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Emily Silverman

You're listening to The Nocturnists: Conversations. I'm Emily Silverman.Many of the people listening to this show are clinicians. We see patients one by one, in the office or in the hospital room. But there’s a different way of thinking about care—a broader way—which is focused on populations, neighborhoods, communities, even entire nations. This is the field of public health where something simple like the tax on sugary beverages or a law about speed limits can have enormous implications for the health of all of us. And yet, in the United States, we spend 40x more on health care than we do on public health.Today’s guest, Dr. Michael Stein, has written a book that explores this asymmetry in how we focus our resources, and offers some explanations for why that night be, and for how we can harmonize these two seemingly very different worlds.Michael is a primary care physician, Chair of Health Policy at the Boston University School of Public Health, and the author of several books, including Me vs Us: A Health Divided, which was a finalist for the 2022 Association of Publishers’ PROSE book award.In my conversation with Michael, he offers a definition for what public health is, discusses the public health interventions that have been most successful across time, and explores the way that language and rhetoric shape how we perceive the efforts of those working in public health.But first, I asked Michael to read an excerpt from his book Me vs. Us: A Health Divided. Here’s Michael.

Michael SteinI

have a friend who runs a hospital. She tells me about a patient who trips on a pothole, falls and breaks his hip. The ambulance brings him to my friend's hospital. The doctors in the emergency room make sure that he, his heart and lungs will be able to tolerate surgery. They take him to the operating room.They put a $20,000 piece of metal in his hip. They sell him up, they make sure he doesn't get pneumonia or a blood clot or a wound infection during his recovery period, they get him up and moving. They arrange for home services to keep him safe and ambulatory. They do all this expensive and expert medical and surgical work, and my friend asks me an exasperation.Now who's going to fix the pothole? Does my hospital team have to go do that too? There has been a one-sided indefatigable. Investment in healthcare, healthcare, and health are very different things. The pothole question sits at the intersection. Who is looking after public health? My friend's job is healthcare, she reminds me.

Emily Silverman

I am sitting here with Dr. Michael Stein. Thank you so much for being here today.

Michael Stein

Thanks so much for having me, Emily.

Emily Silverman

So, Michael, you are a primary care doctor, but you also have a role in public health. Tell us a little bit about how you got interested in the public health aspect of health.

Michael Stein

Yeah, I have been a primary care doctor for multiple decades. I started and ran an HIV program and did that for 20 years, which takes one into the realm of politics and work outside of a hospital. I have been a clinical researcher for most of my career. At a certain point, about six years ago, I decided to move from the medical world to the public health world. They are very different academic worlds, and they're actually very different intellectual worlds as I've tried to write about in this book. And that happened when I took a job at the Boston University School of Public Health directing.. chairing a Health Policy department. So I still see patients, but most of my work these days is around health policy and helping junior people smarter than I to develop new health policies.

Emily Silverman

And what moved you to make that transition to public health?

Michael SteinI think it was a change in time of life. I think part of it was intellectual. I had spent my career doing various kinds of research that included what I would call epidemiologic research. So early in the HIV epidemic, I wrote some of the first papers describing what HIV disease was in women. And I did that for a number of years and then changed into sort of health services research, which is how people use the healthcare system, and I was very interested in the mechanics of the healthcare system. And then I sort of moved as one does through HIV as HIV care got better and better into the world of addiction, where the care was not getting necessarily better and better. And I began doing behavioral clinical trials around that, and then at a certain point, just intellectually, as you can see, I bounce around. I'm interested in what I'm interested in, and started doing more work on policy and decided that it was time to sort of shake it up and go into policy more.Emily SilvermanAnd how did the idea for this book come about?

Michael Stein

This book came about because I would go to parties or barbecues or a friend's house, and I would at some point get asked what I do, and I would use the word health. And a conversation would start with whoever I was speaking with, and about 15 seconds into the conversation, they would be telling me about their latest doctor visit. And of course, you know, that's what people want to talk about, especially since I'm a primary care doctor. They wanna get a little consultation and tell about their issues and…

Emily Silverman

Show you their moles..

