. He is a native of Malta and has served as a field physician with Doctors Without Borders. He also has a new book, The Turning Point: Reflections on a Pandemic, which came out this year. Thank you for joining us today. How have you been?   

SANDRO GALEA: Well, Kristan, thank you for having me back. It's a pleasure to be here.  

KRISTAN: Thank you. Cathy Bradley is the dean of the Colorado School of Public Health, which the Institute has been a longtime partner of. I've recently gotten to work with her and get to know her more as well. She serves as the deputy director for the University of Colorado Cancer Center. Dr. Bradley is a health economist who holds the Paul A. Bunn Jr. Endowed Chair for Cancer Research, which is a lot of her background as well and her research. She serves on many boards, many committees, including the National Academies, among others. She is both an expert in today's conversation, as well as our guide through today's conversation. Thank you, Cathy, for joining us today.   

CATHY BRADLEY: Thank you, Kristan. Thanks for that introduction and thank you for hosting this panel. Such an opportunity time to discuss the topic of public health and where we're going.  

KRISTAN: Why don't I pass this off to you and you'll have a wonderful conversation. Enjoy, everyone.   

CATHY: Fantastic. Thank you. Okay, let's think about the elephant in the room. With President-elect Trump coming into office with some rather interesting picks for leadership in health agencies, would you all like to reflect on what that could mean for public health and where we might be going?   

GEORGES: Sure, let me start. Obviously, anytime you get a new administration, they change people on the deck chairs. Those people bring their ideas to the table and then, of course, the administration as a whole brings its perspective to the table. No one's been confirmed yet and they're going to go through that process. And they're picking some pretty unusual people with backgrounds that have not historically had a hand in government or in public health.  

So I do think there's going to be a huge learning curve for all of them. But I do believe that  one of the things that they clearly articulated is that they want to now pivot to addressing chronic diseases as a core activity, which is good. Somewhere around 6 of every 10 Americans have a chronic disease, at least one chronic disease. 

And probably 4 of 10 Americans may have more than one. Chronic diseases are a big deal. They’re part of the leading causes of death. So as we move to this new administration, we're not all going to abandon infectious disease, but try to see this as an opportunity for us to move a chronic disease agenda forward in the nation.    

CATHY: Sandro, your thoughts to add?  

SANDRO: I echo what Georges has said about a new administration and new leadership. One has to respect that. But I think there are three elements. Number one is: what will the actions of the new administration do to change the structures that shape health? We know that health is driven by the world around us, by our income, our education, the quality of our neighborhoods.  

The first question is, what impacts are the administration's actions going to have on the world around us that is principally responsible for health? The second question is, what impact will the administration's actions have on the tools, processes and mechanics of public health? Now we're dealing with federal agencies, state agencies, local agencies. And the third question is, what impact will the new administration have on culture. Will it be a culture that unites rather than divides? We know that underpins  a lot of the social capital that drives health. 

So I think we have to look at it in those three ways. Of course, it’s very hard to say what's going to happen in the new administration. I think we need to approach it with an open mind, a willingness to listen to new ideas, and the humility to recognize that there might be  different ways of doing things that are still good ways of doing things. 

Having said that, we do have this administration's prior iteration, 2016, to lean on. There were a number of things that happened in 2016 that I think portended disinvestment in the structures that generate health, in the actual mechanics of the actions of public health, and in approaches that were much more divisive than they were uniting. 

And I think all three of those we saw as threatening health. Of course, the last time this administration was in power, 2016 to 2020, it was also compounded by the COVID pandemic, which made things even more complicated. So it is a little bit harder to get a clear picture of what that period was actually like. But I do think that  we have precedent to pay attention to. I think it helps us to organize our thoughts around these three areas and how administration action can affect us in those three areas. By us, I mean, all of us as people who want to be healthy.   

CATHY: Absolutely. If I may add a fourth area, what we observed last time was that a lot of people left – a lot of very experienced people within the government didn't adjust to the new administration and they left. And there was a lot of experience that was drained out of these agencies that we've come to trust, people who knew how to get things done. How might that component figure into it? What can we do as public health educators and professionals to counterbalance some of that?  

GEORGES: I think certainly one thing we can do is try to encourage people to stay. Part of that exodus was also because baby boomers were kind of aging out, and that's going to continue. We should anticipate that's going to continue. COVID obviously had a large burnout factor as well. So that exacerbated the number of people that left.  

As we think about all the people we're training, it's going to be important for us to give them a different set of skills as they move into public health agencies: better communication skills – particularly around risk communication – and better political skills. 

What I mean by that is using political science and different leadership skills to manage people that you don't control. Public health has always been able to manage things by influence, but that has historically been those of us at the top. Now we need to make sure that our entire workforce is imparted with those skills. Because they're having to engage people differently than in the past. Not only are they having to communicate through press releases and new services; they've got to communicate, 24/7 in cyberspace, which is a very different mode of communication. Us old folks are not as good at it as our younger staff members.   

SANDRO: I agree completely with what Georges said. I think there is a danger, in a moment like this, when people who are working towards improving the health of the public withdraw. And I think there's also a danger of people who work towards that of the public seeing themselves as only in opposition to what an incoming administration might do. 

I think those are both mistakes. First of all, we need good people who are committed to the health of the public to keep doing what they're doing, to keep advancing the public health. We need people who understand these challenges that we are discussing here. But I think we also need, at this point in history, to reckon with the long tail consequences of the past 10 years of national divisions – exacerbated by COVID – to learn how public health can go back to being what it should be: a unifying force. A force that unifies based on an aspirational goal that is shared by everybody in the population: that we are all healthier and that our children are all healthier. 

