Understanding hate through a public health lens

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Sandro Galea: The question is how does hate affect health? The people who are expressing the dislike may act on the dislike and hurt others. There is a very direct pathway to trauma and violence.

Gretchen Miller: Hello, this is Prevention Works, I am Gretchen Miller and I think it’s fair to say we live in particularly hateful times – spend any time on social media and you’ll know what I mean.

Sandro Galea: I think there is a pathway through hate changing the public conversation chipping away at civility and that gives license for many to act on their worst impulses to then target and hurt others.

Gretchen Miller: To talk about hate we are welcoming a rather special guest, brought to Australia by The Australian Prevention Partnership Centre. Sandro Galea is one of the most important and innovative voices in American health and medicine. He’s named one of Time Magazines epidemiology innovators and listed as one of the “World’s Most Influential Scientific Minds” by Rueters. He is a physician and author, and dean of Boston University’s School of Public Health.

Gretchen Miller: Welcome and thanks for joining us. Before we get to hatred, can we start with a reflection on health generally? I think we are doing pretty well, aren’t we, globally speaking? It’s better today than it has ever been, for some of course, but poor economic development and poor quality health are inextricably tied. And on the other hand, some high health-spending countries, like the USA still have poor health outcomes. And in fact, life expectancy has dropped over three consecutive years. How can that be?

Sandro Galea: So first of all, it’s important to recognize that this is a better time to be alive from the perspective of health than ever in history. Life expectancy has doubled over the past 100 to 150 years, which is extraordinary, all due to improvements in public health. Having said that, we are at a place in history where we can do better, we can do much better, because we know what it is that we can do to improve our health. So, let’s talk about the United States as an example. The United States has worse health than any other high-income country. That’s despite the fact that it spends more than 40 percent more on health care than its next closest competitor. Why is that?

Well, the answer is because America spends all its money on health care, on medicine. It does not invest in the other forces to generate health and that is a very instructive lesson because it really speaks to what are the forces that generate health. And the forces that generate health are not health care, those forces are the world around us.

It is economic conditions. It is gender equity. It is having stable housing. It is having parks to play in and recreation. It is having healthy food. That is what generates health and those forces the United States under-invests in.

Gretchen Miller: So, do we properly, as a wider community, understand of what public health is?

Sandro Galea: I think we have a challenge with understanding what public health is? I think we simply do not understand that public health is about generating health in as many people as possible, for as long as possible. We tend to think of public health as being about vaccines and hygiene, it is that, but it is much more than that.  Public health is about creating a world around us that generates health. It’s about the air we breathe, the water we drink, the food we eat. It is about where we live, where we work and where we play. That is what public health is about. It is about changing those conditions so that you and I can be healthy, and we can live up to our potential.

Gretchen Miller: As I recall it, there used to be a lot more thought about those wider conditions and their impact on us as a community, and that of course means social health as well as physical health. Do you think that things have changed over the last, 40 to 50 years?

Sandro Galea: Yes, I think they have, and the evidence is that they have. I can speak to this best from the American context where I live. The United States has worse health indicators than any other high-income country, but it wasn’t always like that. That’s really a turn for the worse in American health in the past 40 years or so. There has been a slow gradual disinvestment in the notion that the world around us is inextricably linked to health and I think there have been many forces have contributed to that.

I think one of these forces is the rise in medicine, in the salience of the idea of medicine, that there can be a magic pill, that silver bullet, that you and I can take to make us better and we have grown in our fascination with that notion and some ideas like the precision medicine movement are really the ultimate expression of that thinking.

I think a second force has been a growing disinvestment in collectivism in the notion that our health and our lives are inextricably intertwined. There has been a growth in the idea that I can make myself healthy and I may care about you because I’m a nice person. But really, I don’t really think that my health and your health are interlinked, when in fact of course they are. So, there’s been this growing individualism coupled with a growing fascination about the power of individual behavioural change. Those two have created license for a societal disinvestment from the forces that make us healthy.

Gretchen Miller: And you could add to that economic forces because health is a profitable business?

