How To Make America Healthy Again

Summary

GD Politics Podcast: How To Make America Healthy Again

Host: Galen Droug
Guest: Sandro Galea, Dean of the School of Public Health at Washington University in St. Louis
Release Date: July 14, 2025

---

In the latest episode of the GD Politics podcast, host Galen Droug delves into America's pressing health issues with esteemed public health expert Sandro Galea. Titled "How To Make America Healthy Again," the episode scrutinizes the Trump administration's approach to public health, explores the intricacies of health policy, and discusses the politicization of health information. Below is a comprehensive summary capturing the episode’s key discussions, insights, and conclusions.

1. America's Health Conundrum

The episode opens with Galen Droug highlighting the stark realities of America's healthcare system.
Galen Droug [00:50]: “We spent nearly 18% of GDP on health in 2023. The average per person was $13,400, roughly double the amount spent in comparable countries.”

Despite this hefty expenditure, health outcomes lag behind:

• Life expectancy: 78 years at birth, about five years shorter than similar nations.
• Obesity and Diabetes: Nearly 75% of Americans are overweight or obese, with 12% suffering from diabetes.

Galen emphasizes that the Trump administration's initiative to "Make America Healthy Again" (MAHA) seeks to address these issues, despite criticism over policy changes and perceived shortcomings.

2. The MAHA Report: Framing the Problem

Galen introduces the MAHA report, which bluntly assesses America's health challenges:

• Poor Diet: Shift towards ultra-processed foods resulting in nutrient depletion and increased caloric intake.
• Environmental Chemicals: Rising exposure to synthetic chemicals linked to developmental issues.
• Lack of Physical Activity and Chronic Stress: Contributing to obesity, diabetes, and mental health challenges.
• Over-Medicalization: Excessive prescribing of medications leading to long-term health risks.

Galen Droug [04:35]: “Poor diet, aggregation of environmental chemicals, lack of physical activity and chronic stress, and over-medicalization are the four main issues.”

3. Sandro Galea’s Perspective on MAHA

Sandro Galea agrees with the report's framing of America's health issues but critiques its execution: Sandro Galea [07:25]: “The framing of the problem is largely right. We spend more and get less. It’s hard to think of other sectors where we spend so much and deliver poorer outcomes.”

He acknowledges that while the report correctly identifies key problems, some connections (like screen time’s impact on health) need more robust evidence.

4. Coalition Behind MAHA: A Mixed Bag

The MAHA movement has attracted diverse groups, creating both opportunities and challenges: Sandro Galea [07:59]: “It's terrific to see so many groups engaged. However, the coalition is a motley crew, bringing together disparate interests, which can be problematic.”

Galea notes that prominent figures like RFK Jr., despite his controversial stances, help amplify the movement’s visibility.

5. Health vs. Healthcare: Shifting the Conversation

A significant portion of the discussion focuses on the distinction between health and healthcare. Galea argues that political discourse often conflates the two: Sandro Galea [10:23]: “Health is about the collective conditions that keep us healthy. Healthcare is about treating illness. We need to shift the conversation towards health policy.”

He emphasizes that healthcare is just one component of overall health, advocating for policies that promote healthier living environments.

6. Policy Changes Under MAHA: Expectations vs. Reality

Galea reviews policy changes proposed by the MAHA initiative, praising its conceptual direction but noting a lack of specific implementations: Sandro Galea [20:10]: “Thinking about the foods we subsidize and reducing calorie-dense, nutrient-poor foods are good ideas. These are signposts of where the administration wants to go.”

However, he points out that concrete policies and regulations are still in flux, leaving room for uncertainty.

7. Impact of Policy Shifts on Healthcare Access

Galen raises concerns about the reconciliation bill's implications for healthcare coverage: Galen Droug [21:22]: “Estimates suggest 12 to 16 million people could lose Medicaid or ACA subsidies, leading to decreased population health.”

Galea explains that uninsured individuals may rely on emergency departments without receiving preventive care, exacerbating public health issues: Sandro Galea [21:22]: “Lack of insurance is associated with poorer health outcomes. It means less preventive care and earlier disease detection.”

8. Vaccine Policy Changes under RFK Jr.

A heated segment addresses changes to vaccine recommendations and the politicization surrounding them:

• Replacement of the Vaccine Advisory Board: Revocations of booster recommendations for healthy young people and pregnant women have sparked controversy.
• Rise in Measles Cases: The U.S. is experiencing a 33-year high in measles, correlating with declining vaccination rates.

Sandro Galea [27:41]: “Removing required COVID shots for children mirrors European approaches, which have different healthcare outcomes.”

He stresses the importance of nuanced discussions over sweeping policy changes: Sandro Galea [27:41]: “We need careful, diligent conversations rather than blunt policy shifts that undermine scientific consensus.”

9. The Politicization of Public Health

The conversation shifts to the broader issue of politicization within the public health ecosystem: Galen Droug [33:26]: “A Harvard poll found that 44% of the public distrusts health recommendations from federal agencies under new leadership.”

Galea distinguishes between politicization and partisan divides: Sandro Galea [33:26]: “It’s more about partisan and ideological divides than politicization per se. Public health inherently intersects with politics as it involves societal structures that determine health outcomes.”

He underscores that ideological rigidity hampers collective efforts to improve public health: Sandro Galea [35:42]: “Sharp ideological divides make collective action difficult, which is detrimental to public health.”

10. Rebuilding Trust in Public Health

Addressing the erosion of trust, Galea outlines pathways to restoration: Sandro Galea [39:55]: “Regaining trust requires showing that public health has learned from past mistakes, engaging in honest conversations, and being transparent about uncertainties.”

He advocates for multifaceted communication strategies that emphasize shared values and collective health aspirations: Sandro Galea [41:13]: “We have to present what we know and don’t know, balancing promoting health without overstepping personal autonomy.”

11. Drawing the Line: Settled vs. Unsettled Science

The episode concludes with a philosophical exploration of how to distinguish between settled and unsettled scientific knowledge: Galen Droug [47:35]: “In fragmented media and scientific environments, determining which facts are settled is challenging.”