This is a moment that requires people of good conscience in public health to redouble our efforts, not withdraw and exit. To actually say, “The world needs public health more than ever.” We should always remember that  poor health is directly linked to  people voting for leaders who are willing to rip up the playbook. 

There is a very tight linkage between poor health and political upheaval like what we're seeing happen in this country, that we’re seeing happening in Europe. Improving health is good for societies in its own right, but it’s also good for the stability of political systems. So all of this says we need people who care about health to do more, not less.  

CATHY: All interesting comments. Georges, something that you said triggered some thoughts.  

Historically, public health people have been communicating higher up.  Now we need to communicate everywhere, including in the cyber world, so that we embrace the broader community and show that public health is for everyone. Do you have examples or strategies of where that's worked well? I'm thinking about our students, right? Because one of the things that we want to make sure we don't do is discourage young, bright minds from coming into our field because we’re worried and retreating. We don’t want to see this exodus. We want to be the ones, as leaders of the field, to say, “No, we want you to stay. Here's some examples of how it can really work.” 

GEORGES: Yeah, let's talk about the traditional community meeting. We always pride ourselves on engaging communities. But the historical community meeting has looked this this: We would take our group of staff, we'd work with someone who was trusted in the community, we would go into a school or a YMCA or church, and we'd give them our pitch. 

We’d go there, we’d would speak to them, and then we would ask questions. I would argue that what we have learned works better – particularly in a time where communities are divisive and where people don't have the trust – is reversing that conversation. Go in and say, “We're here.  Tell us what your needs are. Tell us what your problems are.” 

Now, you may have an idea for a program that you want to get them to participate in, or ideas about how you can help them. But I think when we go in, we should listen more and maybe not even give the pitch that night. We should go home, come back later and say, “Okay, we've heard you. Here's our thoughts.” And then have a conversation with them versus giving them the lecture and the Q&A. That's a skill set that we might want to build. The other thing is provoking that conversation, using community health workers to go in and lay the groundwork for that conversation. 

When I was the Secretary of Health for the state of Maryland, I had to go into one of the rural communities on an island. As some of you may know, I was the first African American Secretary of Health in the state of Maryland. So there had been some real conflicts around the preparation of food on that island. Long story, not really worth getting into. But the point was my staff went in to make sure that the community knew that I was coming in to listen to them, not to bring the hammer down on that community. 

I spent some time with the legislators that were involved with that jurisdiction. I spent some time with community leaders. Of course, in Maryland, the political divide is the bridge. People that live on one side of the Chesapeake Bay are viewed differently than people live on the other side of the Chesapeake Bay.   

I live on the west side of the Bay. So I'm a West Bayer, African American, coming into a rural, fundamentally white, blue collar community. So I was an outsider by all kinds of measures. The way we broached that was by laying the groundwork for my coming in. 

Then we came in, we had lunch, we talked. I listened to them. And then I promised to come back with some solutions to the problems that they gave me. The truth of the matter is, we brought them the solutions that we were going to give them to begin with, frankly. But they were altered a great deal based on what we heard from the community, the way we presented everything, and the way we measured the outcomes and success of what we wanted to do.  

SANDRO: I actually don't have much to add to that other than to elevate, underline, and boldface Georges’ comment and experience.  I've said this in some of my writing and speaking: When one commits to public health, one commits to caring about the health of the whole public, not the health of half the public. 

It is difficult to remember that, and particularly difficult to remember that our commitment is equal to the health of the public we may disagree with, as it is to the health of the public that we do agree with.  

If I may be so bold, I’d suggest that those of us in public health, whether in academia, practice, or advocacy, haven’t been as effective as we should have been over the past decade, particularly in these divisive times, at making it clear that our constituency is everyone, not just half the public. 

This is the moment when we need to lead by example and cross the bridge. In Georges’ case, it's a literal bridge. In most of our cases, it's a metaphorical bridge. But we need to to make sure we cross the bridge at all times.   

CATHY: Absolutely. Sandro, do you have any examples that you can give?  Where you've been able to do that successfully?  

SANDRO: I think the challenge is to allow space for disagreement without allowing us to fracture and become disagreeable with others who do not necessarily like what we have to say. The only way to do that is through careful choice of language and through persistent and insistent effort to make sure that everybody's included in our big tent. And I would start that from our very language. It's never us versus them. It's always about us together. And if some of us say things that are offensive, the right approach is to say, “Why is that being said? How can we have the conversation to narrow those gaps?” 

I want to be clear that you see this happening thousands of times every day by all sorts of people who work in our space. I think there has been an abiding narrative of division. And I that narrative does not do justice to the people who are doing this very well every day. 

Our job now is to flip that, to make sure that the narrative reflects that we in public health  are leading that push for unity. Because our constituency is everybody.   

CATHY: Absolutely. We are here to serve everyone – regardless of race, ethnicity, how they voted, where they live – all of those things. Our goal is to bring everyone to the table. The better job we do of explaining what public health is, the benefits we bring, and helping people understand the science, the better off we all are. 

Sometimes though, we get caught up in our academic mindset. As experts, we write about things, we pontificate about them, and when we hear someone say something we disagree with, our instinct is to argue it. I think you're both alluding to techniques that involve stepping back and considering whether the issue is with us. Maybe the reason our message isn't always well-received is that we haven’t done the greatest job of accepting that others genuinely believe things that may conflict with what we believe. 

We're trained to pick things apart, but how do we start conversations without immediately falling back on those instincts? Were there lessons learned during the pandemic that we could apply to do this much better? 

GEORGES: So many. Let me start by saying that the most important thing we need to do anytime we open our mouths – which we should do after spending some time listening – is to say, “This is what we know today based on the information we have right now. I may come back later with a different recommendation based on new knowledge, and that means I’ve either changed my mind or I’m altering what I’m telling you, but I’m doing it for a good reason.” 