Sandro Galea: Yes. There’s no question. But I think economic forces that have reinforced both of those tendencies. I think economic forces have obviously reinforced the development of medicine and curative care. They have also reinforced the notion of the individual behaviourism. This notion that I the individual can control everything about my health and there is an enormous industry around health behaviour change, wellness, and all of that ultimately is predicated on this idea that my health is all about me and it forgets that my health does not exist without context.

Gretchen Miller: So, what are the challenges in this context for the field of epidemiology now?

Sandro Galea: Epidemiology really is about understanding the causes of the health of populations, so that we may intervene and improve the health of populations.

Gretchen Miller: And so how epidemiology opens itself up is a matter of broadening its considerations to all those other areas?

Sandro Galea: Exactly. And that has substantial implications. It has implications for causal thinking and it has implications for the question of how is something a cause and how is something a cause that you can do something about it.

So, let me give you a concrete example. Race is a good example. We do know that there are enormous health differences by race. Is race itself a cause or is racism the cause? Are the social and economic conditions that are faced by people of different races the cause? It’s probably what it really is, it is not really about race which is ultimately simply about skin colour which involves negligible changes in our genetic structure. Race in and of itself is immaterial to our health. What is material to our health enormously so is racism that people face, the economic opportunities, the structure of intergenerational transmission of wealth and opportunity that people of different races face. And those are the causes that are most of interest to epidemiology.

Gretchen Miller: We’ll get to that a bit later. You have also talked about how epidemiology could take advantage of big data and has been reluctant to do. What did you mean by that?

Sandro Galea: Epidemiology has as one of its defining features, I think one of the things that makes epidemiology an interesting and worthwhile discipline, is that it’s very rigorous in thinking about data and how data contributes to incite about the causes of health of populations.

As a result of that, I think epidemiology has been careful, perhaps suitably careful, about what data it uses. At the same time, that care perhaps sometimes becomes cautious and reticence to embrace the availability of big data things like social media data, which of course is involves millions and billions of data points, and I have written that insofar as epidemiology is about understanding the causes of population health, we should engage with all data sources that can give us insight. And if those data sources are big data sources, then we simply need to learn how to deal with their imperfections.

Gretchen Miller: Especially big data sources like social media, which is so chaotic.

Sandro Galea: But there are insights to be gleaned from that, that we really cannot of get from anywhere else. For example, I think social social media data can inform us about the public conversation about how does the public conversation change how we think and how we act, you really cannot get that anywhere except from social media data.

Gretchen Miller: So, your book ‘Well’ is a clarion call in a way, but of course you were hinting at this before, it’s not concerned with the popular ‘wellness’ industry with its shonky gizmos and dubious recommendations for personal wellbeing and that’s really important, why? What’s happened to the idea of wellness?

Sandro Galea: It’s been very interesting. I think the idea of ‘wellness’ has been taken over by an industrial segment. I think it is a commercial segment that promotes ideas about what an individual can do in isolation, on the promise that it’s going to make you well. And that is another manifestation of our focus on individual wellbeing at the expense of thinking about the world around us.

The story I have used to illustrate that, if I may, is the story of a goldfish. And if you have a goldfish in a bowl and you’d like your goldfish to be healthy, you tell your goldfish to exercise, to swim around the bowl 10 times clockwise, 10 times counter-clockwise. So it stays fit, and when you feed it a little flaky food that you feed goldfish you tell it not to eat too much so it doesn’t get obese. And when the goldfish gets sick, you get a goldfish doctor, so it stays healthy – and that’s what the wellness industry does, swim around the bowl and eat well, get a good doctor and then of course one day the goldfish dies and you say, why did the Goldfish die? It exercised, it ate well? Well, the reason it died is because we didn’t change its water.

That’s really my concern about a wellness focus is a singular focus on individual and individual behaviours. It is forgetting the water and the water is everything around us. The water is our social interactions, our social networks, the places where we live, the policies and laws and regulations within which we live, whether our roads are safe, whether we are under danger of being assaulted because we walk down dark streets. That’s the world around us.

Gretchen Miller: Thank you. So, your book is about what it takes to make a well society really. And the contents page of your book lists some really big themes, that actually are big themes throughout human history, from money to power and politics, place, love-hate, compassion, choice and luck. These aren’t traditional keywords for epidemiology, they’re more archetypal forces?

Sandro Galea: Yes, they are. But they are forces that are ineluctably linked to our health and I think we need to take them into account.

