[song playing]

Blind Willie Johnson: In the year of nineteen and eighteen, God sent a mighty disease.

It killed many a-thousand, on land and on the seas.

Brian Lehrer: No, that's not The Brian Lehrer Show theme, it's the song Jesus Is Coming Soon by Blind Willie Johnson from 1928. That's pretty eerily familiar if you're able to make out those lyrics. In the year of 1918, God sent a mighty disease. It killed many a thousand on land and on the seas. That's eerily familiar enough, that those lyrics would've been written a 100 years ago. Now what about these? Listen carefully.

[song playing]

Blind Willie Johnson: Well, the nobles said to the people, "You better close your public schools."

"Until the events of death has ending, better close your churches too."

Brian Lehrer: Wow, they were debating public school and church closures to save lives in that pandemic. If that old recording was a little hard to hear, the lyrics of what we just heard was, Well, the nobles said to the people, you better close your public schools until the events of death has ending, better close your churches too. I'm playing this today because the link to that song was tweeted out yesterday by my next guest, Dr. Sandro Galea, Physician and Epidemiologist, Dean of the Boston University School of Public Health, previously with Columbia University's Mailman School of Public Health here in New York. He is now the author of a book called The Contagion Next Time, which challenges our whole way of thinking about how to prepare for pandemics and deal with them when they do occur. Hint, this doctor solutions have less to do with medicine than you might expect.

Dr. Galea, thanks for joining us, and welcome to WNYC today.

Dr. Sandro Galea: Thank you for having me, it's great to be here.

Brian Lehrer: To start with the song, you tweeted that it captures not just the story of the 1918 flu pandemic, but also the importance of humility in the face of the conditions that shape disease. Why humility?

Dr. Sandro Galea: Yes, I'm delighted you started with Blind Willie Johnson. I think humility is fundamentally a focus on what matters most to us. It's a capacity to understand that the world is a complicated place, and to recognize that what seems like the obvious solution is often not the obvious solution.

If I may elaborate on Blind Willie Johnson, and I'm really grateful to you for playing that song, he was born at the turn of 20th century in Texas, and he grew up poor, blind, Black in Texas at that time. When he was about 40, he developed malaria. His wife took him to hospital for his malaria, and he was turned away from the hospital and then he died. The reason I often bring Blind Willie Johnson is I ask people, "Well, what killed Blind Willie Johnson?" Of course, what killed him was malaria, but it wasn't just malaria, it was also poverty, it was racism, it was domestic violence, it was homelessness, it was all the forces he experienced in his life.

I use it as a metaphor to say, we want to treat malaria, obviously, we want treatments for our diseases, but unless we deal with the racism, with the domestic violence, with the poverty, with the lack of access to care, fundamentally, people actually cannot even get the treatment for malaria. I think it's a mistake, it's a cognitive error we make all the time where we as a country invest all our money in treating malaria, metaphorically, and we neglect to focus on the other forces, and that's really is what the book is about.

Brian Lehrer: Right. We'll reveal to the listeners who haven't figured it out already, what the title of your book, The Contagion Next Time, is a reference to, and how that relates to your essential thesis. Historically, I hadn't heard that old song before, and that second lyric really shocked me, "The noble said to the people, you better close your public schools until the events of death has ending, better close your churches too." Were they debating public school closures and church closures, pro and con, in pursuit of public health during the 1918 flu pandemic? I guess they must've been.

Dr. Sandro Galea: They were. We have a long tradition as a human species, let alone as a country, of actually debating these same things that we've been debating so vociferously for the past 20 months. These are, in many ways, not new issues, and the same power dynamics, the same inequities that we've seen now have played out a 100 years ago, which means, of course, we should've learned something, and my hope is that we can learn something now.

Brian Lehrer: I want to come back to that later in our conversation because I think, for as much as the basic premise of your book is going to sound like progressive politics to a lot of people, it looks to me like you were maybe not as much in favor of some of the lockdowns as seem to run along progressive lines over the past year and a half, so we'll get back to that. The title of your book, The Contagion Next Time, is an intentional riff on James Baldwin's classic from the 1960s, The Fire Next Time, but his book was about racial inequality. You're the Dean of a public health department at a major university, make the connection for everybody.

Dr. Sandro Galea: Well, the connection is the James Baldwin's book is really one of the most searing indictments of racism in America as far as I'm concerned. Racism and its consequences played out very clearly in the consequences of COVID-19. Simply put, just the one axis, Black Americans had two times the greater risk of dying from COVID than did white Americans. There were also Indigenous Americans and Latinx Americans. We're just focusing on Black-white differences. The reason for that is twofold. Number one is that Black Americans had a greater risk of getting COVID, and number two is there was greater risk of severe COVID once Black Americans developed COVID.