And when you do come back to update your recommendation, remind them that you told them this could happen. Explain why you’re making the change, and avoid the usual ‘fire-and-forget’ approach. We often rely on press releases to announce something, and then when things change, we just put out another press release without having the conversation to explain what that change means. 

This happened with masks. It happened with what we understood about the efficacy of vaccines in reducing transmission. We need to spend the time to overly communicate with people to make sure they understand those changes. 

SANDRO: Let me build on that for a second. If anyone’s interested in this specific topic, I wrote two pieces on my blog, The Healthiest Goldfish, over the past two weeks about this idea of false certitude, which ties directly to what Georges said...the challenge we face when we express false certainty and say, 'We are right.' 

There are two problems with that. Number one, it leaves no room for us to later say, “Actually, the facts have changed. We now know differently.” Number two, it leaves no space for disagreement. If I’m 100% right, then if you disagree with me, it becomes an argument. 

So I think it’s critical to communicate with humility, recognizing that facts and data change, and as they change, we may change our minds. So we need to make sure we communicate in a way that’s like a conversation, not an imperative. If there’s ever been a time to see how false certainty and an overly definitive way of communicating can backfire, it’s in the post-COVID era. 

Now what’s tragic is that we’ve long known this from public health science. Anyone who works in behavioral interventions knows, for example, that overly aggressive campaigns against harmful products can backfire. There’s good data showing that people are more likely to embrace the harmful products. There’s literature on this when it comes to tobacco. 

COVID, with the fear, urgency, and the antagonism – let’s be honest – of the federal administration at the time, pushed us into this overly definitive, false certainty approach. That has resulted in the lack of trust and backlash we’re seeing today 

CATHY: So that fits in perfectly with a question we just got in the chat, where the questioner asked about how we use personal stories. They referred to how anti-vaxxers are very effective at saying, “You know, my child is autistic because of this vaccine,” and bringing forward these powerful, emotional stories that parents are going to be worried about. 

Public health has a way of being understated. We save the world on a regular basis, change the course of history, and don’t tell our stories. From my own experience working in the cancer world, I’ve seen how effective it is to show someone who was diagnosed with cancer, had a very bad prognosis, was treated with a new, exciting drug, and then went on to recover.  

But the prevention side of the story is harder to communicate. You invest in it, but you don’t observe the outcome. You don’t see that miracle happen in front of you. How then do we incorporate personal stories to highlight the observable outcomes in public health? How do we show that we saved someone’s life in the following ways today? 

GEORGES: Maybe let Sandro go first. I know he's done a lot of these in his books.  

SANDRO: Well, my general answer to this kind of question is that I am deeply hopeful the next generation will find better ways of doing this than ours. I don’t mean that glibly. I really believe the nature of communication has changed dramatically in the past 10 years. And as a subset of that, the nature of public health communication has also changed dramatically. 

Yes, we need to weave stories into our communication. I see Martin Volker has asked about stories, and I completely agree. As Georges mentioned, I’ve tried to weave stories into my books, but I haven’t, for example, tried to engage in the rapid-fire, call-and-response storytelling that’s common on many social media platforms. That’s just not something that’s native to me. But younger scholars, activists, and public health practitioners are much more engaged in that. 

I completely agree with Martin’s comment. We need to acknowledge this generational shift and make sure we’re improving in science communication. This should be part of the training for future public health professionals. That said, I don’t think every single person in public health needs to be great at communication. Not everyone needs to be active on platforms like TikTok. Instead, we have to make sure that some people in our field are intentional about mastering these mediums as they become more important for engaging Gen Z and Gen Alpha. 

Collectively, we need to tell the story of public health better. On science communication, I’d like to add one final thought. If ever there was a field that should be on the cusp of evolution and reinvention, it’s health communication. We can view this as a negative, but I like to look at it positively. It’s an exciting moment to rethink how we communicate for health in the coming decade. 

Here we are at the end of 2024. If we think back to the end of 2014, I doubt any of us would have predicted that the next decade would require a complete rethink of health communication. And goodness knows what we’re not seeing today. 

GEORGES: No, I think Sandro is absolutely right. When talking with an individual who's articulated a challenge with their family member and a disease, I remind myself is that I'm not their physician. I'm not seeing them. I've not examined them. I’ve not looked at their medical record. So I'm not in a position to have a debate about the etiology of their loved one's condition. So I show empathy and acknowledge their loved one's condition. I'm not in a position to debate because I don't know what caused the autism or other disease that the family member has. Sometimes I'll go and say, “But here's what we know based on science today.” And I'll give them the evidence as I see it.   

The other thing I think we need to do is a better job of articulating what we do know through case studies. The reason there's an abundance of stories about vaccines causing autism, lead causing intellectual disabilities, or conflicting claims about what nutritional supplements do or don’t do is that we don’t have enough good science out there to counter them. If we put the right information out there and allow people to do their own research, they’ll usually make decisions more grounded in evidence and science than in misinformation. People are pretty smart. But when you only have one point of view being debated, and it’s framed in terms people can relate to, as we often say, “meeting people where they are,” then that’s all they’re going to hear. 

Because we’ve moved into these siloed ecosystems, people only hear one viewpoint. We need to enter those conversations as frequently as we can, bringing the evidence we believe to be correct. I think that would be really helpful. 

CATHY: I agree. You know, as Dean, I'm constantly saying to our school, “Tell our stories. Tell our stories of success. Tell it in a relatable way.” 

But I'll tell you, one of the challenges – and this ties in well with another question we got in the chat –is that sometimes, no matter how clearly we tell the story or how solid the science is, if we’re not trusted, it’s hard for people to be receptive. If they see us as being on "the other side," whatever that other is, they may not see it as really good, credible science. How is it that we restore that trust? 