For example, luck. We never talk about luck and we would never think to talk about our luck unless we feel we’re being particularly unlucky. But you and I are both sitting here relatively able-bodied and a lot of that is due to luck of the genetic draw and of the parents we happen to be born to and when one realizes that, it should imbue us with humility to recognize how much luck plays a role in the generation of our health, and we should recognize that.

Gretchen Miller: Humility is an interesting word for an epidemiologist.

Sandro Galea: There’s a chapter on humility in the book. And the reason there is a chapter on humility in the book is to try to urge us to have the humility to recognize that what we think causes health changes as we know more and more, and we should be not be as rigid about our preconceived notions.

I use the example that 200 years ago we used to think that our health was determined by a balance of our blood and our bile, yellow bile and brown bile and our phlegm. That’s why we used to bleed people when they had fevers. We used to bleed people when they had fevers because of the notion that their blood and phlegm was out of whack and that they needed to be bled out to let out the bad blood out. Now you and I are sitting here today and we think that’s silly.

Why would you ever think that but that was the prevailing understanding of the costs of health for 2,000 years. In fact, our understanding that’s different than that is relatively new to only the past 200 years. So that has implications for how we think today and let me give you one more concrete modern example.

What is the leading cause of death in Australia or the United States? Is it heart disease, or is it tobacco smoking, or is it low education? Now, the answer is of course it’s all three. It depends on your paradigm. If you’re looking at the physiological paradigm, you’ll see it’s heart disease. If you look at the behavioural paradigm, you’ll see its tobacco smoking. If you’re looking at the social structural paradigm, you’ll say it’s low education. But how we label the causes of death matters for how we invest our resources, if the leading cause of death in our mind is heart disease, we are going to invest in a national institute of heart disease research, be it in Australia or the United States. If we say the leading cause of death is tobacco, we are going to invest in national institute of tobacco smoke research. If we say it’s low education, we are going to invest in a research institute about how education affects health. So, we have to have the humility to recognize that our lens on the world dictates how we operate, where we put our resources and the research questions we ask and the actions we take.

Gretchen Miller: So, we don’t have time to talk about every aspect and every archetypal force that you mention sadly, but we should spend some time talking about hate and public health, as you did in that incisive discussion, hosted by the Prevention Centre earlier this month. It’s fascinating because when you speak about cultural power, and that is one of the topics of your book. There seems to be so very much hate around lately and I’m pretty sure that that level of hatred and fury isn’t healthy. We will talk about how practically on a policy level we might address this shortly. But first, we should unpack what hate means. Can you give me a definition?

Sandro Galea: I think the standard definition of hate is an intense dislike of the other, of someone else of one group to the other, and from a health perspective the question is, how does hate affect health? And I think hate affects health in three ways. Number one is that people who are expressing this dislike is that they may act on this dislike and hurt others. There’s a very direct pathway to trauma and violence, physically hurt others – that’s number one. Number two is, I think there is a pathway through hate changing the public conversation, hate changing our social compact, hate chipping away at civility, and that gives license for many to act on their worst impulses to then target and hurt the other.

Gretchen Miller: And so, we’ve got physical one-on-one violence, but then we’ve got more insidious violence you’re talking about?

Sandro Galea: Yes, more group-like violence.

Gretchen Miller: And that doesn’t have to mean gangs attacking other gangs?

Sandro Galea: Not at all. It simply means that we’re dealing with populations, millions and millions of people, and we have a responsibility to collectively encourage the better angels of our nature, and I worry that hate and hate speech in public gives license to the worst angels of our nature. That’s what I mean by that. I think the third pathway is that when we become accepting of hate as a norm, we accept policies and practices that create marginalization, that we marginalize and separate ourselves from each other and from the other. So for example, hate as a guiding public policy will result in efforts to segregate, to separate the races and that we know with health is associated with poor health, because segregation is linked to differential availability of resources and the groups that are marginalized, the groups that are vulnerable, will end up having less access to those resources.

Gretchen Miller: And that simply speaking is about things like good public hospital care, but also good education, good social resources, like parks and all of that. So, I wonder if you’ve personally spent any time on social media as you investigate your thesis, and have a thought about the frenzy of fury and hatred that we’re seeing?