The question is why is that? Well, on the first reason, greater risk of getting COVID, that is entirely dependent on economic patterns, because Black Americans are more likely to work in essential industries and low-wage jobs which require physical presence or not having the luxury of working from home to protect oneself from getting the disease. The second, which is more severe COVID, is patterned on morbidity and underlying disease, and that underlying disease-patterning, which is greater burden of disease among Black Americans than white Americans, has been with us for centuries, and that reflects the marginalization and the disenfranchisement of Black Americans in this country. Really, these forces, which have now come to be referred to as structural racism, have shaped the consequences of the pandemic. I do not think that one can see the pandemic without actually looking at it through that lens.

Brian Lehrer: Indeed. I think that, was it New York City or New York State that just recently officially listed racism as a public health issue, alongside the other things that we might traditionally think of, the diseases, diabetes, asthma, obesity, lung disease, heart disease, racism is on that list now, right?

Dr. Sandro Galea: That's correct. New York City Health Commissioner, Dr. Chokshi, understands this quite well, and the New York State Health Commissioner, Dr. Bassett, who is just coming in, also understands this quite well. I think in public health, there's a growing awareness that the health of the public is inseparable from the underlying social and economic context in which we live, and a large part of that is racism.

Brian Lehrer: How do we put that into play as policy beyond just naming it? This country, as you know, Dr. Galea, has been debating how to end structural racism and the inequality that results from it, this way too permanent de facto caste system, if we want to call it that, for 50 plus years since the main civil rights laws were passed, and with some progress, some real progress, but it should be entirely unacceptable to everyone, that all these decades later, the disparate impact of the pandemic reveals, yet again, how concentrated darker-skinned Americans still are in those lower paid jobs. In this case, the health consequences that flow from that, the life expectancy consequences as well.

Do you propose in the book some top concrete ways out beyond naming the problem so explicitly?

Dr. Sandro Galea: Well, I think number one, naming the problem is critical. Number two, I think we need a range of policy efforts that pay attention to the particularities of the dimension we're talking about. For example, you mentioned a few minutes ago that I'm not as much of a fan of some of the lockdown approaches, and the reason for that is simple, it's because a blanket lockdown inevitably ends up disadvantaging minority groups. If you're shutting down schools, and we know this, you end up with minority groups having less access to Wi-Fi, less access to places where the kids can actually get on Zoom and learn properly, and we also know that more affluent schools opened earlier.

An approach that actually takes an anti-racist approach which recognizes the forces in the world around us that disadvantage one particular group need to say, "If we take this blanket approach, we're going to deepen that disadvantage. Should we take that approach or should we think differently about it? Should we try to take an approach that recognizes that there are divisions that some groups are more disadvantaged? Let's make sure we protect those groups with any approach we take." I actually think it requires deliberate thinking about any policy decision we make to say, "How is this marginalizing or furthering disadvantage of a group that already burst the brunt of disadvantage?"

Brian Lehrer: Listeners, we welcome your thoughts and questions for Dr. Sandro Galea. How can we prevent a repeat of the desperate results of this pandemic, the next time one hits, or, for that matter, the chronic health disparities that we were living with before COVID, and are still living with and will be living with after it? His book is called The Contagion Next Time. He's the dean of the Boston University School of Public Health. 212-433-- WNYC, if you want to call in. 212-433-9692, or Tweet a comment or a question @BrianLehrer.

Dr. Galea, could you use a really sad COVID headline from today to put this into global perspective? It was reported that the world just experienced its five millionth COVID death, and I'm curious how you see it globally beyond the US context that we've been talking about so far.

Dr. Sandro Galea: The global perspective is almost unbearably sad because it really reveals this enormous global health and equity. I think what COVID has done, broadly speaking, is it has elevated and revealed things that were already there. Much of what we're observing about COVID is not new, but COVID surfaces it.

From a global perspective, we take for granted, for example, that life expectancy in the US is 20 years higher than other countries, and we do not stop to ask why is that. That exists because of deep global inequities in access to the resources to make us healthy, to clean air, drinkable water, safe food, to parks where we can exercise, to safe workplaces. The world is completely divided. There are large parts of the world that have far fewer resources than we do, and we should really be asking ourselves, "Why is that?" What's our moral responsibility to actually deal with that? Of course, this has played out not just in COVID deaths around the world, but also we're seeing it now with the gross under vaccination in many parts of the world, particularly in Africa. These reflect global health inequities that we should, at the very least, be asking why is this the case? Is this acceptable? What responsibility do we have to try to fix it?