SANDRO: Yeah, I'll try to. You know, the challenge with trust is the old adage, right? It takes decades to build and moments to lose. One thing that’s certain is you can’t really build trust in a moment of crisis. I’ve used a metaphor in some of my writing and speaking: if you’re on a ship in a storm, and the captain says to her crew, “Trust me, let’s do this difficult thing,” well, if the crew doesn’t already trust her, that’s not going to go very far. You need to generate trust when the ship is sailing calmly, when people know you’re committed to the same values and that you know what you’re doing. 

At the end of the day, I see trust as the intersection of three forces. I think you need competence. I think people need to see a commitment to shared values. And there has to be the imagination and cultural will to act on what the trustworthy person is asking. 

Those elements are built over time. We need to start building them now, not during the next pandemic. We need to keep building them through the anticipated adversity of the next few years, especially for the goals of public health. And we need to demonstrate these principles through our actions and behaviors, through how we communicate science, how we conduct science, and how we include others. Now’s the time, not during a crisis. 

GEORGES: I absolutely agree with that. I think now is the time for us to get out there and have these conversations. We need to acknowledge and engage with people we disagree with. At the end of the day, most people can identify the right problem. It’s the solution or the pathway to that solution where we see differences. 

So if you can get people to agree that everyone ought to have health insurance coverage so they can see a doctor, or that everyone should have safe, nutritious foods – these are big, common sense ideas. From there, you can work collaboratively to come up with solutions that make sense. And again, it’s important not to go in with preconceived notions about what people perceive or understand those solutions to be. 

CATHY: One of the things I see some members of our field doing is panicking right now about what’s coming ahead. Maybe some of them are experiencing PTSD from COVID, or they’re just worried about what happened last time and projecting that into the future. They’re panicking. 

I think it’s really important that we, ourselves, start to calm down so we can sow trust and build it now. If our immediate reaction is to panic, we’re probably not sending the right message to build that foundation of trust. And trust is where the foundation of science is built – along with shared values, understanding science and agreeing on the problem. Then comes the harder work of agreeing on the solutions and finding ones that work for everyone. 

I see this widespread panic across our profession. How do we overcome that for ourselves, our colleagues, our future students, and even the people around the dinner table? I was recently asked, “Are you stockpiling vaccines?” No. But these kinds of things have crept into people’s consciousness. 

How do we move out of that space? Because I think it’s really critical that we do so. 

GEORGES: Well, you know, I’m an ER doc, so I think the first thing you do is take your own pulse in the middle of a disaster. If you’ve got one, you’ve got time, so don’t worry about it. People just need to step back, take a deep breath, and solve the problem. Sandro, your thoughts? 

SANDRO: Well, you know, I’m also an ER doc, which is one of many reasons why Georges and I agree on so many things. I think he’s exactly right. I think there’s a danger in a moment like this. I mean, this was scheduled before the change in administration. But there’s a danger of saying, “The sky is falling.” You’ve seen it in conversations starting to emerge. 

There is going to be resistance to all sorts of evils about to be wrought. And that’s just the wrong attitude. I think this is a moment that calls on public health to have clarity and sharpness of intention. We need to be clear about what we need to do, clear that we need to build trust, clear that we need to demonstrate competence, and clear that we are driven by values people care about. We need to build the political will behind what we want to do in public health. We have to do this in a way that listens and is open to ideas, but also with sharp clarity about the things that matter so we can speak out when those things are threatened. 

That last sentence – which I suspect most people in this room would agree with – is easier said than done. To return to the ER metaphor Georges started with: when you’re in the ER and there’s an acute emergency, it’s very easy to lose your head. But what a good ER doctor does is this: she never loses her head. Ever. And it’s on us in public health to not lose our heads, especially now. 

I’ve argued – and I realize this isn’t a universal perspective in the public health community –that we lost our heads a bit during COVID. I don’t want to see us do that again.  

CATHY: I’ve certainly seen some of us preemptively lose our heads in anticipation of losing our heads. We’ve started to do that ahead of time. So definitely a good message to send to our community is that we need to be thoughtful about the challenges our profession will face. We must resist the temptation to spar with everything that’s said and continue to combat with science, values, and a solid set of information. 

What’s the right response when people feel tempted to react? This has become our social media world, where a provocative comment is put out, and there’s an expectation that we suddenly have a statement about it. How do you react to that? 

GEORGES: Well, I tell my staff that when we put out press releases, we’re putting them out for a reason. We always ask ourselves: what is the outcome we’re hoping to achieve by making this statement? And we do that all the time. Sometimes it’s just to be on the record. But most of the time, it’s for a very, very specific outcome we hope to achieve. 

We also try to be balanced, meaning we look for opportunities, sometimes going out of our way, to praise people. I learned something early in my management experience: one minute of praise goes a long way in an organization. If you can find people doing something right and champion what they did, it makes it much easier when you need to disagree with them later. And, of course, when you do disagree, do it in a way that’s not disagreeable as part of the process. 

SANDRO: Just to echo one aspect of what Georges said, which I agree with completely, it’s the importance of always asking ourselves a very simple question: What are we trying to achieve? 

Before we say something or do something, what are we trying to achieve? And when you apply that test to yourself, you realize that sometimes the right thing to say is not X, but Y. And sometimes the right thing to say isn’t X or Y, it’s nothing at all. Now we have to be clear about what we’re trying to achieve. 

As Georges said correctly, sometimes what we’re trying to achieve is simply to put something on the record, even if it sounds outrageous or unpopular. That’s fine. But most of the time, when we say or do things, we’re trying to achieve real change. And sometimes, perhaps most of the time, achieving real change isn’t about saying the thing you want to say but saying something different that allows us to achieve change. 