Michael Stein

Show you their moles. Absolutely. And tell you about their aunt's problem, and how do I know a heart surgeon in Cleveland, and a variety of things. And the word health immediately went to healthcare, and yet here I am now in this public health world where there's this very different understanding of what health is, which is not related to the one by one care that physicians provide. And so trying to talk about health in this broader, slightly more abstract and impersonal sense with people at an individual level at a party was difficult, and it became very clear to me that people had no idea what public health was or what its mission was or what its ethos was or what it even meant. And so this idea that healthcare was really quite distinct from public health was just dramatically clear to me as soon as I entered the public health world and, and what I found was a complete lack of understanding in the healthcare world and a disregard in the healthcare world that was reflected, I found as I began to paw around a little bit in our social and economic funding of healthcare versus health, right? So what you find out very quickly and pretty easily is that as Americans, we spend about 11 or $12,000 per person per year on healthcare. And by healthcare, again, let me say, it means medications and hospital visits and ER visits and doctor office visits and physical therapy and all of those things related to a healthcare system. So that's $11,000 per person per year, and when you look at Americans, we spend about $285 on what's considered public health per person, per year. So that's a 40 times difference between these two realms. So if we fund it very differently in the United States, healthcare versus health, well, it would absolutely make sense that people would not understand what public health was, since we value what we fund and we value healthcare and we don't particularly value public health, therefore. And so, when I tried to come up with a reasonable, why is that? How has that happened historically? And I approached it really sort of quite ignorantly, and by ignorantly I mean, as a healthcare provider who didn't know a lot about public health, I decided to write a book. And what I did in the book, Me Vs. Us, is try to give you the reader, who's meant to be a lay reader, eight or nine reasons why it has come to pass that we value health care more than health, and some of the reasons, frankly, I think are good reasons, understandable reasons, and some of them are reasons that we really should reconsider with the obvious end goal of being, well, let's tip the field back a little bit. It shouldn't be 40 times more for healthcare. It should be less than that. We should increase our funding for public health, which probably means decreasing our funding for healthcare, which is itself a tricky thing in the United States. And then a small part of the book at the end says, listen, I've set these two against each other, health care versus health, they're obviously people like me who do both, right? So it's a little bit of an embellishment. So let's talk about some solutions to bring the two closer together. So in addition to trying to reconceptualize the funding of public health, let's talk about how to merge the two worlds at the practical level, at our level as individuals.

Emily Silverman

So you said earlier that you would sometimes go to barbecues and cocktail parties and people wouldn't really know what public health is. You do offer a definition in the book for public health, and I have it here in front of me, but maybe I'll ask you, what is your cocktail party barbecue definition of public health?

Michael Stein

What I call it is “three P's.” So public health is about populations, so it's about groups of people, whether it's a town or a county, or a even a health plan. Populations are of course distinct from one by one, which is what we do in health care. We take care of patients one by one. So the first P is population. The second P is about prevention, right, that the healthcare system is sometimes snidely called the “sick care system” by people, right? We only take care of people when they get sick. There's a little bit of attention to prevention, but frankly, it's not where the dollars are, and that prevention, which really has to do, I would argue, with the conditions of the world, how to keep people well. So “populations” is one p, “prevention” is a second sort of aspiration or goal of public health. And the third p, I would say, is “policy,” which is that public health, because it involves populations, because it has to be delivered at scale, has to involve policies... legislative policies, regulations set at whatever level we're talking about. So those are the three Ps, the goals of public health, the aspirations of public health. Now that's different from, well, how do you deliver those three Ps? Like where is that happening, right? Like if I want to go see Dr. Emily, I can come see you at a place that has a building and I know where to find you. Well, how do I find public health? Like where do I go for that? Well, of course, there are public health departments, which I would say most doctors, let alone most people, have never been to, don't know where they are, don't know that they have an address in their town. And those public health buildings, those public health people, it's about 300,000 people are employed in the public health system in the United States, are not existing under a single public health system. So that adds another level of confusion, right? We have hundreds of what I would call mini systems of public health. At the top of those mini systems some people would say is the Centers for Disease Control, which is a policy guidance body, but below that are all of these public health departments. Every town in my state of Massachusetts has a public health official. Well, that's quite amazing. Like every single town has one. Other states divided differently and can have county health departments, but all of these systems are mini systems. They function on their own. They're not necessarily integrated with the town next door. They don't necessarily share funds. They compete. They have different technologic infrastructures. And so when you have a pandemic, as we just have gone through, the sort of decentralization and the lack of standardization across our hundreds of mini public health systems have an effect on the outcomes of our pandemic because we're organized in that way. So to go back to your big question, three Ps are the sort of aspirations and then hundreds of mini systems of public health is a delivery that try to match those three aspirations. We live in a world of public health. We think about health care.