Brian Lehrer: There's certainly inequities in the distribution of vaccines right now. We've been talking about that on the show for the whole period of months of the vaccine era, but there's a paradox here that I want to ask you about is, well, which is that the US is the richest nation in the world, but has also had, I think the highest rate of COVID and of COVID deaths of any country. Correct me if that's wrong. How does that fit with the more poverty equals more death and disease premise of the book?

Dr. Sandro Galea: That's a great question. In the book, it frames things globally, focuses very much on the US, but the truth is there's a lot about viral transmission that we do not understand. It's a lot that we still don't understand as to why the US ended up with, at least as of right now, the highest rate per population than other parts of the world, and I suspect that over the years, we'll understand that a little bit better.

Focusing on the US, the question becomes why is it that we did so poorly? Why is it the country's [unintelligible 00:13:06] leaving aside viral transmission dynamics which one could talk about? Fundamentally, we did so poorly because we had poor underlying health. Our health as a high-income country is the worst compared to all other high-income countries. Although we as a country spend more on health than all the other high-income countries, we actually have the worst health compared to all these countries. We live shorter, sicker lives. There's one thing we've known since the beginning of this pandemic, is that the people who are most at risk of dying from the virus are those with underlying health conditions.

We as a country, we're in some way sitting ducks. We have a country of people who live sicker shorter lives than other high-income countries. When we had that high rate of transmission, we're at higher risk of death from that transmission. What that should teach us, of course, is that we should tend to our health once this pandemic is over, not waiting until the next pandemic, because the next pandemic will come. It could be worse than this one, and if we remain a country of people who are sicker than we need to be, we will once again be sitting ducks for the next pandemic.

Brian Lehrer: Dr. Galea, you have a fan in the Bronx. Jane in the Bronx is calling in. You're on WNYC. Hi, Jane.

Jane: Good morning. I'm a big fan of Dr. Galea's work, and I just wanted to ask you about an article, long-ago article, which I have found so useful as a public health person where you talk about death attributable to social factors in the United States, and you break it down. It's not just racism in your article, at least at that time, and this is from several years ago, it's low education levels. It's racial segregation, the residential segregation. It's low social support. It's individual-level poverty. I'm sure you remember the article. It's income-

Dr. Sandro Galea: I do.

Jane: -inequality. A fantastic article to me because it helps connect the dots for people who might not understand that it's not a person's race that has anything to do with the COVID mortality rate. It's not their race, it's not even a real thing science-wise, real thing socially wise, but not science-wise, but the virus doesn't go around and say, "Oh, this person's skin is dark. I'm going to infect them." We all know that, but then I think it's hard for people to actually connect the dots, and when they hear things like Blacks get COVID more than whites, I think that sometimes maybe inadvertently re-enforces the idea that there's something about Blackness when that isn't the case at all. Your article was so fantastic in using real data and breaking it down. I'm wondering if you can comment on your updated thoughts on that fantastic article, it drew me to follow you a lot-

Dr. Sandro Galea: Oh, thank you.

Jane: -and how it plays out in terms of COVID so that we can help people understand the connection between these things that look on the face of where I live, how could that matter? Oh, wait a minute, people who live in segregated communities, all of us actually, are all hurt by that, white and Black, I would argue. Your article doesn't really go into that, but that might be a further thought.

Anyahow, big concept, and how great it is that epidemiologists could help us understand and connect the dots between things that might not seem apparent to some people.

Brian Lehrer: Jane, thank you so much. Dr. Galea, go ahead.

Dr. Sandro Galea: Thank you, Jane, and thank you for going back to that article. Fundamentally, it is a host of factors, education, housing, stable income, that all matter to our health. Perhaps a way of connecting the dots, as Jane was asking, is let's take something like segregation. Redlining was the practice that really started almost 100 years ago, where the federal government was trying to encourage Americans to own homes. They established The Home Owners' Loan Corporation, and The Home Owners' Loan Corporation was there and helping guide banks as to where to make loans mortgages. To do that, it would take maps and color them green, yellow, or red.

Well, the areas that were green were banks were encouraged to make loans. The areas that were redlined, marked in red, were areas where African-Americans lived, this is in the 1930s, and banks were discouraged from making loans there. Now, what did that result in? That resulted in two things. Number one is Black Americans, white Americans were segregated. Number two, Black Americans could not buy homes, and as a result, accumulated less wealth and had fewer assets. Number three, the neighborhoods that were historically redlined, 80, 90, 100 years ago, are now neighborhoods that are lower-income neighborhoods where there's poor housing stock, where there are more people living per room. COVID comes along where risk of transmission has increased dramatically if you're around other people, and those same neighborhoods where there was redlining, now, 90 years later, have higher rates of COVID.