So I would challenge us all to use this simple test of “What are we trying to achieve?” as a filter between what we want to say and what we intend to do. I think if we did that, we’d be more successful. 

CATHY: Oh, great advice. Great advice. Taking that moment and not giving in to the tendency to suddenly respond or try to sound like we’re right could do us all some good. Yeah, weaving this question in with something related that came up in the chat. Do you think our culture of individualism works against us in some ways when it comes to trust and science? For example, if you have universal health insurance, are you more likely to trust that system if you have a stronger sense of community versus prioritizing individual rights? Or when you get a public health recommendation, it’s sometimes seen as an infringement on your right to make a personal choice, even if it benefits you and everyone around you. Do you think our culture or society somehow stacks the cards against us in that way? And then, how do we address that?  

GEORGES: I think it’s a false choice between individualism and community. I think the premise that we’re somehow separated into those who believe we should pull ourselves up by our bootstraps and those who rely solely on others is a false one. Every time something bad happens, the folks in the church come out to care for their loved ones and their parishioners. When there’s a disaster in the community, people come together and bond. 

The issue is how people see the need for community versus individualism on a particular issue. Our challenge in public health is to broaden people’s understanding of the need for community engagement, especially on issues where the mindset might be: “If that person just got a job, their world would be different.” While that may be true for some, there are many for whom that is not true. The solution is in building community engagement to address these broader challenges. 

In fact, if you strengthen the community, you’re also more likely to grab those individuals who might not take the steps they need to from an individual perspective. By changing community values, you create an environment where they feel the need to be part of that community. 

SANDRO: You know, I'm heeding my own  advice in terms of, “What are you trying to achieve?” I actually have nothing to achieve by adding to that, because Georges’ answer is perfect. So I'm going to say nothing. I'm just going to underscore Georges’ answer.   

CATHY: Fantastic. Wow. Very good. Something I want to bring up – something both of you have mentioned, tangentially and directly – is the idea that public health is about everyone, not just half the population. We’re growing our tent. We want to make it bigger. 

A lot of the time, we frame that as equity. We talk about health equity as including everyone – that everyone gets better, everyone benefits from strong public health science and strong public health recommendations. In the last couple of years, we’ve seen a backlash against DEI and that’s been conflated with the idea of equity. So now, whenever we talk about equity, there’s this notion out there that people are somehow getting ahead unfairly. And if anything riles people up, it’s their own sense of fairness, right? 

So how do we address those concerns? Equity, we agree in public health, is one of our core values. We’ve all said it this morning in slightly different terms. But how do we address this issue as it gets caught up in the broader backlash against DEI? 

SANDRO: I can start. I think, like many things in the past decade, there has been a social construction, like a simulacrum, of a much more complex and important issue. 

That social construction is this notion of overweening DEI enterprises that impose unappealing, identity-driven, simple solutions on organizations and societies, when we should be thinking much harder. But that’s not the truth. The truth is that the principle of equity – and the principle that none of us would like to be born into a country where the sheer random lottery of where we are born, or the random lottery of the color of our skin, which has absolutely no biological significance to our health, determines our health – is a universal one. 

That we should make sure there are no structural reasons keeping some people back purely by the accident of birth is an idea that’s accepted and embraced by the vast majority of people in this country. DEI efforts, which were intended to solve a problem widely acknowledged and embraced by Americans, have become the target of attacks because they are seen as representing something undesirable. 

So I don’t think that the sound and fury around this notion of DEI efforts as harmful has much substance. I think fundamentally, it is on us to be consistent and persistent in saying that we aspire to a world of equitable opportunity – equitable chances, equitable access to health care, and equitable health for everybody. That is a core value of what we do, and we need structures and systems to achieve that. 

I don’t feel strongly about calling the program DEI, or DEIB, or DEIJ, or DIA, or even JEDI. I don’t feel strongly about the name. I do feel strongly about the importance of having systems and structures in place – across organizations, small and large, all the way to the national level – to make sure we have equity of opportunity so everybody has the chance to live a healthy, rich life. 

GEORGES: I’ll build on that and just say, you know, we’ve allowed people to redefine DEI into something that it isn’t by framing it as exclusive. It’s not exclusive. It was always meant to be an inclusive term. If we have to change it to IED, so it’s inclusion, equity, and diversity, okay. 

But I think the principles are still there. We just have to make sure we’re articulating DEI in the holistic way it was intended. We need to talk about it not just in the context of racial equity, but gender equity, rural-urban equity, and even equity between communities of the same race. 

I’ve looked at lots of rankings of states. If you look at county health rankings in predominantly white states, and you compare counties that are right next to each other, you still see 2-3 year differences in life expectancy between those counties. You have to articulate that so people can take the race issue off the table. Then you can have the conversation. But you have to do that intentionally so that people understand you’re addressing all the areas where disparities are, and that the solutions are universal. Making sure people have a livable income, ensuring they’re not exposed to toxins in their environment, providing equitable access to safe, affordable food, good education, and so on. All of those social determinants, what we know fundamentally impacts health, the 80 percent of factors that occur outside the doctor’s office, that empower or disempower you to be healthy. But we have to approach this intentionally and make sure that everybody sees themselves in this. I think that’s something we’ve failed to do, making sure everyone feels like they’re included in the tent. 

So whether it’s reversing the initials, redefining what the terms mean, or just showing up and telling people what we really think, we can’t allow others to redefine these principles for us. I think it’s important for us to do. 

CATHY: Fair statements. All of that. I want to bring a question from the chat in, which is, “Please address how we're about to lose doctor black doctors due to misguided rulings against quota systems for medical schools.” 