Emily Silverman

You mentioned earlier that the way public health is set up in the United States is through this patchwork of mini systems. In the book, you describe it as “hyper-local, episodic, and necessity driven.” And I was wondering if you could speak briefly to just why it's like that. Like how did we get there? You talk about how in 1916 we almost got a centralized, coordinated national health system and then that fell through. What are the historical origins of this, I would say weak, decentralized, underfunded patchwork that is the American public health system.

Michael Stein

I'm not a historian. I don't know that I know this so well, but my understanding is obviously the idea and the general practice of what I would call public health really began in the 19th century in the Western world. This idea of populations, preventions, and policies. And was part of social life and not really part of necessarily health life. It was a part of government life and it was not really part of health care. And then in the 1910s, '16s, '20s, there was a movement among physicians who were a more highly thought of, an organized body even in the beginning of the 20th century, who got interested for that moment, probably for lots of sort of social reasons around then in sort of these social issues about poverty and ventilation and nutrition and other things that they were thinking about or seeing in their patients. And there was a moment where it looked like, the sort of equivalent of a Surgeon General, wasn't called a surgeon general back then, but a sort of administrative health official, recognized in our federal system, was a physician who wanted to sort of envelop public health and have it all under one aegis and have a single system. And so there was this moment where sort of the American Medical Association and doctors said, there's this rickety, amorphous system called public health and we're gonna subsume it.And for whatever reason that broke down, physicians became more interested in the development of private practice and loss of interest in sort of these grander social issues and social issues sort of pushed away and physicians went in in their direction, which over the years, of course, developed into insurance structures, et cetera, that drove pricing and the public health system sort of disappeared again into government bureaucracy. So there's a moment where the two touched out of interest mostly by physicians, which was then lost. And I don't know that I can give you all of sociological reasons why that happened. But really since the beginning of the 20th century, the two have been quite apart.

Emily Silverman

The subtitle of the book is “A Health Divided.” You have a foot in both worlds. You're a primary care doctor, you also do public health work. When you say divided, what do you mean by that? And I guess specifically one question I'm interested in is like kind of the doctor and the public health official. Is there a rivalry there or an antagonism there, or is it more one is just oblivious of the other or ignorant of the other's existence, or vice versa? Or talk a little bit about the individual and the collective and healthcare and public health and that division and how those two parts relate to each other or don't relate to each other?

