Friday, September 9, 2022

Q&A with Michael D. Stein




Michael D. Stein is the author of the new book Me vs. Us: A Health Divided. A physician, his other books include Broke. He is Professor and Chair of Health Law, Policy and Management at Boston University's School of Public Health.


Q: What inspired you to write Me vs. Us?


A: I am a primary care physician who took a job in a public health school six years ago. That transition opened for me a new way of thinking about the world. I understood for the first time that health and health care offer very different perspectives.


Health care, the work I did in my medical office—interviewing, examining, testing, diagnosing, treating--involved taking care of patients one by one (what I call “me” work).


Creating health, on the other hand, involved more broadly thinking about populations (what I call “us” work), preventing illnesses that might affect them—whether infectious disease or obesity—and the policies it takes to make life longer and better.


Certain statistics that I learned soon after joining the public health world really bothered me. Why did the people living in the richest counties in the US live 20 years longer, on average, than people living in the poorest counties?


The combination of causes—poverty, bad water, bad air, poor food—could only be addressed by public health officials working at scale (if the political will was also there) in those places. Place matters; public health strategies are both hyperlocal and national.


In addition, it’s clear that the life expectancy gap would never be filled by putting more money into health care systems, even if those systems addressed the inequities in care we all know exist in the poorest places.


So writing Me vs. Us is my way of saying: Reader, if you want to improve the health of all, then let’s turn the conversation away from doctor visits to public health and understand why we haven’t paid adequate attention to public health over the past 50 years, while pouring money into health care that now constitutes nearly one-fifth or our economy.


Q: You write, “Covid-19 presented the opportune time to discuss Me and Us contending world views. In short order, everyone became a doctor, assumed an intimate perspective about health and disease transmission.” What impact do you think the pandemic has had on people's attitudes toward medicine and public health?


A: There is nothing like an infectious disease outbreak to make us think that other people matter for our personal health instead of thinking that we alone determine whether we will be well tomorrow.

There remains, even at the tail end of Covid-19, a greater attention on the health of those living around us. We think: I’d rather this infection is gone from my community not only so that others don’t suffer, but also because then I can safely ride the bus, go to the market, sit in a theater.


We want out health care system to function (and not be overwhelmed as it was in early 2020), but we realize preventing illness is the best to way unload the burden on health care providers.


I like to think that the pandemic also made clear that suffering is unjustly distributed in this country. Who bore the brunt of Covid-19?. The old, the homeless, prisoners, people of color, essential workers, the uninsured. Caring for these groups requires thoughtful policies, a clear public health to-do list, and not more doctors and nurses and hospitals and MRI scanners.


Let’s hope that we can carry forward a few of the lessons we should have learned from this pandemic: paid sick leave helps, improved ventilation in buildings helps, free vaccines help.


Unbelievably, terribly, sadly, more than a million people have died in this country. Those who have the privilege of good health should not forget that health is a fleeting and precious thing and that we all are one diagnosis or one accident away from disability.


Q: What do you think are some of the most common perceptions and misconceptions about the field of public health?


A: I’m not sure there’s a clear picture of the field of public health out there. In good part the confusion is justified because we don’t really have a public health system. We have instead about a hundred mini-systems, networks of city, county and state health departments.


The Centers for Disease Control and Prevention (CDC), famous for its scientific prowess, the agency we naturally think of as the centerpiece of American public health, actually has no final authority over these mini-systems. And so, as we saw during Covid-19, there was really no federal coordinating center that could handle a nationwide infectious disease outbreak.


What do the 270,000 public health workers of America do when there is no outbreak? There is no standardized job description for a public health practitioner. The everyday work depends on where you work.


In general, public health workers are responsible for clean water, food, and air in their communities, and must be ready to respond to acute threats from infectious or environmental agents, while also administering services to prevent diseases (like vaccinations), and providing an accurate accounting of disease rates for their community.


It’s a potpourri of functions that as we’ve seen in these past few years must be performed by overstretched staff, with meager budgets, in crumbling buildings, using archaic equipment. All while explaining to citizens its rationale for various recommendations on the best programs to reduce the burden of the country’s leading causes of death. 


Q: Looking ahead, as a doctor, what do you see when it comes to the “Me vs. Us” situation facing the medical and public health fields?


A: The US ranks about 40th in the world in life expectancy and about the same in infant mortality; that is near the bottom of the list of developed countries. At the same time, we spend vast amounts on health care.


In those nations whose residents have higher health status and longevity, they spend about $2 for social supports for every $1 they spend on health care. In the US it’s about 90 cents on social support for every dollar in healthcare. That’s less than half the investment.


Until we’ve reversed our priorities we are doomed to die younger than we need to. And I say this during the week that our latest national data shows average life expectancy falling dramatically in the US.


Q: What are you working on now?


A: Despite my public health cheerleading, I continue to see patients in a medical office. I have a book out in a few months called Accidental Kindness: A Doctor’s Notes on Empathy. It’s a series of essays about doctors and patients interacting, and I try to unlock the mystery of how kindness, or unkindness, happens during illness, always a time of stress and complexity.


I include stories of patients I’ve cared for, and stories of when I have been a patient. I interrupt in places taking the reader on digressions about the neuroscience of empathy, how we make medical decisions, and studies that have evaluated whether kindness actually affects medical outcomes. It just got a starred review in Publishers Weekly, so I’m hoping people really like Accidental Kindness.  


--Interview with Deborah Kalb. Here's a previous Q&A with Michael Stein.

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