Galea proposes that societal consensus and ongoing dialogue are essential for delineating scientific boundaries: Sandro Galea [48:43]: “Lines are drawn through social conversation and multiple inputs. It’s a collective, evolving process.”

He warns against premature consensus or perpetual doubt, advocating for a balanced approach that allows for adaptability as evidence evolves.

Key Takeaways

• Holistic Health Approach: Emphasizing that health is a collective responsibility extending beyond mere healthcare access.

• Policy and Structure: Recognizing that societal structures, influenced by politics, play a crucial role in determining public health outcomes.

• Nuanced Vaccine Policies: Advocating for evidence-based, nuanced discussions around vaccine recommendations rather than politicized mandates.

• Rebuilding Trust: Acknowledging the need for transparency, honesty, and inclusive dialogue to restore public trust in health institutions.

• Dynamic Knowledge Assessment: Understanding that scientific knowledge is continually evolving, necessitating adaptable and collective decision-making processes.

Notable Quotes

• Sandro Galea [07:25]: “We spend more and we get less. It’s hard to think of other sectors where we spend so much and deliver poorer outcomes.”

• Sandro Galea [10:23]: “Health is about the collective conditions that keep us healthy. Healthcare is about treating illness. We need to shift the conversation towards health policy.”

• Sandro Galea [21:22]: “Lack of insurance is associated with poorer health outcomes. It means less preventive care and earlier disease detection.”

• Sandro Galea [33:26]: “It’s more about partisan and ideological divides than politicization per se. Public health inherently intersects with politics as it involves societal structures that determine health outcomes.”

• Sandro Galea [39:55]: “Regaining trust requires showing that public health has learned from past mistakes, engaging in honest conversations, and being transparent about uncertainties.”

• Sandro Galea [48:43]: “Lines are drawn through social conversation and multiple inputs. It’s a collective, evolving process.”

---

This episode of GD Politics offers a profound exploration of America's health landscape, dissecting policy initiatives, ideological influences, and the delicate balance between individual autonomy and collective health responsibilities. Sandro Galea's insights provide a roadmap for navigating the complexities of public health in a polarized political environment, emphasizing the need for informed, inclusive, and adaptable approaches to foster a healthier America.

Transcript

[Galen Droug]

What are the challenges of a politicized public health ecosystem?

[Sandro Galea]

I think I will approach that by challenging the notion of politicized, because I don't think you mean politicized. I think you mean partisan and ideologically driven divides in the ecosystem, which I think is different than political. By political, what I mean is understanding that the decisions we make as a society about how we structure the world we live in matters.

[Podcast Host]

Hello, and welcome to the GD Politics podcast.

[Galen Droug]

I'm Galen Droug.

[Podcast Host]

There's little doubt that America faces a health conundrum. We spent nearly 18% of GDP on health in 2023. The average per person was $13,400, roughly double the amount spent in comparable countries. Meanwhile, the results are lacking. American life expectancy at birth is 78 years, about five years shorter than the average of similar countries. And nearly 75% of Americans are overweight or obese or with 12% having diabetes. I could keep citing statistics, but you get the point. The Trump administration has set out to, in its own words, make America healthy again. And while the similarly named commission's first report got a lot of attention for faulty citations, it's also surprisingly blunt about some of the challenges the country faces, perhaps more so than any other recent administration. That blunt assessment, though, has been paired with changes that critics say pose more.

[Galen Droug]

Challenges to American funding.

[Podcast Host]

Cuts to the Food and Drug Administration, cuts to research on things like the impact of chemicals on health, changes to eligibility for Medicaid, food stamps and Affordable Care act subsidies, and replacing the vaccine advisory panel at the cdc. So American health finds itself in a position not so different from other issues under Trump. An administration that is more candid about naming the problem than many others in politics, but with some controversial and even self defeating solutions.

[Galen Droug]

Here with me to talk about it.

[Podcast Host]

All is the dean of the School of Public Health at Washington University in St. Louis, Sandro Galea. He's authored many books and also writes about public health on the substack, the Healthiest Goldfish. Sandro, welcome to the podcast.

[Sandro Galea]

Thank you for having me, Galen.

[Podcast Host]

So first, I want to ask if.

[Galen Droug]

You agree with my framing of the Trump administration's approach to to health.

[Podcast Host]

Blunt in naming the problem, but controversial.

[Galen Droug]

Or even self defeating in its solutions.

[Sandro Galea]

Yeah, I thought that was actually a very nice summary. Making America healthy again is a terrific idea. I welcome it and I think many of us welcome it. And in fact, many of us have been writing about the need to make America healthier for many decades. So it's really refreshing, actually, to see the administration taking a clear eyed view on the fact, which I think you summarized quite nicely in your introduction, that we spend far more on health than we get out of it. I've previously written about this under the sort of title of an unhealthy mismatch. We spend more and we get less. I've often challenged audiences when I speak or in my writing to think of another sector where we far outspend our next closest high income country competitor and deliver less. In fact, it's actually hard to think of other sectors where we I think it's acceptable to spend as much as we do and to have outcomes that are nowhere near as good. So the notion that we should make America healthy is a terrific notion and should be applauded.

[Galen Droug]

If folks have heard about that Maha report, it might be about some faulty citations or maybe some of the things.

[Podcast Host]

That were more controversial around vaccines. But when I started reading it, I.

[Galen Droug]

Thought, wow, you know, like when Michelle Obama started talking about healthy food and.

[Podcast Host]

Labeling added sugar, she sparked a backlash.

[Galen Droug]

From the right and parts of the food industry.

[Podcast Host]

And here's a commission led by the.

[Galen Droug]

Secretary of Health and Human Services of.

[Podcast Host]

A Republican administration really just laying into America's health problems.

[Galen Droug]

And so I want to read a little bit from that report. This is going to take a second, but I think it's worthwhile so that.

[Podcast Host]

Folks get a sense of the problem.

[Galen Droug]

As the Trump administration sees it in its own report addressing children's health. So here's how they lay it out.