Michael Stein

I don't think that there's personal animosity in 2023 between public health officials and physicians. I do think that there is a different ethos, right? That the ethos is really in healthcare, which has trickled down to our patients. They think in these terms and the terms of doctors and patients are similar in that I hink of them as sort of American ideas of life as a individual journey that I'm responsible for my health just as I'm responsible for my career success or my career failures. So Americans, to my view, are particularly self-absorbed, one could say in the pursuit of happiness, you know, I just came back from Japan where things are so very, very different, but we're particularly self-absorbed and, and we, we believe that we can optimize our health, right? If we're, if we're wealthy enough and can control things like, you know, our sleep and our nutrition and our step count, right? Those are the things at the moment that we're faddish initially interested in believing that that will give us immortality. You know, we are optimizers and of course our physicians, clinicians, nurse practitioners, etc., play into that, right? They're optimizers themselves, and they see their job as optimization. It's the triumph of the therapeutic in our world. And public health, as I've described, has a very different ethos, right? It's US oriented and the people in a public health department are not thinking about individual visits. They're thinking about the hundred thousand people who live in that town who have diabetes and what that means, and how care can be offered to them as a group. And that public health perspective asks different things to us. And so, you know, this is an old, endless American dilemma, right? The dream of the self versus the dream of the community. It’s Emerson versus Thoreau. It’s Freud versus Marx. We've dealt with this idea of sort of what's more important, the individual or the group, forever in this country. So I think that's the primary distinction between the two groups. It's a matter of ethos. Obviously their day-to-day work looks different, but to me it's mostly conceptual. And this idea in the public health world, which is so important and you know, was really a COVID issue issue is, you know, how much we think of health as a shared commodity. What is it that we share? What is the public in public health? What do we mean by that “public” in public health?

Emily Silverman

So we've talked a lot about public health, what it is, how it's defined, where it happens. Tell us about some of the biggest public health triumphs or successes because that was a really interesting part of the book for me.

Michael Stein

There are classic ones that you know are not so close to my era, right? Where most of the success, interestingly, has come early in time, right? You know, the classic ones are about nutrition and vitamins. Another one has been cigarette smoking, right? Tobacco use in the United States, which as is the case with most public health issues, which are enormous because they're population based are slow to progress. But you know, we have had 70% of Americans approximately smoking 50 or 60 years ago, and now it's 15%. I mean, that's a dramatic change that's come about for lots of reasons. We've made decisions, again, restricting our personal liberties, frankly, for the good of general health around speed limits. So we've changed the way we drive and that has dramatically changed injuries and deaths per mile driven in the United States. So, you know, tho those are sort of three classic ones, but we have other ones popping up that I would say in the last 50 years we've made negative progress about because we don't admit they're a public health problem. So a classic one where I think the split is going back to this split between healthcare and health, is this idea of overweight excess weight. Some would call it obesity. I think that's a fine word, but it's controversial these days. So obesity to me is a classic public health problem. And that has been taken on and thought about as a healthcare problem. And by healthcare problem, I mean that both within the healthcare system where we do things like at the end of the day, offer an increasing number of bariatric surgeries, but all the way back to an individual problem where people believe that they can diet their way out of excess weight. And what we've seen, of course, with billions of dollars put into the healthcare system and into the sort of individual self care system through dieting, billions and billions of dollars for 50 years, is that our obesity rate is exactly the same or higher than it was 50 years ago, right? So we have 40 or 50% of Americans who are overweight at this point, probably to the detriment of their health in many cases. Now, if you say to yourself, well, this is an individual problem and some would even push it further and say, well, you're heavier than you should be because you're irresponsible. You're an irresponsible eater. This is a problem that's worthy of shaming. Well, that is a method that has gotten us nowhere in 50 years. So if I don't believe it, right, if you say that 40 or 50% of the population is obese, well, 40 or 50% of Americans are irresponsible. That just doesn't make sense to me as a common sense person. So then I say, well, this is not an individual or healthcare problem. There are large systemic issues that are driving weight in the United States. So let's talk about this in terms of my three Ps, right? We talk about this in terms of a population, well, that's everybody. Since 50% of Americans and approximately that many children, of course, are overweight, and we wanna prevent that. So that's the second P. But this is a policy issue when you have a food distribution system that subsidizes cheap corn syrup and other things so that the cheapest things in our supermarkets are obesogenic, and our entire distribution system puts that in front of our faces constantly, from large portions to cheap food. Well, that's why we have a population that is obese and the only way it can be changed is not one by one through bariatric surgery or good behavioral counseling by Michael and Emily. It's by changing the system that allows our population to eat cheap food that has them gain weight. Again, Japan, you don't see any obesity. It's a completely different diet. It doesn't subsidize corn and other subsidies, and so we get to the three P's. The third P, which is policy. These are policy decisions. We have made the decision to subsidize sugar in the United States and subsidize sugar farmers, and as long as we subsidize sugar farmers and make that the cheapest thing in our supermarkets, we will have a weight gain problem. No matter how many diet books and surgeries there are, this is a political decision. It is therefore a public health matter. And so there's one where we've made little progress over the same period of time where we've made lots of policy decisions, including, as I said, with speed limits in restricting individual liberties and in changing policies around smoking and secondhand smoking, and the price and taxation of tobacco, which was the primary driver of decreasing smoking in the United States is about taxes. I'm telling you, if your sugar was twice as much as your, um, you know, fruit, you would have a very different looking population. And, and that's, those are decisions that we make as a population.