Sandro Galea: Yeah, I worry about that. There is a substantial social media outrage over really the smallest thing that then results in groups othering other groups. I mean just with my visit to Australia because it was built that I was talking about hate and a couple of forums triggered social media micro-storms of people criticizing me. At a personal level, it doesn’t particularly affect me, but that’s just problematic of the larger social discourse and I feel like social media in no small part, because it feels anonymous, allows this rending of social fabric. It allows us to cast aside the responsibility towards civility towards one another and that is problematic.

Gretchen Miller: Do you think that in some ways it reflects on our collective mental health, these outpourings, these storms as you say?

Sandro Galea: Yeah, it’s an excellent question. I think because mental health, I’ve often said is the canary in a coal mine. Because mental health changes rapidly. It changes much more rapidly in response to social exposures than does let’s say heart disease or cancer. So I do think that mental health is changing in response to this vituperative culture that we’re living in and there are data to show that social media does affect mental health or data to show that seeing images on television or transmit social media are associated with poor mental health after traumatic events, for example, and I would expect that social media experience is likewise linked to adverse mental health.

Gretchen Miller: I wonder about the disinhibition that allows us to let fly, as you say the worst angels of human nature? It’s interesting that you use the word angels, but you do talk about leadership in relation to letting those angels fly. What do you mean by that?

Sandro Galea: Well, the problem, the central role of leadership in any institution, be it national or municipal or in a private or public institution, is culture and norm setting. That’s what leadership does and if leadership is going to signal that language that harms others is acceptable. It is not unreasonable that those who are following a leader, in whatever particular context, are then going to think that it is.

So that’s what I mean when I say it gives rise to the worst angels of our nature. I do think that leaders have a particular responsibility to use their words carefully because their words are setting the standards for everybody else who is in their institution. So, I do worry about that than at the global level we see this all the time with the language is being used by some very prominent leaders.

Gretchen Miller: Obviously being hated can lead to being shot. I mean that’s a really just simple equation if you’re in the USA. What are some of the other health impacts of hate we might see somewhere like Australia where guns are not available?

Sandro Galea: The consequences of hatred, if you’ve followed the paradigm I am saying, is that there direct consequences in terms of trauma and violence and indirect consequences because you end up with other forces like segregation, discrimination and racism that extend throughout the entire health spectrum. We know that there are mental health consequences of these forces there are physical health consequences. We know, for example, spatial racial residential segregation is associated with heart disease that groups that are minority groups that are segregated have worse heart disease indicators and groups that are not.

Now, why is that? There are a whole range of forces through social stressors that in and of itself has physiologically detrimental effects through the absence of resources that promote health and those resources are access to good health care. Yes, but more importantly, access to education that leads to better health behaviours, access to parks and recreation, access to nutritious food, access to healthy habits and healthy environments.

All of those are socially patterned, socially structured. And in a world where policies and regulations are patterned on a dislike of one group by another and particularly where the dominant group is setting policy in a way that further disadvantage of a marginalized group. We are going to be reinforcing the negative forces that harm health of marginalized groups.

Gretchen Miller: Is hate therefore mainly an issue of race in the context of your research?

Sandro Galea: I think race has historically been perhaps the most obvious manifestation of hate. But I think hate emerges on multiple other social dimensions. It emerges around immersive social class, particularly lately around immigration status among aliens, and the othering of aliens is a particular concern in the United States. And I know it’s also a concern to some extent in Australia. I think hate is ultimately the fundamental force that drives misogyny, which is based on genders. We see hate based on religion. I think there are many different dimensions, all related to aspects that define us and all of it. And all of it, all of it should be abhorrent.

Gretchen Miller: I wonder about measurable impacts. Maybe you could give me some examples of how you’ve been able to measure this?

Sandro Galea: We have done work looking at the health of Arab-Americans in the post 9/11 context where there was a rise in hate directed at those groups become stigmatizing of Arab-Americans marginalization of Arab Americans, and we showed that those groups had worse health indicators as a result of the social stigma. The hate that came from the turbulent moment of cultural time, and I actually don’t think that that’s resolved. I think Arab-Americans remain marginalized in the United States to this day.

Gretchen Miller:  In a way that they weren’t before?