GEORGES: Yeah, affirmative action programs have been misunderstood for years. I'm always fascinated when people tell me they can't find any. I always say, “You didn't look hard enough.” Most of the affirmative action programs, what they fundamentally really did was look for people who were qualified to participate in the competition to go to med school. That's what they really did.  

They went and found low income individuals of color, low income whites, underrepresented people in a variety of disciplines, and gave them the opportunity to compete to get into medical school. Quite frankly, I wish the medical schools would hold their ground, fight those things in the court and not allow people to redefine affirmative action. 

Because the truth of the matter is, the skill to get somebody through STEM education, it's a big skill. You have to recognize that other societal things are limiting the number of African American physicians, in particular, going to medical school. There are a large number of diversion programs that we have.  

Those diversion programs mean catching kids and sending them to jail. These are kids that are in the school to prison pipeline. We have to fix those diversion programs so that the pool of individuals eligible to get into to these higher education programs increases. That also creates opportunities for more first generation students to go to school. And then, for all students, we need to make the cost of medical education much cheaper. Because the truth of the matter is that nobody's going to be able to afford it. It's gotten way too expensive. It's out of control.  

SANDRO: I have little to add to that. I’d just say that there’s a good body of literature about the structural constraints on people who come from backgrounds with fewer assets – whether financial, physical, or social – and how those constraints affect their path toward medicine, particularly specialties. 

The system is set up with clear impediments for those from lower-asset backgrounds to advance into the higher levels of clinical care. And those are the things that fundamentally need to change. 

You know, exportation and pipeline programs are part of the solution, but at the core, these are structural challenges. 

GEORGES: You know, the other thing is – and I’m a proponent of legacy programs – I don’t personally think we should get rid of them. What I mean by that is, we now have second- and third-generation, and sometimes first-generation physicians, who have gotten into school. And now, they want their kids to follow them into that same school. 

Often, those kids get preference because their parents went to that medical school or university. Quite frankly, the really well-to-do are going to get in no matter what. Daddy or Mommy is always going to buy a new building, and they’re going to get in. The challenge is, how do you address those kids who have worked hard, whose parents are already in the field? 

It’s been that way for plumbers and electricians, and for people in the entertainment industry. And now, suddenly, we’re talking about shutting the door on legacy programs for people in the professions. I think we need to rethink that. It needs to be fair and we need to find fair ways to do it. But the fact that someone’s family member went to a school creates a family history and a sense of belonging that I think actually helps that individual succeed. They’re more likely to graduate because their parent went to that school. 

CATHY: Well put. I have not heard it articulated that way. Very interesting.  

SANDRO: There are multiple layers to this problem. So much of the opportunity for leadership in this country is funneled through schools where fewer than six percent of students end up going. That is a structural problem. It’s even more of a problem that many of the opportunities to attend those schools are reserved for legacy admissions and non-academic achievements. It is even more of a problem that, for the other half of the opportunities, competing to get into those schools requires layer upon layer of advantage. 

So these are all structural challenges. And I feel like the public conversation has been very superficial about this. But then again, it’s through conversations like this one, hosted by the Institute for Science & Policy, that we can articulate how complicated these issues are and, just as importantly, how important it is that they are tackled. 

CATHY: Going back to the earlier question I asked about our society being more individualistic than community-oriented... Sandro, you made a statement that we’re willing to live with the fact that so many people in this country, by virtue of where they’re born, literally aren’t provided the same opportunity, the same access to health. 

That’s in direct conflict with everything public health is about. And that’s one of our biggest challenges. How do we start to break that down? 

SANDRO: I think, perhaps this is the hopeful side of me, I don’t think we are okay with that. And by "we," I mean society at large. I think society, capital W "We," does not understand that this is a political decision. We don’t understand that these are political decisions we are making that create systematic barriers for some of us to achieve what all of us consider to be fundamental birthrights: the opportunity to be equally healthy, not determined randomly by where we’re born. 

You know, one can get philosophical about this and talk about Rawlsian experiments, asking, “What kind of world do you want to be born into if you’re behind a veil of ignorance? If you don’t know where you’re going to stand on the health scale, wouldn’t you choose a world where everybody is actually healthy?” I think that fundamentally has deep, profound appeal. 

The reason we – again, capital W "We," meaning all of society – accept that inequality exists is because we don’t understand that it is changeable. Now, we – small w "we" in public health – do understand that. And if we fail to communicate that, then it is our shortcoming. 

My challenge to public health audiences is often this: if we in public health don’t communicate that, then who else will? Whose job is it? Before COVID, leaving COVID aside completely, American life expectancy had dropped year over year for three years in a row. It was the first time that had happened since the 1918 flu pandemic. And yet, in public health spaces, I would often hear: “Well, there’s opposition. There’s a spirit of individualism. Americans don’t believe in this or that.” My challenge to public health is: whose job is it but ours to change that? It is our job to change that. 

So Cathy, I think this notion is accepted in broader American society because it’s not understood that it’s a matter of political will to change it. And I think it’s on us to communicate that. 

GEORGES: Well, I’ll tell a story. I remember being the health commissioner in D.C., and the Queen of England – I've told this story before – came to D.C. on a royal visit. Later, it was time for the obligatory trip for some of the lower-income community kids to go to London. These kids were excited, you know, and I happened to be in the office of the chair of the health committee of the city council. 

Some of these kids were in his office, and after they went off to lunch, we started talking. I was articulating what a wonderful trip I thought these kids were going to have. Honestly, I was trying to figure out how to get myself invited on the trip. I was talking about how they were going to see the Queen, see Buckingham Palace, see all the things I had aspired to see in Britain. 

And then I realized I was having a one-way conversation with the chair of the committee. So I said, “Okay, what am I missing?” 