Emily Silverman

I really like the example of obesity because when you put it like that, it just seems so obvious, like clearly this is an epi phenomenon related to nutrition and movement and things like that. And you kind of wonder like, well then if that's the case, why are we not looking at those parts of society? But then you talk about money and you have a whole chapter in the book about money. So, it all makes sense when you realize that these injectable medications that reduce obesity, very profitable, bariatric surgery, very profitable, corn syrup, infused cheap food in the supermarket, very profitable, not very profitable to talk about things like nutrition and movement.

Michael Stein

It's not only nutrition and movement. Again, it's sort of legislative, and I write a chapter in the book about if only we followed our business practices into the world of public health, right? So you talk to any person in the money world and they say, give me your return on investment. You know, show me, show me… I'm gonna put my money down, show me I'm gonna get my money out of it, which is not an unreasonable way for our legislators to work. And in fact, when you look at major policy interventions that have been suggested around, for instance, sugar sweetened beverages and taxing them. So, our giant slurpees, our giant cans of Coca-Cola, etc., the estimated return on investment of these kinds of legislative interventions is about 55, somewhere around 45 to 55. So that means for every dollar I as a government official spend on creating tax structure around these things, I'm gonna get $55 back in health benefits. That's incredible. There is no medical intervention, from a flu vaccine to a statin pill, that comes anywhere close to 55 to one return on investment. So why is that not public information? Why are we not talking about that? Why are we not making those decisions? Well, you know, you can decide in the end that I don't care about a really great return on investment because I don't wanna piss off certain industries and the senators who represent the states that house those industries, and we can have that political discussion, that's fine, but let's at least have it in an open way about what the numbers show and the numbers show that legislative interventions, including those that address obesity, can a) make major differences, and b) have great rates of return.

Emily Silverman

I was reading a parenting book recently. I have a one-year-old daughter, and this concept in the book came up, I think it was called counter resistance or something like that, where basically if you tell the child to do something like get up and put on your shoes, or you know, go put away your toys or even something that they might want to do, like, why don't you go over there and eat that strawberry, just by virtue of being ordered to do it, there's a counter resistance that comes up within a tendency to want to resist, to not be told what to do. And how that can manifest with, you know, tantrums and things like that. And so I was really interested by the chapter in your book about public health as a morality thing. And I think you say in the chapter, public health is an argument about how to live and it uses the language of virtue. It uses command language and how sometimes it runs the risk of seeming self-righteous. And you know, I could imagine someone listening and saying like, you know, he's telling me I can't have my slurpee, like, I don't know. That's my choice. Or something like that. That counter resistance coming up of like, you can't tell me how to live. And so I'm wondering if there's any thoughts on that. Like how do you tell people what's best for them in a way where you can actually get them to go along with it, as opposed to making them feel scolded like a child and then awakening the counter resistance within.