[Podcast Host]

First, poor diet. The American diet has shifted dramatically toward ultra processed foods, leading to nutrient depletion, increased caloric intake and exposure to harmful additives. Nearly 70% of children's calories now come from ultra processed foods, contributing to obesity, diabetes and other chronic conditions. Next, aggregation of environmental chemicals. Children are exposed to an increasing number of synthetic chemicals, some of which have been linked to developmental issues and chronic disease. The current regulatory framework should be continually evaluated to ensure that chemicals and other exposures do not interact together to pose a threat to the health of our children. Third, lack of physical activity and chronic stress. American children are experiencing unprecedented levels of inactivity, screen use, sleep deprivation and chronic stress. These six factors significantly contribute to the rise in chronic diseases and mental health challenges. And fourth, over medicalization, There is a concerning trend of over prescribing medications to children, often driven by conflicts of interest in medical research, regulation and practice. This has led to unnecessary treatments and.

[Galen Droug]

Long term health risks. Those are the four main issues as they lay them out.

[Podcast Host]

They also go on to talk about.

[Galen Droug]

The Threats to children's health from industrialization.

[Podcast Host]

From corporate capture of agencies. They call out sugar over and over again. At one point citing quote, a recent study published in Nature Medicine estimated that sugar sweetened beverages alone may be responsible for about 1.2 million new cases of heart disease and 340,000 deaths worldwide in 2020 alone.

[Galen Droug]

What do you make of that framing of the problem from that MAHA report?

[Sandro Galea]

I think the framing of the problem is largely right. I don't think there's anything new in that framing. And don't get me wrong, actually I do not mean to minimize the importance of the MAHA report highlighting it. I actually think that the report is correct that sedentary lifestyle, that ultra processed food, calorie dense, nutrient poor food are contributing to obesity, which contribute to a whole range of diseases. I think the report is correct that sugar sweetened beverages are a part of that. I think the report is correct that we can and should do better. You know, you get into some of the details and the report does connect many dots that are not so clear about the dot connection. For example, the evidence on some of the food additives is nowhere near as robust on evidence on other pieces. The evidence on, for example, things like screen time and its association with young people's health, while wildly speculated on, the evidence is not so clear. But that's around the margins. I don't want to take away from the fundamental point that the report's diagnosis is correct.

[Galen Droug]

It seems like the MAHA movement has made for some strange bedfellows, right? I mean, it has, it has. Republicans in Congress more frequently represent the interests of big agriculture or the food.

[Podcast Host]

Industry, some of the interests of pharma. And this report flies in the face.

[Galen Droug]

Of some of those interests. And we even heard some pushback from some congressional Republicans when this report came out. How does this coalition of the Make America Healthy again strike you like who?

[Podcast Host]

Who's a part of this?

[Guest Expert]

Yeah, it is at some level terrific to see so many groups engaged in this question. It for those of us who've been in this space, and by this space, I mean this space of the health of populations thinking about the fact that America's not as healthy as it should be. We have been writing and thinking about this for about a couple of decades and to see these groups come together and coalesce around this is a positive. It's a really good thing for the country. It's a good thing for the world. Now at another level, the fact that it is a bit of a motley crew of groups that have come Together represents a failure of mainstream health because we have not given mainstream health the opportunity to see what they really want, which is fundamentally healthier country, for their children to come to fruition. Now, we could say all we want, that we've been agitating for it, advocating for it, but we have not been heard. RFK Jr. To his credit, has been heard, and he has been able to put himself in a position where a lot of these folks, and a lot of it actually comes. Here's this movement, the Maha Moms movement. Parents of young children who want the children to be healthier see this as a moment in time, opportunity to create a healthier world for their children. All of which is to be applauded now that it had to take someone like RFK Jr. Who also has, as I'm sure we're going to get to in a second, quite dubious positions, and has been public about a number of positions that are really challenging to pretty well established scientific consensus. To bring these groups together is problematic. I'm not sure exactly what it says about the moment we're living in, but I'm trying to extract from the moment the positive. The positive is these issues are more visible than they have been in the past quarter century, and it is outstanding that we're discussing them.

[Galen Droug]

We're going to get into some of the specifics of the policy actually enacted. But I want to focus on something that you've written a lot about first, which is that America's obsession with health care in some ways misses the point of health. Right? The goal is for Americans to be healthy. But so often the political conversation solely focuses on access to care once Americans are already sick. Why haven't we talked more about health as part of the political conversation heretofore?

[Guest Expert]

I think there are several reasons for that. First of all, it's important to remember that we used to talk more about health. If there was a Surgeon General's report, which came out under a surgeon General, Jerome Adams, and in it there is.

[Sandro Galea]

A very nice graph that showed that.

[Guest Expert]

Until the 1960s, that conversation, and they.

[Sandro Galea]

Did an analysis of things in newspapers.

[Guest Expert]

Et cetera, the conversation was much more.

[Sandro Galea]

About health than it was about healthcare. And then it flipped and it became much more dominantly about healthcare, about the.

[Guest Expert]

Individualized approach to cure rather than a.

[Sandro Galea]

Collective approach to keeping us healthy.

[Guest Expert]

Many reasons why that happened. I think there was a rise, a very prominent rise of organized medicine. Medicine became much more prominent. There were successes of medical care, which are stories that are easy to tell, stories that are compelling. We all know Someone who has been helped by excellent medical care.

[Sandro Galea]

We all hope to be helped by excellent medical care when we need it.

[Guest Expert]

And I think there was a rise in.

[Sandro Galea]

Coupled in general in the country with.

[Guest Expert]

A much more individualistic focus on. It is ultimately about me and about treatment in me. The problem with that is that it misses the larger point that no matter how good the treatment for me is, I would rather just be healthy and not need treatment to begin with. And that's what we have lost in this whole transition. You know, I've used many metaphors for this, but just to use a. A very simple one just to get us started.

[Sandro Galea]

You know, medicine is curing you when you're sick the same way as your car mechanic is fixing your car when your car is broken. But you would rather just be driving your car in good roads that the car doesn't get broken to begin with.

[Guest Expert]

And that's what we have lost.

[Sandro Galea]

We have focused all our attention on.

[Guest Expert]

The fixing rather than thinking about how.

[Sandro Galea]

To stay healthy to begin with.

[Galen Droug]

And in fact, this is the metaphor of your substack, right, the healthy goldfish, which is you can sort of feed the goldfish and put it in the right light and pay attention to it and whatnot. But if the water that the goldfish is swimming in isn't changed or isn't kept fresh, that the goldfish isn't going to be healthy. And in some ways the health environment that we are in as Americans is the water that's correct.