And he said, “You don’t get it, do you?” Of course I didn’t. He explained to me that these kids weren’t excited about going to London. Washington, D.C., is a city 10 square miles in size. These young people live in Wards 7 and 8, east of the Potomac River, the most impoverished part of the city. 

From where they live, National Airport – which many of you know, if you’ve been to D.C., is right outside the city – literally less than a mile away. But all these kids see from their homes is a plane coming over the horizon as it takes off. So, in a city just 10 square miles, these kids had never been to the airport. 

They had no concept of what an airport was or what getting on an airplane would be like. They were excited about going to the airport itself as their big experience. Now, of course, once they got to London, they had a great time and brought that experience back home. But the point I’m making is the hopelessness and helplessness we’ve built into our society, where people don’t have any experience outside a small area. 

When you talk to those kids, many of them don’t think they’re going to live to adulthood because of the problems they face in their communities. They’re living a full life now, like someone with a terminal disease. They’re going to buy gold chains. They’re going to get pregnant. They’re going to risk HIV/AIDS because they don’t believe they’ll live long enough for AIDS to even express itself. 

And in that way, they understand their reality. They’re better epidemiologists than we are. We have to make sure we help build these communities and invest in the people living there so there’s less hopelessness. 

By the way, I’m talking about these kids in D.C., but this is the same for rural America, the Appalachians, rural Mississippi, Hispanic communities in the Southwest. In so many of these places, we have not invested in the way we need to. People in these communities need to feel like they have a future, that they’re part of something moving forward. 

I think public health plays an enormous role in making that happen. And I think that’s our central challenge. Over the next four years, that is absolutely our central challenge: making those folks feel like they are part of the collective. 

SANDRO: I couldn't agree more.  

CATHY:  Absolutely. It's by public health touching every part of our society and every part of that system. We have such a responsibility to change that. 

I want to make sure I bring up one of the questions that’s come into the chat before we start to wrap things up. The question is about maternal mortality. Should it be a policy priority, or rather, why isn’t it? The United States ranks poorly in maternal mortality, and there are many areas where the U.S. is simply falling behind other Western countries in major markers of health. Where should we prioritize? 

GEORGES: Yeah, you know, we’ve done this a lot. I remember the Bush administration doing the Healthy Families Initiative. There have been so many maternal and child health initiatives in our nation, and yet we continue to fall far behind. 

Let me just start by saying that a third of our counties in this country don’t have access to reproductive health care. A third of the counties. And I think that’s a problem. I’m not talking about abortion per se. I’m talking about any type of OBGYN services, clinicians that provide reproductive health services to women. 

We’re not paying enough attention in our delivery systems. We just haven’t focused enough on either the acute care side of this or the prevention side of this. And yeah, it’s a crisis, and it’s a growing crisis. Add to that the most recent Dobbs decision, which has exacerbated even the acute care part of reproductive health care. That’s a problem, and we’re going to have to address it, and address it soon, because these are lifelong problems for those children born with a range of challenges and disabilities. And with maternity itself now becoming a death sentence for women, we have to fix this. 

SANDRO: Yeah, I’m always a little bit uncertain about how to address the “What is the priority?” question because I actually think there are a lot of important issues, and different outcomes are differently important to different people. I feel like perhaps a better approach is to lay out the spectrum of challenges facing health and to say that our work on any and all of these is important. We should act pragmatically where we can make a difference on any number of these areas. 

That ranges from what Georges mentioned to the ongoing threat of pandemics and infectious diseases, to the many downstream consequences of climate change, to the unconscionable gaps in health achievement between group, marked by racial, socioeconomic and educational status. Then there are the mental health challenges that are increasingly recognized as a real concern, particularly by younger generations, and which disproportionately affect people with fewer assets and lower socioeconomic status. 

All of these are critical to the health of the nation, not to mention globally, because that’s something else we could talk about. I think they all need to be part of the vision of public health. We need to ask, where are the opportunities? 

The last election was an interesting example of this. We saw the Republican Party brought back to power after four years. We also saw a number of state-level legislative votes that were very clear endorsements of positions directly in contrast with Republican party positions. I think that showed there are opportunities to act in particular areas to advance public health goals. We need to be principled, but also pragmatic. 

CATHY: I’d like to turn the conversation now, as we start to end our time together, to what you’re optimistic about. What are you excited about for public health going forward? We deal with such serious issues. We ask people to face things they often don’t want to face. Then on a practical level, I knew someone who worked in a public health department who once said the problem is that we take the fun out of life by telling people what not to do. 

This is now an opportunity to reframe that, to think about what we’re excited about and put public health in the most positive light. How do we make people excited about public health? I think that’s an important part of the message too. 

SANDRO: Public health is a story of success and triumph. The sentinel achievement in human history has been the doubling of life expectancy over the past 150 years. Nothing else compares. Life expectancy globally went from 40 years to about 80 in high income countries. That is extraordinary. That’s the triumph of public health. 

It is a healthier and better time to be alive than any other time in human history, despite setbacks. Public health needs to lean into its role as creating freedoms – freedom from unnecessary disease and disability. We should not allow ourselves to be put in the box of being against freedom. A lot of the public health agenda is predicated on a health and human rights framework. The central tenet of human rights is individual autonomy. Individual autonomy means freedom. 

We’ve allowed the narrative to be sidetracked. Fundamentally, public health is about creating joy and bringing opportunities for everybody to live rich, satisfying, full lives. We should be about joy, not the opposite. 

GEORGES: I would agree. We often get so bogged down solving problems and don’t spend enough time talking about our triumphs or telling our own story. Far too often, the story is about boiling water today or wearing masks because there’s a wildfire. Instead, we should be saying: “You know, for the last 20 days, nobody fell. Nobody got injured. Nobody got sick at a restaurant.” 