Michael Stein

Yeah, I love the idea of counter resistance. It's true of not only one-year-olds, right? It's true of so many of us. And in fact, it drives me crazy as a person in public health. I am embarrassed by the language of public health in a certain way. And frankly, this idea of self-righteous, what I call, you know, “the language of should.” You should do this, you should do that is, you know, is not effective and drives me and many people crazy. And it became, in fact, you know, of course it is the language that civil libertarians, right, don't want, right, will resist to the end. It was a central feature of our communication difficulty around COVID, right? Don't tell me I should wear a mask. What do you mean I should wear a mask? So, when you have discord between an understanding of what might be helpful, what might be expensive, and what you're allowed to invade on me, you know, it is very tricky. It is a communications problem with your one-year-old and with your red state, right? It is the central issue and has to be some understanding of giving up civil liberties. And now with a one-year-old, you can pick them up and move them to another place and the behavior gets done whether they like it or not. Similarly, nationally, when you set a tax on something, people can then make the decision. But in general, what we know is if the cigarette tax is higher, they're gonna smoke less. Now, they can still smoke, 15% of people still smoke. It just becomes more and more expensive to them to smoke. So there are, without using the word should, right, without using that language of virtue or language of passive aggressive command, which as I said, I don't like, it drives me crazy and I think is ineffective and certainly as you know it, the individual provider level, it's ineffective in general. You know, it's trying to inform people as best you can and trying to be curious about why it is that they resist something that you know better than them, and that now that you've shared your knowledge, they should know better. And then some people decide, well, despite knowing better and despite understanding the risks, I take these risks because X, Y, and Z. And the X, Y, and Z with mask wearing are more sophisticated than with a one-year-old, but they are listable and provocative and personal and can't be resisted in a certain way because we're not China. We're not zero COVID where we lock people up for these decisions, but we do the best we can in informing them and understanding, you know, that there is a diversity of opinions based on that. So, I don't like the language of virtue as I've said, and I don't think it's effective. And I think it's hurt the world of public health very much. You know, and when you take the language of virtue and apply it to very large and complicated issues like poverty, it's hard, right? This is hard work, like we know that income is the major driver, not income, income or assets, income, wealth, however you want to measure it. There are different measures of it. But, money drives health in the United States. Okay, well, we understand that and well, now how do we fix that? How do we fix poverty in the United States?

Emily Silverman

Easy peasy.

Michael Stein

Yeah, it's easy peasy, but I would say it is the major public health determinant. And that’s to say, I'm asking for big trouble by saying that. As opposed to saying smoking, you know, that's pretty narrow. Poverty, that's pretty big. So, that's another piece of this sort of virtual language and where it gets in deep trouble because the solutions are not obvious.

Emily Silverman

There’s an example in the book about the traffic speed limit, seatbelt laws, and I think this particular example came out of the UK where some leader decided to raise the speed limit in a certain region, and they did, and the number of car crashes and deaths went up sharply. And then I think they might have dialed the speed limit back down, and then the deaths went down sharply, and it was almost this physical response that's so predictable, so mathematical that for every two mile per hour increase in the speed limit, you get X number more deaths. And it's simply math. It's just how the physics of it all works, and I think one of the more provocative chapters was about how the benefits of public health are invisible. If you get into a car accident or don't get into a car accident, you might not really have a sense for the statistics around what makes that likely, what makes that unlikely. You may talk about things like freedom and individual liberty as like, I don't have to wear a seatbelt, and if you tell me I have to you're infringing on my freedom. But what about the freedom from car accidents. I think sometimes the individualists co-op the concept of freedom and, and underestimate the power of things like public health measures and legislation to actually offer freedom in the form of not being in a car accident. But that's invisible. So talk a little bit about the invisibility of the benefits that we get.