[Sandro Galea]

And even more so in part, and you know, some of this is sort of. Many people have written about fish and David Foster Wallace is a very nice metaphor, had a nice metaphor on this as well, is the water is literally invisible to us. Right. Because it's all around us. So the reason I like that metaphor of water is because you tend to forget it, because it is everything around us, whether you and I are healthy, Galen, is because the food we have available to us, the air we're breathing, the water we are drinking, the fact that each of us in our own spaces are in safe environments, that we're not worried about violence when we step outside, these are the reasons we are healthy. And one tends to forget that. We tend to forget that's what's keeping us healthy. And we only think about our health when all of a sudden something goes wrong, which is why we have as a society over leaned on medicine, because that's when we think about health.

[Galen Droug]

Yeah. You know, this is something that I've noticed in politics as well.

[Podcast Host]

In fact, the only two Presidential candidates.

[Galen Droug]

I guess, during the time that I've been paying attention to this, that I've.

[Podcast Host]

Ever really heard talk about America's health.

[Galen Droug]

Explicitly and not just healthcare. Or were Mike Huckabee during the Republican primary in 2016 and Marianne Williamson during the Democratic primary in 2020.

[Podcast Host]

And so it comes up, but it's.

[Galen Droug]

Oftentimes from more marginal characters in American politics. And I guess you could say that RFK Jr. Is also a more marginal character.

[Podcast Host]

But even folks like Bernie Sanders who.

[Galen Droug]

Make, you know, healthcare a prominent part.

[Podcast Host]

Of their agenda or others don't really talk about health. I mean, is there a sort of weird incentive structure that prevent ambitious politicians from talking about health?

[Sandro Galea]

I'm not sure about incentive structure as much as I think it's a. It's a misunderstanding. In one of my books, I pose readers the challenge, what I call sort of the dinner party challenge, to say to readers or listeners when you're having a dinner party next and start a conversation about health. You know, you can use this podcast as a. I listen to this podcast. This is what health. And start a conversation and check how long it takes for somebody to use the word healthcare interchangeably with the word health. And it's always under five minutes. Somebody will inevitably say healthcare, when actually what they mean is health. So I think it's deeply ingrained, and I actually think that maybe you mentioned Bernie Sanders is a good example. I think figures like Senator Sanders, who have spent a long time and I think have thought deeply and carefully about how to make healthcare better, almost lose sight of the fact that healthcare is downstream to what we fundamentally need to do, which is to make us all healthy. And, you know, we tend to think about, for example, healthcare policy. Well, we should be thinking about health policy, some of which relates to healthcare, but some of which relates to all the other structures in the world around us. So it is a. A frame shift. It is a frame shift in how we think. In one of my books, which was called, well, the subtitle of the book is what we need to Talk About When We Talk About Health. Now, that was actually the title I wanted for the book, but the publisher said, well, nobody's going to read a book with such a long title, which is perhaps wise. But the subtitle was very intentional. Because what I've been trying to do is to shift what we talk about when we talk about health. And what we should talk about when we talk about health is, yes, healthcare. And I don't want to be misunderstood. Nothing that I've ever written or said is in opposition to the importance of healthcare. When I am sick. When you are sick, we want excellent healthcare, so we should be very clear about that. But I would rather not to be sick at all. So I would like to invest in a world which keeps me as healthy as possible for as long as possible.

[Galen Droug]

Yeah, I'm not trying to, you know, name drop or anything here, but.

[Sandro Galea]

But go ahead.

[Galen Droug]

I went to undergrad at Johns Hopkins, so I was surrounded by public health students and pre med students. I was not one of them, but I ended up in an economics of health class because I had to, you know, take a certain number of econ classes. And that seemed like a good enough option.

[Podcast Host]

And one of the challenges of the.

[Galen Droug]

Economics of health is that unlike other markets, you can't purchase health, which you.

[Podcast Host]

Can purchase is healthcare.

[Galen Droug]

And so when we talk about the economics of health, we end up talking about the economics of healthcare. But that's not actually like, usually in a marketplace, you're purchasing the thing that you actually want, like a house or, you know, a dog or a car.

[Podcast Host]

But in the healthcare economy, you aren't.

[Galen Droug]

Purchasing the thing that you want because it's not for sale. Health. Right. You're actually just purchasing healthcare.

[Sandro Galea]

No. And what you will hear from many of us who are in the population health space are things like health in all policies, for example. And what that approach, which has been around now for about quarter century, says, is that we need to recognize that. So therefore, we need to make sure that the Ministry of Finance, the Ministry of Housing and Urban Development, the Ministry of Sanitation, or whatever office it is, recognizes that what they do has implications for our health. And the only way to really create a healthier society is by making sure that all these other sectors do things that align with creating a healthy world. There have actually been some formal examples where this has been attempted. For example, New Zealand passed at one point a few years ago a wellness budget. And you can look this up, you can find this where all the various ministries were charged with making sure that their budget aligned with some national priorities, one of them being creating national wellness. So that means the Ministry of Finance is asked, well, if you want to do that, how is it aligning with wellness? Ministry of Transportation says, if you want to do that, how is it aligned with wellness? And that is, I think it's an interesting formal experiment for how one aligns this. And I've come to think that you do need to do that, and you also need to shift the national conversation. You know, we've done studies for Example, Galen, where we ask people, and these are in large population surveys, to say, what do you think matters most for your health? And we give people a whole bunch of things. The most common answer people agree to matters most for their health is healthcare. That remains the commonest thing that people say. The least common thing that people check off is politics. Now, if I were to answer that, I would actually put politics first because I actually think politics matters more for my health and for your health than does healthcare. Why is that? Well, because politics determines the world in which we live. Politics determine whether the air I breathe, the water I drink, the food I eat, whether all that is healthy. Politics will determine whether or not I'm actually at risk of violence by walking outside my door. Politics determine whether or not I can afford a house. Politics will determine whether or not I have a livable wage. All of these flow from politics. Now, again, this is not an either or argument, this is an and argument. And what I've been trying to do in my writing is to shift our understanding of health away from just healthcare towards a much more holistic view of what generates health.