Sandro Galea: I think in a way that they were not before. I don’t think Arab-Americans were ever fully assimilated, but certainly in a way that they were not before, and particularly every single time when there is an incident of global conflict which involves a particular group you end up with this stereotyping and marginalization of that group in this context being Arab-Americans. So there are data that showed us this.

Gretchen Miller:  Is that mostly around mental health or is it starting to play out in terms of physical health? It’s been what 18 odd years.

Sandro Galea:  It’s both the best available data is about mental health, but I would expect now to be seeing its shadows in physical health as well, right?

Gretchen Miller:  So, I wonder if hate results in poorer mental health outcomes for the haters?

Sandro Galea:  Yeah, it’s a good question. I think there is a little bit of evidence on that, but not very much. Most of the evidence is in the domestic violence literature where abusers have been shown to have poorer health that is associated with that defining characteristic, and it’s complicated. Why is that? It’s probably a whole set of factors that are actually go with that behavior of abuse and typically it is male-on-female behaviour, not exclusively, but typically.  But I think the existence of hate in the hater represents a confluence of negative forces that I would expect would harm the health of the person who is allowing themselves to hate, not as much as but also worth considering in the context of hate and it’s dynamic.

Gretchen Miller:  So given that hate is such an all-encompassing challenge, it’s philosophically so, psychologically, spiritually, socially, all of these things together affecting our public health. It’s also preventable and I wonder if hate is an emergency and if we should see it as a crisis?

Sandro Galea: That’s a great question. It really is an odd moment in history to be sitting here and saying, should hate to be a public health crisis? It was sort of inconceivable five years ago that we’d be sitting here having such a conversation, but it does feel like this conversation is worth having right now and we haven’t discussed in this chat that one of the challenges with hate as a public health issue is that guns, particularly in the American context, give voice to hate.

In many respects, if the tools that haters have available to them are blunt spoons, they’re only going to do so much harm. If the tools available to them are guns where one can kill easily, one can do a lot more harm acting on that hate. So, there’s this confluence of hate going mainstream, a giving of license to forces that aim to hurt and harm others. And the ready availability of tools that one can use to exercise that harm, to act on it, that is that is an unfortunate confluence of factors.

Gretchen Miller:  And it does seem like a critical point in the US with a massacre just about every other day?

Sandro Galea: It does, it does feel that way in the US demonstrably has about one mass shooting, which is defined as about four people, being shot every day of the year. About 40,000 Americans dying from guns every year. Guns are a defining epidemic of our time in the United States.

Gretchen Miller:  We have some legislation around hate and there are some sobering figures that the Prevention Center has put together around that legislation, which is worth articulating here. In Victoria for example, there were 4257 fueled by hate incidents over a four-year period, but in that same four-year period across Australia, only 21 people were convicted of a hate crime. And the police service has been accused of having its collective head in the sand about hate by US hate crime expert Matt Browning.

In Tasmania, the Northern Territory and the ACT, racial vilification isn’t a criminal offense, but it is in the other states. However, in New South Wales, where it is a criminal offense, there has not been a single person convicted of threatening or inciting violence based on prejudice since those records began – even though some of our most public media figures have actively incited violence. I just wonder why our public officials find hate so difficult to deal with, even from a legal perspective and a criminal perspective?

Sandro Galea: If I think the challenge in Western democracies has been the tension between freedom of expression / freedom of speech and what to do with speech that harms others. Freedom of speech does not mean that there should be a license for unfettered speech, all speech ultimately is limited in some way by official sanction or informal social sanction. We limit our speech all the time. So, the notion that is often bandied about the table. Well, it’s all about free speech, I can say what I want, is frankly nonsense because I do not see what I want and neither do you. We live within a world of constraints on our speech. Most of those constraints are informal and some constraints are formal. Speech that exists only to harm others, speech that cannot be rebutted, that is simply fabrication and not based on fact, and whose sole purpose is to put others in danger should be constrained.

Gretchen Miller: On a population level then, let’s get to some brass tacks. If I’m a public health policy public health policy maker and hate is surely preventable, and preventable disease is what concerns us here at The Australian Prevention Partnership Centre, how do I address this, practically speaking, what can I do?