Michael Stein

The idea of prevention, which was one of my three Ps, is of course saying that there's a future world out there that could be worse if we don't take these measures. That's what prevention is, right? It's an imagined future that's bad. Well, it's hard for us to imagine the future, or we disbelieve the future. I think I give the movie reference there, right, in the book where It's a Wonderful Life where the angel comes and shows somebody their future if they decide to do this particular course of action, which we don't get to have an angel show us our future. But the angel comes down and says, “if you make this decision, here's what's gonna happen to you in your town, and if you make this decision, you know those things won't happen.” That's a sort of form of prevention, an angelic prevention, but it says, you know, there is this other course that could happen. That's sometimes hard to resist. We don't believe it. It's the future. It's imaginary. So, you know, again, in the book I suggest, well, part of the language should be a change from sort of preventing deaths to saving lives, right? Doctors save lives, right? They don't prevent you from dying from cancer. They save your life from cancer. Well, flu vaccines save lives. They don't prevent cases of flu. They save 60,000 flu deaths a year. And so let's change the language. I'm into sort of rebranding public health at the moment to sort of get away from some of these trappings of the word, you know. People have even tried to change the name public health to population health because of the terminology of public. Who knows what that means? Public's associated with governments. We are a country who is very ambivalent about government action. Let's get rid of the whole word public and public health. Like I'm a school of population health. I'm not a school of public health that's happening around the country now, right? So everybody's aware that there's a slight branding problem, but this idea of sort of your example of speed limits and if you wear seat belts, it helps me and it helps you is that whole thing, which is trying to get the velocity to escape from the medical perspective, which is what can I do to make myself happy and healthy to the public health perspective that says, in addition to helping myself, there has to be that clause. What can we do to improve the health of others? That's a different perspective. It takes a different amount of energy to get to that perspective, and I think that's what you're describing, and that's to go back to the divide of me versus us.

Emily Silverman

Or not even others, but us, like you said, me versus us, because within that Us is me. It's not me and other, there's me, my body, and my individual, but then there's my neighborhood. I think you say in one part of the book that the neighborhood is the unit of change. I thought that was really beautiful. You also talk about how people do not choose between things. They choose between descriptions of things. So this idea of the descriptive difference between preventing a life and saving a life and the emotional impact that that has. And you offer a thought experiment in the book, and I can't remember exactly what it was, but it was like, “what would someone have to pay you to be infected with a virus that you have some small chance of dying from, versus let's say you already have the virus, what would you pay for the cure?” Or it's just basically it's the same scenario reversed just with different language.

Michael Stein

Exactly. So I come up with a hypothetical program about, there's an outbreak of an unusual disease and it's expected to kill a certain number of people and you offered a reader or a listener, you know, two programs to combat the disease, right? And one of them says, you know, if program A is adopted, 200 people will be saved. And if program B is adopted, there's a one third probability that 600 people will be saved and two thirds that no people will be saved. And people like program A because it used the word saved. It doesn't get into all this probability language. And, of course, the two programs A and B are identical, but it's the language that prepares them to like that. And similarly, if you had a program where if it's adopted, 400 people will die. And if you give them another program, there's a one-third probability that nobody will die in two-thirds, that 600 people will die. They again choose, when you're talking about death, then you're willing to take the probability. And so again, the two programs are identical, but the probability language and avoiding dying suddenly rules the day; whereas, if you just use the word saved, then no one wants to hear the probability language. And so the problems are completely identical. The risks are completely identical. The answers should be identical, but they aren't. And that's how we think about public health. It depends on how the program… the context is framed, and I think we just need to be super aware of that every time we talk about public health.Emily SilvermanSo we’ve covered a lot of ground here. For the audience, what are some of your takeaways from all your reading and writing on this topic? For people listening, maybe some of them are interested in going into public health as a career, or maybe people aren't. Maybe they're going to be a doctor, you know, providing in a clinic or a hospital, but want to be more aware and conscious of how the work that they do fits into or doesn't fit into public health. What would you leave us with? Or maybe it's a solution… like what direction do we need to be moving in to create a healthier Us?