[Galen Droug]

I want to get into some of the challenges once public health starts more explicitly engaging in politics, but first let's get to some of the specifics. So are there places where you see sort of policy changes that, that align with either Maha's health goals or what you think should be the health goals at the state or national level currently? We'll talk about the positive first. The next question is about the most recent reconciliation bill.

[Podcast Host]

So are there at the federal level.

[Galen Droug]

Or even just at the state level, movements towards a healthier society under this administration?

[Sandro Galea]

Yeah, I actually think that a lot of what is stated in the Maha report. Now, the Maha report is heavy on concept and light on specifics, but I think the idea of thinking about the foods we subsidize, I think the idea about thinking and taking a careful look at when we medicalize sufficiently, when we over medicalize, I think the idea of shifting away from calorie dense, nutrient poor foods, these are good ideas. So insofar as they are at least they are signposts of where the administration wants to go. That's a good thing.

[Galen Droug]

Okay. But not specific policies that have been implemented at this point or new regulations or whatnot.

[Sandro Galea]

Well, we are in a very policy fluid moment, as we know.

[Galen Droug]

Fair enough, fair enough. Okay, so let's talk about that reconciliation bill, which also means talking about healthcare specifically. The estimates are that the new eligibility requirements for Medicaid and ACA subsidies could lead to between 12 and 16 million people losing coverage. Once that's implemented, that number gets tossed around a lot. But I want to dig a little deeper. What happens when people who aren't insured need healthcare attention?

[Sandro Galea]

Well, when people who aren't insured have emergencies, they go to emergency departments and emergency departments will take care of anybody. And so we as a country fortunately will stabilize anybody who comes to the emergency department. What happens is that all of a sudden after that, people then fall through the cracks. People are not connected to healthcare providers. People don't get follow up. People don't have healthcare providers who they can go to for routine preventive care. So a lack of insurance and the data on this are very clear that having access to healthcare, AKA through health insurance is associated with healthier people who live longer, healthier longer lives. It means getting better preventive care. It means getting better acute care when you need. It means getting screening for things like cancers earlier when you need it. So if the result of the current big beautiful bill is this 12, 16 million people who are going to end up uninsured, we are going to in the next five to ten years become a less healthy population. Now one thing that. Let me just add one thing to that, Galen, for a second because I think there is a danger when I say something like that of a listener saying, okay, but you know what, that's not about me. So I feel bad about that, but it doesn't really affect me. And I think it is important to recognize that whether we like it or not, unless you are going to wrap yourself in bubble wrap, your health and my health are interconnected. Now the most obvious example of that, by the way, was the pandemic that we just went through. If we ever needed a reminder that my health and your health are interconnected is recognizing that if you have a infectious disease that's spreading in one segment of population, everybody else is at risk. There are many other examples of this. So I want to move us out of thinking that the consequence of big beautiful bill are only for some people. Yes, some people are going to bear the brunt of them, but all of us are going to feel this.

[Galen Droug]

Wait, what do you mean by that? I mean one way that folks would argue that this affects everyone is that if hospitals are treating people who are sick in emergency rooms as opposed to through routine screenings or whatnot, ultimately those people aren't going to pay those hospital bills. So the cost is still on society to fund, but it's just going to be funding more emergency room visits than you know, the actual Medicaid that people were on, or the ACA subsidies or whatnot. And that ultimately this could have a negative effect on the budgets of the hospital system, which is why we saw $50 billion also appropriated to rural hospitals. So from a funding perspective, folks will make the argument that this ends up affecting everyone because you're going to have to pay for folks healthcare one way or another. But you're talking specifically about health, correct?

[Sandro Galea]

I'm talking specifically about health. I'm talking about the fact that we know there's plenty of studies on this, for example, that we are all less healthy if some of us are less healthy. That is true in terms of illnesses that are transmitted by particular pathogens, for example infectious disease. I already used that example. Illnesses that are transmitted through behavioral contagion. You are going to eat less healthy if your friends eat less healthy. You are more likely to smoke if your friends smoke. Which means that once you have one segment of society with particular behavioral patterns that are health harming, you're gonna have more people who are health harming. Another mechanism is through the system becoming unaccustomed to operating at a high level. For example, maternal mortality in this country. We know that moms die about four times the rate higher than in other high income countries, which is a real tragedy. We also know that particular groups, particularly minoritized groups, are more likely to have a higher maternal mortality. But we also know that moms who are among in the richest 1% of counties still die twice as much as mothers in comparable high income countries. Why is that? Because the system is actually not operating at a level that it could be operating to save lives. So some poor health among some of us affects all of us. And I think it's important just to remember that so that we do not approach the need to create a healthier world just from a place of charity. Yes, I think charity is important if some people are bearing the brunt of it more than others. But there's also a clear interest that we all have in being all healthier.

[Podcast Host]

Today's podcast is brought to you by you, the listener. This podcast is possible because of paid subscribers. At GDPolitics.com paid subscribers get access to about twice the number of episodes. They can join in our private chat and send in questions that we'll later answer on the show. And most importantly, they ensure that we can continue to try to understand politics and the world with curiosity, rigor and.

[Galen Droug]

A sense of humor.

[Podcast Host]

When you become a paid subscriber, you can also connect your account to wherever you listen to podcasts and never miss an episode. Join the GD Politics podcast community today at gdpolitics. Com in fact, go to GDPolitics.com right now and become a subscriber. We will still be here when you get back. That's GDPolitics.com and thank you.

[Galen Droug]

This ends up creating a very sort of structural view of health, which is has political undertones to it. And I really want to get to that part. But first, let's talk about vaccines because We've talked about RFK Jr. And his role in government so far, but some of the biggest news that he's made as Health Secretary is removing and replacing the Vaccine Advisory Board at the cdc. Now, that board is not responsible for approving vaccines, but for determining recommendations for who gets what vaccines when. One of the changes they've made is recommendations against healthy young people and pregnant women getting Covid boosters and that sparked lawsuits and whatnot. We also I just got an alert before chatting with you today from the Wall Street Journal showing that we're at a 33 year high in terms of measles cases and that vaccinations against measles have declined nationally.