To Jane's point, it has nothing to do with race as a genetic skin color. It has everything to do with race is a social construct that we marginalized and disadvantaged a particular group, which then goes on to have adverse consequences 90 years later. Really, it's raised as a social construct. It is income and wealth as a social construct. It's housing, it's our access to childcare. It's all of these forces that fundamentally keep us healthy.

I might go back to the Blind Willie Johnson's story that we started with. Blind Willie Johnson died of malaria. Malaria was the disease, but what set him up to die of malaria was homelessness and poverty.

Brian Lehrer: Joan in Manhattan, you're on WNYC with Dr. Sandro Galea. Hi, Joan.

Joan: Oh, hi. I wanted the doctor to address the issue of uninsurance and how that affects everything. The fact that we are the only wealthy country that does not have a national health plan for everybody, and we know that causes low life expectancy, but what's interesting too is it causes low vaccination rates. I did hear that the group of people, it was passed over very quickly, it was on NPR, they were saying who's most likely to be vaccinated, who's least likely to be vaccinated, and they were doing it politically. They said, "Well, Democrats are most likely to be vaccinated, and Republicans are the least likely to be vaccinated just ahead of the uninsured."

Then they just dropped it and went on to the next thing, and I said, "Wait a minute. Wait a minute. Why are the uninsured the least likely to be vaccinated?" We know vaccines. They've just been trying to give them away, so we know that it isn't because the vaccine is expensive. It's obviously probably free everywhere in the United States. They're desperately trying to get everybody vaccinated, but the uninsured are not showing up for vaccines. Why do you think that is? Well, I think it's because they have already had such bad experiences with the healthcare so-called system, and you can't really call it a system because it's non-rational, systems irrational, but the uninsured have been so badly treated. They get no healthcare at all, or they get crappy healthcare, and they don't trust the system. Everybody ringing their hands about this vaccine hesitancy, oh my God, why are we having all this vaccine hesitancy? I would suggest that until we get rid of our, what I'm calling single-payer hesitancy on the part of major Democrats and all Republicans, until we get rid of our single payer hesitancy and get ourselves a good single payer system, we will have vaccine hesitancy.

Brian Lehrer: Joan, thank you very much. I will note that part of the premise of your book, Dr. Galea, is that we talk too much about health insurance when looking at the real roots of health disparities in this country, and yet health insurance disparities do run along racial lines and class lines as well. How do you respond to Joan who's obviously an advocate of single payer.

Dr. Sandro Galea: It strikes me that the access to health care when we need it is a fundamental human right. The fact that we don't have it as a country is a real tragedy.

To Joan's point about vaccines, this is well known, that the single biggest indicator that you're going to get a vaccine is actually having a healthcare provider. People who have not had healthcare providers are much less likely to get a vaccine, which then that's how it ties into people without health insurance. We've known this for a long time. Of course, now that we realize that we might actually need to get people vaccinated quickly for something, we might make an effort to make sure that everybody has health insurance so that everybody can actually have a healthcare provider.

I think to go back to some metaphors, it's like health insurance and doctors, a little bit like a goalie in soccer, like you actually want to have a good goalie as the ball comes close to the net to save the ball, but you really want to be able to move the ball up field, meaning to stay healthy, and to stay healthy, you need to have a park where you can exercise stable income, livable housing, clean air, drinkable water, and that's what you need for a whole team to keep you healthy. This is not an argument against medicine or against health insurance. Not at all. We all want a good doctor and a good nurse when we're sick, but we'd all rather not be sick to begin with.

Brian Lehrer: Lucy in Westchester, you're on WNYC. Hi, Lucy.

Lucy: Oh, hi. I think it's really simplistic to constantly say racism is the problem with all of these things. I'm a Black 56-year-old mom. I see my kids when they went to college, there are Nigerians who come here, they are Black. They work hard. They believe in education, and they realize, "Wow, if I work hard in school, I could get my college education paid for." Then they go into the workforce. I just don't buy that. I'm sorry, I'm walking in the woods, but also the culture. there are cultural problems, a large group of Blacks don't believe in exercise, eating the right food. That's not racism, that's from years of that's how they were raised. This is the diet that you eat, exercise isn't important. I think when you constantly blame racism, that only makes it worse because then you're giving people a reason not to succeed.

Brian Lehrer: Dr. Galea, a big challenge.