We’ve got to tell our own story. We’ve allowed others to tell our story, and we need to take that narrative back. Public health is both a best buy and a top national value. That doubling of life expectancy and how it happened, that story has been lost to history. Only we know it, and we need to tell it. 

By the way, medical cure people do that all the time: “We gave these people this drug and cured XYZ disease.” “We replaced a hip, fixed a heart.” People love those stories.  We don't get out and champion ourselves as much as we need to. 

SANDRO: You can get into your car and not unduly worry about dying every time you drive because we’ve created safer cars and rules against drunk driving. You can eat food without worrying about getting sick. You can breathe the air without worrying about it giving you bronchitis or exacerbating your asthma. You have laws that allow you to go to work without fear of being injured and incurring a lifelong disability. These are the conditions that we live in. 

These are freedoms from unnecessary disease and public health made that possible. Georges’ point about framing public health as a “best buy” is critical. We just need to be better at telling this story. 

CATHY:  I think so. That was certainly one of the objectives here, to think about it. I'll share with you some thoughts I have around opportunities ahead. One, I think we're going to start talking about public health in a way that we've never talked about it before. Because people are going to bring up things about vaccines. They're going to talk about preservatives and foods that they've taken for granted. I think it's going to take center stage. In many cases, we've taken public health for granted.  

We get in the car, we put the seatbelt on. Now, we’re going to have a chance to start talking about things that we just assumed were settled science again. This is an opportunity for us as a field to start thinking about how we're going to do that. This will be an opportunity that we haven't had in the past to talk about public health at the dinner table, to talk about it with our neighbors. 

I think we should really embrace that opportunity. Some of the [Trump public health] appointees like to be in front of a camera and talk about  things that we might otherwise just disagree with. But we're now going to be able to enter into a thoughtful conversation and establish a baseline where we haven't had it before. 

So that is one of the things that I'm excited to have the opportunity to do. We also have an opportunity to embrace new technological methods, so that public health really becomes a much better science, a science that is on par with other sciences across the board. 

And I think now, we have a chance to communicate in a way that people can understand. So we'll be given that opportunity. We have the opportunity now to be even better than before, and we understand the importance of communicating. Not just assuming people will go, “Of course, I need to get a vaccine.” 

So as we close out, what would you like the audience to take away?   

GEORGES: Let me start by just saying that our  future is bright. I think that we have an enormous opportunity to move our nation forward. We're coming out of a pandemic. It has been a tough four years. There's no doubt about that. But we have an opportunity to move the nation forward in ways that I think others have not recognized. There's an opportunity for public health to say, first of all, “We are the nation's chief health strategists.” 

We need to own that. That's our job, to be the nation's chief health strategists. Whether you run a health department or work at a nonprofit organization, you have to make sure that you're the voice of reason, the adult in the room, using the best evidence and best science that’s known.  

We also should redefine ourselves in the minds of the public as the best listeners in the community: “We're here to listen to you,  and we're here to work with you  to achieve optimal health.”  If we can achieve those three things – owning that we're the nation’s chief health strategist, thinking about it every day, and making clear to the community that we're here to listen and help them achieve their goals – I think we'll be most successful.   

SANDRO: Yeah, I think that's right. The future is bright. I really love how you led with that, Georges. It is an important time for public health. Look, it's been a rough 10 years. 

The rise of social media – along with political approaches that divide populations – threatened the collective fabric that public health needs to do its work.  

I think it's taken us a while to see this clearly. But I think this is a pivot moment where we are reimagining public health, reimagining what to say, reimagining how to communicate. Part of that is leaning into the positive.  

Not only do we want to be the healthiest nation in one generation, we want to be healthier tomorrow. Public health is going to make that possible. And we want to create a big tent in order to do that. We’re vigilant for potential threats, but ultimately, I think we should lean more into opportunities. This is a really interesting and important moment for public health.  

CATHY: Georges, did you want to add anything to that?  

GEORGES: To the extent that we can be part of helping to re-achieve societal cohesion, we need to do that.   

CATHY: It looks like one of our audience members is going to supply you with some personal stories about how and where the medical science community has succeeded.  I agree that this is an exciting time for public health. This is a time to be very, very optimistic. We're actually being handed an opportunity.   

You can't tell your good breaks from your bad ones, unfortunately, in life. This may be our opportunity to take a step forward in educating those around us, to embrace the community, to infuse public health across the  community and see it accepted as a friend, not a foe.  

We have a nice comment in the chat that says, “Heartened by the professional and positive approach.” Any final thoughts from our audience in terms of what you would like to put before the panel? 

GEORGES: November 25th was Public Health Thank You Day. I just want to take the opportunity to thank  our public health workers for the extraordinary work that you do, and for your leadership. We here at the American Public Health Association salute you and everything that you do. So I thank you. And, of course, to my good friend and colleague,  Dr. Galea and to you, Dean Bradley, thank you for the opportunity to be here today.   

SANDRO: I will simply echo that. First of all, it's a privilege to be here. I want to thank the Institute for inviting us and Kathy for your moderation and Georges, as always, for the privilege of conversation.  

It's conversations like these that fill me with hope. It is how one shifts the conversation. I believe in the importance of these conversations. It's a conversation between three people with another 50 people in the room. Then another 50 people in the room. Then another 50 people in the room. That is how we change our collective thinking and make the world better than it used to be. It will be better even in the coming decade. We’re at a pivot point now. It's a moment that's making a lot of us pause and reflect, and that's okay. That's a good thing.   

CATHY: I agree. I appreciate you both for your insights, your perspectives, for bringing us back to the stories of public health. It's not all over. That this is an opportunity for us in how we move forward. So, I think that's a great place to close out. 

For more on this series visit our 2024 Symposium page.