[Podcast Host]

So healthy people not getting a Covid booster.

[Galen Droug]

You're the professional here. You can tell me how important that is. Doesn't seem like the sky is falling, but what do you make of these sort of broader changes to vaccine policy? What? Or attitudes towards vaccines?

[Sandro Galea]

Yeah. You know, as with many other things about the current administration, there are real challenges and real difficult issues around which reasonable people can disagree that deserve careful conversation and perhaps teasing apart with tweezers or with a scalpel. But instead we are dealing with them with a bludgeon. Is it true that it is perhaps helpful for us to shake up how we look at how we've been thinking about vaccines? Yes. Does that require changing the entire Acer board? No. Is it true that sometimes some people may have particular conflicts of interest? Yes. Does it mean everybody does? Absolutely not. So I think it becomes hard to see what is right and useful amidst the noise and the smoke of what's happening at the moment. So now, just to hone in to your particular question, as you said, Covid boosters for healthy people probably pretty low efficacy. The notion of COVID shots for children, which in this country has really resulted in enormous schisms in the public conversation. Well, the American approach to Covid shots for children has been dramatically different than the European approach. Throughout much of the pandemic. Europeans did not require Covid shots for children. In America we did. There's reasons why you might argue one versus the other, but I think it's hard to say that removing required Covid shots for children is some sort of enormous abdication against what is accepted scientific consensus. Because our European colleagues, who have very good healthcare systems, who have very good read of the evidence, have chosen to take this in a different direction than we have. I'm using this as a particular example before everybody starts writing in and saying that I'm against vaccine. Just to be very clear. I'm not. But the reason I actually give that caveat is because I feel like these issues inflame so much. All I'm trying to say is I think there is space here around some of these things for people to look carefully at the evidence, perhaps even to come at different conclusions. The way to solve that is through careful, diligent conversation. It's probably not through using a sledgehammer to wipe the slate clean and to putting people in positions of authority who have a long track record of dubious statements about vaccines. So that's around the current vaccines at the moment. Let me just make a comment about measles for a second. Part of what I'm saying about us needing tweezers or scalpel or careful discernment about what we argue about, what we don't argue about is knowing what is settled science. We have saved all over the world millions and millions and millions of lives through the measles vaccine. What is sad about the measles vaccination case is that, yes, we're at a low right now, but it's important to remember the low did not come with RFK Jr. We have, as a country, been trending down in our measles vaccination rate for about 10 years. So RFK Jr. Like many, let's use this term, revolutionary moments, did not invent this like this has been. We as a country have been trending in this direction for about 10 years. What he was able to do was to capture and capitalize on a moment. So I think it calls on us to take a step back and say, how do we think carefully about what brought us here so that we can do better as a country? And Maha ties back to where we started to my mind capitalized on an instinct that many in this country have had for a long time that we are not as healthy as we should be. And that instinct is correct. Now, that instinct happened to have found an unusual outlet in the current Secretary of Health, Human Services and a lot of the Maha movement. But can we now then take this moment, take that outlet and turn it into a positive.

[Galen Droug]

To pose the question bluntly, why do people think that vaccines cause autism?

[Sandro Galea]

Well, there has been, I mean, at a very, very technical level, there was a paper that was published in very prominent medical journal the Lancet that was fraudulent and wronged is eventually withdrawn. That made that connection. That paper, which was now 30 years ago, spawned a whole series of conspiracies and movements behind it. You know, autism is really heartbreaking in that there has been, there's no question there has been an increase in autism in this country over the past 25, 30 years. There are many reasons for the increase. It remains fundamentally unclear comprehensively why the reasons are. And we are human. And when we are human, when we have unexplained diseases like autism, when we have unexplained consequences, we are trying to find a link. And since autism manifests in childhood and children are getting many vaccines, it was perhaps not particularly surprising that stories would arise about link between autism vaccines. The fundamental bottom line is that the science about vaccines and autism is very clear that there is no link.

[Galen Droug]

You know, I think one of the biggest challenges today that we've already started poking at is the politicization of health information. And a. You know, for example, a Harvard Chan School of Public Health poll in April of this year found that 44% of the public says having the new leaders in charge of federal public health agencies will make them trust health recommendations coming from these organizations, organizations less than they used to. Now I have to think that that's mostly people on the left, but the public health agencies already lost a lot of people on the right during the pandemic. What are the challenges of a politicized public health ecosystem?

[Sandro Galea]

I think I will approach that by challenging the notion of politicized, because I don't think you mean politicized. I think you mean partisan and ideologically driven divides in the ecosystem, which I think is different than political. By political, what I mean is understanding that the decisions we make as a society about how we structure the world we live in matters as we started talking in this conversation. I don't think you can have the health of the public without aligning the structures in the society within which we live. Hence, there is nothing wrong with saying that public health tangles with politics. I mean, the earliest triumphs of public health, formal public health today traces its roots to public health efforts in London in the mid 19th century. In Germany around the same time, a lot of that emerged from political actions to clean up post industrial London, which resulted in enormous gains in life expectancy. So saying that to create a healthier world, you need to engage with the structures that generate health, which I might think would be called engaging in politics. There's nothing wrong with that. What I think you're getting at is the ideological divide, which is largely partisan around very rigid ideological lines, where if you are, I'll use your term, on the left, you say blue. If you are on the right, you say red, and blue, and red will never concede that there's anything good in red or anything good in blue. That I think is the problem. And why is that a problem? Well, the definition, if you take a step back, of public health, there's many definitions, but the National Academy of Sciences, what used to call the Institute of Medicine, had a report that called Public Health what we do collectively to create the conditions so we can all be healthier. Now, hopefully, anybody who's been listening to this podcast will understand that that definition makes a lot of sense, because it's ultimately about what we do collectively to create a world that makes us healthier. Well, foundational to that is what we do collectively. And it's really hard to do things collectively when, if you and I have to do something together, if you and I are not talking, well, it gets pretty hard to do things collectively. So I think that's the problem. The problem is sharp ideological divides driven by partisan concerns.