Dr. Sandro Galea: It's a big set of questions, Lucy. I think the one of the previous callers said it right, race is fundamentally a social construct. It represents our full set of life experiences. In this country in particular, given its history of race dominating political experience over, really since the country's founding, it has been a proxy for a whole set of other experiences. If you are of a particular race and you have experienced worse neighborhoods, access to worse foods, access to worse schools, all of those are then going to become part of your lived experience. All of those are going to become poor health. None of that I think takes away from the notion that we all have individual autonomy, and we all have a responsibility for taking in health messages and living in a way that promotes health.

If I may come to vaccines for a second, it is too easy, I think to say, well, you should get vaccinated. Well, if you have been in a position where throughout your whole life, you've been given reason to mistrust the health system, where you have never been treated with respect, where you have actually never had the attention that you thought you needed, well, why would you then trust the health system today when we urgently say you should get vaccinated?

I think it's not so simple as to say individual autonomy, individual determination is separable from our context. I think the two are deeply interwoven. I agree completely with Lucy, that there is nothing simple here. These are all really complex problems, but I think we, as a society, have for far too long erred on the side of saying it's all about individual responsibility without recognizing that what we consider to be individual autonomy is nested within the context that we live in, within the choices that we have available to us, within the experiences that we come in and that we encounter day in, day out.

Brian Leher: Before you go, Dr. Galea, can I get your thoughts on a couple of things in the news right now? I'm still kind of haunted and therefore re-evaluating my own position by your take on those lyrics from the blues song we played at the beginning from 1928, about the 1918 flu pandemic. The noble said to the people, you better close your public schools until the events of death has ending, better close your churches, too. You write about what you see as the heavy bludgeon of the early lockdowns, including shutting schools may have been overbroad and may actually hurt the more socioeconomically vulnerable people in society who you're trying to help.

Even though what was in the public health officials' minds, I think at that time was protecting the people who are most vulnerable, because if you're going to stop the transmission of the disease, you have to stop contact person to person as much as possible when we were at that beginning surge of the pandemic. Now we have still a bunch of rules, vaccine mandates for city workers. That was a big debate in the earlier part of this program. That's a huge debate in New York City right now. I'm not sure if it is in Boston too where you are. Vaccine mandates to get into restaurants, and get into clubs, and things like that. I wonder where you are on that, if you thought the lockdowns were too blunt an instrument.

Dr. Sandro Galea: I think we need to distinguish which time period we're talking about. In March April of 2020, when this was a new disease, we did not understand, I think a blunt approach is to say, let's try to protect as many people as we can, were entirely reasonable. It's hard to second guess that period of time, when really we're dealing with something we did not understand.

Then you move to the fall of 2020. By then we knew that the disease ultimately was severe among people over a certain age, among people with underlying conditions. We knew the children were actually very low risk of both getting COVID or transmitting COVID or have severe COVID. We knew, for example, that there were many other much more severe threats to children's lives, including things like motor vehicle accidents, like car accidents. We also know that education is perhaps the single biggest predictor of people's health over their life. That making sure that everybody's as educated as possible reduces mortality over the life course.

When we keep kids out of school, and we know now that kids math scores, for example, over the years 2020 substantially lower than they were in 2019, 2018. When we're keeping kids out of school, we are now injecting into the system a disadvantage to all the kids who work at those school, and the disadvantage is not experienced evenly. It is kids who already are disadvantaged, kids in schools that are predominantly schools with kids of color in them, which are the ones that are suffering the most, while kids in schools with predominantly white kids have the resources or have opportunities to get homeschooling that is adequate.

We introduced a system that further disadvantage the kids who need the most help because of fear about a risk that it was actually relatively small for kids and for the people around them. I think we acted in that way because we were afraid. We weren't thinking actively about our goal as a society should be to narrow gaps, narrow both social and economic gaps, and narrow health gaps, and not let another disease help us widen gaps, which is exactly what this virus did. I think that requires a cool head, but also clarity about our priorities, clarity about our values.

Brian Lehrer: Dr. Sandra Galea, epidemiologist and physician, is Dean of the Boston University School of Public Health. His new book has a title that riffs on James Baldwins' 1963 classic, The Fire Next Time, it's called The Contagion Next Time. He's got a virtual book event coming up on Thursday. If you're interested in getting onto Zoom and hearing more of him, five o'clock, Thursday, via the Harvard bookstore, where he will be in conversation with Arianna Huffington, that's free, but there is a suggested $5 donation. You can find the link on the Harvard bookstore event calendar, or we'll post the link too on our show page at wnyc.org, click on Brian Lehrer Show.

Dr. Galea, thank you so much.

Dr. Sandro Galea: Thank you for having me.

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