Michael Stein

One way is for the general listener who knows, and has thought very little about health, healthcare, or a career in either, the message is the third P, which is policy. Which is that the way that you and I individually, physicians very involved, and the way my cousin, right, who works in a fish market are related around public health, is that we each get one vote, and the policies of public health are driven by who we vote for. Some people would say, having watched COVID, that the primary public health official in each state is the governor. Nobody in the public health or the medical world. It's the governor. That the policies are political by definition, and that when we vote, we are voting about health issues and that if we wanna be interested in public health, that we need to think about for each policy is there a public health impact, whether it's our town's policy, our county's policy, our state's policy, or our national policy that we're voting for at that moment. Do the contestants in that political race speak about health and speak about it in terms of their policies, and their policies could be around housing and eviction laws. It could be about snap payments for childhood nutrition. It could be about the closings of hospitals, so it could be very literal about health or healthcare, and it could be about these things that certainly affect the world we live in, such as evictions or paid sick leave, right. These are policies that all affect our health and that we watched play out, or not play out during COVID. So for the general listener, your involvement in public health has to be through politics and my, frankly, my interest in public health plays out through politics. I'm politically involved because that's where the policies get played out. So that should be part of the answer. Now, sometimes I talk to highschoolers, so let me give you the second answer because these are people who are our generation, right, that's coming up. But I often say to high schoolers is, you know, the topics of public health are…they’re topics, right? They're about sex and pregnancies, children and drugs, and suicide, and how we talk about these things, sort of public communication, that's what they're interested in. So, the subjects are natural. Secondly, we've seen with young people, I mean, one of the great things is that a public health issue, for instance, like gun safety, the politics of that has been led by student groups, right? These are teenagers coming from Parkland, etc., who have driven health policy and public policy, and there's power in numbers and there's power in numbers of young people. So I think that's exciting. I would say that often people, and not all young people, but many young people are interested in service in the lives of others and public health, as is healthcare, is about the lives of others. And the final thing that I think people are interested in about public health is that, you know, it's sort of detective work. Like, you know what's good for a community and how do we show that it helps. So the detective work comes out, obviously when the city of Jackson, Mississippi has no water to drink. Like, what happened? I can't flush the toilet. I can't drink the water. My business is closed. Or Flint, Michigan, right? We see these dramatic examples where communities, neighborhoods are affected, and so it is very personal and very local to people, and I think that that can move them at a time when they're young and essentially healthy and have no reason to interact with the healthcare system. So, the issues, the detective work, the power in numbers and the topics, I think are just things that bring young people into the game, and I love that.

Emily Silverman

So a lot of the people listening are clinicians. So even if they're not public health workers, what can they do in the room with a patient one-on-one to raise some of these issues to bring the idea of public health to their patients, and I don't know, maybe counseling or some other way of bringing public health into the exam room.

Michael Stein

What I've learned over these years, and it's really sort of changed my practice, is to remember something that's obvious, which is, and I've mentioned this before, most of your patients' lives are not spent with you. They're spent at home and in their communities, and therefore, what's important to them at home in their communities, we need to be curious about what's important in your life. And secondarily, what are the things that you think are affecting your health or have affected your health recently that are part of your life outside of this office and these particular complaints that you're giving me. Sometimes they may be related, and those things could be anything from the power of my house goes out every day and I lose my insulin supply. It could be that I'm being evicted. It could be that I feel discriminated against all the time. It could be that I'm stressed because I run three jobs. It could be…I eat only sugar. That's all I can eat. So there are home life, community life, neighborhood life issues that we sometimes overlook. And so, in the physician's office, if you have the time, and the complaint is not an overwhelming one for the limited time we have with each patient, we need to be curious about and explore the 99% of life outside of the office, which are the conditions of life, the public health conditions that people are dealing with.

Emily Silverman

Well, thank you so much. I learned so much from reading this book, and I encourage listeners to pick up a copy. Just learn more about the public health aspect of health because it's certainly something that I haven't been as focused on as I have the health care, you know, being a physician myself. So thank you Michael for being here. I have been speaking with Dr. Michael Stein about his book, Me vs. Us: A Health Divided. Thanks again.