Sandro Galea:  I think first and foremost we address it through how we live on a day-to-day basis? I think our public health, those in leadership positions in public health, have a responsibility to set an example by being careful that they are promoting the antidote of hate which is like I’ve written, is love or agape. Ultimately, it is language that is inclusive and that promotes equity and justice. That’s number one.

Number two is that we should call-out hate when we see it and I think we have a responsibility to have the kind of conversations you and I are having, where we say this is a public health issue. We should be very clear that hate should be intolerable, even if it had no health consequences, but the fact that it has health consequences makes it an important issue for us to tackle from a health point of view and you’ve upped the ante in this conversation by saying, is hate a public health crisis, which I must admit I hadn’t thought of it that way, but I think there’s an important conversation to have because that raises awareness and raises alarms, appropriate alarms, that this is a social force that we should not be tolerating.

Gretchen Miller:  And so, as a policymaker, to help change the public conversation. Does that mean we are talking about policy makers working with lawmakers and urban planners to bring about a more civil society?

Sandro Galea: I think that would be lovely.

Gretchen Miller: Is there one practical way about going about it because we’re talking you’re talking about agape … you know, we’re talking Greek here.

Sandro Galea:  We are we’re talking about the basic criterion for health. The basic criterion for health is that all public policy and all private sector actions should be weighed against the standard of how they affect health and if that’s the case then we should be thinking in policy about how is it that particular policy language? How is a particular policy contributing to health? That should be the basic criterion that guides our public policy.

Why, for two reasons. Number one, the world around us is what drives health. And number two, health is perhaps the single most important unifying value. You and I may disagree about a whole host of issues about what matters to your life and to my life. We do not disagree that we would both like to be as healthy for as long as possible, and we want our children to be as healthy for as long as possible. So therefore, that creates a common ground which we can build. We can say, what are the forces around us that should align to achieve that aspiration?

Gretchen Miller:  Why do we care about health? What does health bring us, as humans?

Sandro Galea: I see health as a means, not an end. Lets use the analogy of driving our car. How many people enjoy taking their car to the shop, nobody. What do you want from your car and what I want from my car is that it works, and it lets me do what I’d like my car to do. Maybe I get the thrill of driving the open road or maybe I just use my car to go from A to B, it doesn’t matter. That’s what I do and what you do. Health should be the same way, it should be a means, we should not have to worry about our health. We should all die healthy. That’s what we actually want to be. We would like to be as healthy as possible for as long as possible.

I think health creates the potential for us to flourish, creates the potential for you to do what you like to do and me to do what I would like to do. We would like our health not to be in the way.

Gretchen Miller: So it should be a secondary thing. It shouldn’t be something that we have to be concerned with.

Sandro Galea: Correct, that’s the kind of world I would like to live in.

Gretchen Miller: Because there are other things to be concerned with.

Sandro Galea: There is a whole set of potential that humans can achieve by not having to worry about being healthy or not. I would like to see the human potential unleashed by people being as healthy as they can possibly be.

Gretchen Miller: So what is the healthy antidote to hate? Is it inclusion? Is it kindness? Is it love? Is it empathy, care or compassion? And how do we how do we buy these at the chemist?

Sandro Galea: Well, I like all of those things. My favourites are love and compassion. Compassion is an effort to restructure the world to bring about the forces that generate health, it is an effort to do good. Martin Luther King had a good definition of compassion. Compassion is not giving a coin to a beggar. He said, it is asking why is he a begger to begin with? That is compassion. What are the forces around us that result in some of us not having lives that are as rich as they should be, and saying, it is a better world if we act on those forces so that everybody can realize their potential, that’s compassion.

I think love is love of others. We started the beginning by you asking me to define hate and I said hate is a dislike of others. By love, I mean an embrace of humankind and saying that all people are ultimately equal and we should create the forces that everybody has the potential to realize their talents and to do what they would like to do in their life. That is the alternative to hate – love and compassion.

Gretchen Miller: Professor Sandro Galea, thank you so much for your time today. It’s been an absolute pleasure. You can find show notes and links wherever you get your podcasts or on The Australian Prevention Partnership Centre’s website and The Australian Prevention Partnership Centre hosted Professor Galea, and it also hosts Prevention Works.

I’m Gretchen Miller and we will see you next time.