[Galen Droug]

You know, I think there's a pretty strong suggestion that the public health profession brought some of this polarization of public health information on itself, particularly during the pandemic. So, you know, for example, basing suggestions of behavior during the pandemic on partisan views, like supporting the George Floyd protests, but not supporting going to church or other forms of protests. You know, recommendations that sometimes seem to be more about opposing Trump than following the evidence available at the time on things like strict lockdowns or school closures or what have you. I guess, first of all, would you agree with that critique of the public health profession during the pandemic?

[Sandro Galea]

Well, I've written a whole book about this. Anybody who's interested. It's called Within Reason. It came out in December of 2023. You can read the reviews of it, and you can read the whole book. The bottom line is I think there are many things that public health did wrong during the pandemic. But I'm not answering your question because your question is asking me to come up with a simple, blanket answer. And I think the answer is really complicated. I think there are many things that public health did that it should have done better. The book is called Within Reason for a Purpose, because I think our role in public health is to help societies inform society what the evidence suggests, to inform societies what it is that we should do to create a healthier world so we can all live longer, healthier lives and ultimately let societies decide about the values that societies prioritize. I use the example often in my writing, for example, about speed limits. We know there's plenty of evidence that if we were to lower the speed limit nationally to 25 miles per hour, we would save tens of thousands of lives. Now, how frequently have you heard of public health advocating strongly for a national reduction of speed limits to 25 miles per hour? Well, not very often because it really hasn't happened. Right. Because we have implicitly accepted some level of risk because of other values, in this case perhaps getting from A to B faster. Public health needs to have the sophistication to persuade rather than scold, to have conversations to bring people along towards our shared aspiration of living longer, healthier lives. And we lost sight of some of that during the pandemic. There were many other forces that contributed to that, including, by the way, this ideological divide that I talked about, the partisan and pretty cynical manipulation of what was needed to be done for health for partisan gain. But public health played a role in that. Anybody's interested in that, please take a look at the book, let me know what you think.

[Galen Droug]

Yeah. So it sounds like what you're saying, if I try to apply what you said, maybe more abstractly to the specifics of the pandemic, is that public health officials or professionals were pretty black and white and perhaps we're not open to a discussion of trade offs and values like they should, like they have been in other aspects of health.

[Sandro Galea]

I, I am, I, I'm willing to say yes to that.

[Guest Expert]

Yes.

[Galen Droug]

Okay.

[Podcast Host]

How does the public health regain the.

[Galen Droug]

Trust that it lost during the pandemic? And, and that's not just sort of me putting the question out there in the abstract. Right. Like the polling shows that public opinion of the public health profession declined between 2018 and 2023, significantly, and mostly amongst Republicans. And, and so I also put that alongside, you know, now that RFK Jr. Is the secretary of Health and Human Services, you see increasingly now Democrats are. People on the left are more hesitant or tentative about the suggestions that come out now.

[Sandro Galea]

Yeah. But we should be clear it wasn't just about Republicans. The lack of trust. The drop in trust has been across the board, although more pronounced among Republicans. Well, I think the sure way not to try to regain trust is by saying, trust me. So I feel like the way to regain trust is by showing that we have learned. It's by having the conversation. It's by coming on your podcast and being willing to engage the conversation, by being honest about what we know and don't know, by encouraging everybody who is within the ecosystem that generates health, be.

[Guest Expert]

It formal public health, be it in.

[Sandro Galea]

Medicine, be it in politics, be it in the media, to make sure that we present what we know and what we don't know. And we are careful to be honest about that, to be clear that there are limits to restrictions on personal autonomy that we as a society are willing to tolerate, and that the promotion of health is not the only social good that matters to all of us. It's by saying those things and saying them again and again and again. In time, we will regain trust because it is important to all of us. Remember, what we're trying to do is doing something collectively to create a better, healthier world. And we all want that. I mean, to come back to the Maher Report. The Maha report is framed around the health of children. And I have found over the years when I've published books and had the opportunity to speak to sort of do what's typically called things like right wing radio. And I've talked to hosts with whom I don't agree with on very much, but we agree and we've always agreed on the fact that I want my children to be healthy and they would like their children to be healthy. So there is much at stake here. And I think it is important that the conversation happens so that we can actually move collectively towards a healthier world.

[Galen Droug]

You know, I think one of the challenges here is that Public Health by Design views health challenges through a structural lens, you know, like the racial politics of food deserts or the racial history of vaccine skepticism. And it's quite an academic way of viewing the world. Now, I recently talked to Joan Williams about a book that she wrote called Outclassed. She's a scholar who talks about class divides in America and how they map on to politics.

[Podcast Host]

And increasingly that sort of structural, academic.

[Galen Droug]

Way of viewing the world is something that resides on the left, whereas folks on the right are more inclined to see the world through a lens of personal responsibility and the like. And there's also this increasing educational divide where Democrats more and more have four year college degrees from places that would help them see the world in a more structural way, and Republicans increasingly don't. And frankly, 60%. More than 60% of the country also doesn't have four year college degrees.

[Podcast Host]

So is there just a tension here.

[Galen Droug]

About the whole worldview of public health versus some of the values and worldview of Americans who maybe don't go to college or emphasize more personal responsibility or the like?

[Sandro Galea]

Well, I think the simple answer to your question is their attention is yes. The perhaps deeper answer to should there be attention is I don't think there has to be. I think. Is a structural view of health causation correct? Absolutely. Is an individual view of health causation correct? Absolutely. It's not one or the other. I'll go back to the speed limits example. Is it true that limiting speed and enforcing speed limits saves lives? Sure. Is it true that it doesn't matter what you do as a speed limit, you can actually get in your car and drive it as fast as you can go and crash yourself anyway? Of course it's also true. So it is simultaneously true that structurally we can create a world that encourages us to and channels us into living healthier, longer lives. And it is also true that we have individual autonomy and we want to have individual autonomy to take risks sometimes and to be unhealthy if we want to. One example which I use in my speaking is the point of health is so that everybody can live rich, fulfilled lives autonomously. That means I want you to be healthy so that you have the freedom to skydive if you want. Now, thank you. I have no interest in skydiving. I think it's foolish, but please go ahead. And I think it's a mistake to say to overdraw a line which over restricts autonomy in public health. For many decades now, one of the core tenets of public health has been this notion of health and human rights. And you talk to anybody who's in the public health ecosystem and we're all on board with that. But we tend to forget that at the heart of human rights is personal autonomy. Personal autonomy means you should be empowered to and given the space to live rich, fulfilled life. I mean, let's take a concrete example for a second, Galen. Let's take the example of helmets with motorcycle driving. With the exception of two states, we as a country make it mandatory to wear a helmet when you ride a motorcycle. Now why is that? Well, the risks of dying in a high speed motorcycle crash are very high and helmets do make a big difference. Now in insisting on helmet wearing, we are restricting your individual autonomy to have your hair and your curls flow back in the wind. Right. But it is a trade off we're willing to make. But the trade off in order for us to be willing to make it should come from thoughtful conversation, not from the assumption that we are definitely going to prioritize the health side of the house over the aesthetic windswept hair part side of the house. And I think as societies come to a place which we can live with, by the way, we don't require wearing a helmet when you drive your car. Now, if we all were to wear a helmet when you drive a car in car crashes, our chance of survival would also be higher. Why don't we require a helmet when we drive a car? Well, we are implicitly making a risk calculus that we're willing to live with that risk for the sake of the autonomy of not wearing a helmet. So we make these trade offs all the time. And public health should be a guide to society, to making these decisions. But by the way, public health should not be making these decisions. These decisions should be made by society. In an ideal world. We don't live in an ideal world. Right. But in an ideal world, our elected representatives have the wisdom and dispatch to have sophisticated conversations to arrive at a place that balances multiple competing values to help structure a world where we can all be autonomous but have the freedoms to live long, healthy lives. That's the ideal world. Of course, in a world where, as we've been discussed, we're riven with ideological factionism and with pretty thoughtless partisanship, we're pretty far from ideal world right now.

[Galen Droug]

So in other words, the public health profession provides the research and information, but the actual decision making and debate is for politicians, leaders, the public to ultimately decide.

[Sandro Galea]

That is how I see it, and that is how many who have thought about this within population health have seen it for many decades now. That doesn't mean that's how it has always been expressed. And I think the reason it hasn't been expressed that way and it hasn't manifested that way, particularly during the pandemic, is a large part of the reason why we are in the trouble we're in right now.

[Galen Droug]

Well, and it's also in some ways an abdication of duty on the part of the politicians. I mean, it is in part public health professionals coming in and saying, you know, this is what the science says. It's black and white, even when it isn't necessarily. But it's also politicians worried about making the wrong decision or facing blowbacks or just sort of deferring and saying, you know, well, this is what the, the public health professionals Say so I'm just going to do that without engaging in a harder values based conversation about the trade offs that could land them in a more difficult position politically.

[Podcast Host]

Does that make sense?

[Galen Droug]

Like politicians maybe also have an incentive to abdicate decision making authority.

[Sandro Galea]

Well, let's be clear that there's a lot of. There's. There's a lot of not doing things quite as well as should be to go around here.

[Galen Droug]

So you recently wrote on your substack about the drawing the line problem in public health and I think this is a good way to sort of tie together a lot of what we've been talking about here. You write, in fragmented media and scientific environments it is becoming harder than ever to determine which facts or expert views constitute settled knowledge and which remain open for debate. You go on to say, fundamental to my asking these questions is a recognition.

[Podcast Host]

That if we draw lines of consensus too soon, we risk premature closure and.

[Galen Droug]

The exclusion of nuance.

[Podcast Host]

If we wait too long, we risk.

[Galen Droug]

Descending into chaos, endless doubt and indecision.

[Podcast Host]

It is worth then taking a moment to determine where and how we should.

[Galen Droug]

Draw a line between knowledge that is.

[Podcast Host]

Still in flux and knowledge that might be deemed settled, or at least as.

[Galen Droug]

Near settled as it is possible for knowledge to be admitting. Space for reevaluation of priors and an open minded consideration of all we think we know. This gets like philosophical here, right? Like, have you ever taken a theory of knowledge class or something? Like, how do we, how are we.

[Podcast Host]

Sure we know what we know?

[Galen Droug]

But how do you go about assessing where to draw the line?

[Sandro Galea]

Yeah, well, that was pretty well put.

[Galen Droug]

I. Yeah, you, you wrote it, so it was, it was pretty well put.

[Sandro Galea]

I, I don't think there's any one formula for where to draw the line. I think the line is the line is drawn through social conversation. The line is drawn through multiple inputs. The line is drawn by multiple actors. Certainly I should not be the only one drawing the line. Neither should you be. We collectively should be drawing the line and when the data change, we should change our mind. And I think all of that is true. So I suppose, although I didn't write that in that piece, the line drawing should be a constant. It is an evolution. There might be a line today, there might be a line tomorrow. And I think one of the mistakes that we made during the pandemic is making it seem like the line was drawn and it was absolute without being clear. These are the data on hand and this is where we draw the line today. Stay tuned, we might come back to you tomorrow. And we did not do a good job of educating the public. Or at least we allowed ourselves to be caught up in the ideological debates that told the story through a particular lens. And that's how people saw it. So you're right that I think the drawing the line problem captures nicely our conversation. Because what it does is it pushes us to say knowledge changes. Science is hard, certitude is hard to come by. And can we all be sophisticated enough and thoughtful enough to recognize that that's the case? Act on imperfect knowledge. Act. We don't have to be paralyzed, but be willing to change our minds when things change towards the end of elevating shared values. And I would argue among those shared values, high among those shared values, but certainly not. The only value is making sure that we all live long, healthy lives.

[Galen Droug]

All right. Well, I think that is a good place to end things. Thank you so much for joining me today, Sandra.

[Sandro Galea]

Thank you Galen. I've enjoyed this.

[Podcast Host]

My name is Galen Droock. Remember to become a subscriber to this [e-mail] and wherever you get your podcasts. Paid subscribers get about twice the number of episodes and access to the videos for the podcast. You can also join our paid subscriber chat and pass along questions for us.

[Galen Droug]

To discuss on the show.

[Podcast Host]

And most importantly, you ensure that we can keep making a podcast that prioritizes curiosity, rigor and a sense of humor. Also, be a friend of the podcast and go give us a five star rating. Maybe even tell a friend about us.

[Galen Droug]

Thanks for listening and we will see you soon.