192: Health Is Infrastructure, with Sandro Galea

Health isn’t a button you press or a pill you take. It’s the world you live in, the air you breathe, the stability of your housing, the safety of your streets, and the way your workplace treats you on an ordinary Tuesday.

We sit down with physician and epidemiologist Sandro Galea, dean of the public health school at Washington University in St. Louis, to challenge the default American habit of treating health as something we only address once it breaks down. 

We talk about a more practical, more hopeful frame: health as infrastructure that needs continuous investment. That means prevention and the social determinants of health, not just clinical care. We also dig into resilience and why it’s not about pretending nothing hurts. Resilience is the capacity to bounce back, and that capacity depends heavily on context, not just on personal grit. Sandro shares his healthiest goldfish metaphor to make the invisible forces around us visible, from community conditions to the cultures we create at work. 

From loneliness and social connection to the long tail of pandemic recovery, we keep returning to a tough public health question: how do we balance individual freedom with responsibility to the collective? 

If you care about prevention, mental health, workplace well-being, and building healthier systems that actually help people heal, this conversation offers a grounded way to think and act. Subscribe, share with a friend who cares about health beyond health care, and leave a review with your biggest takeaway.

Sandro Galea, MD, DrPH, is the Margaret C. Ryan Dean, and Eugene S. and Constance Kahn Distinguished Professor in Public Health at the Andrew M. and Jane M. Bursky School of Public Health at Washington University in St. Louis, and Vice Provost for Interdisciplinary Initiatives for WashU.

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Responsibility To The Collective

Sandro Galea 0:01

There's no easy answer to that. It is actually quite complicated to address what is my responsibility to the collective and how much should I be giving up? And how much should the collective be giving up? These are difficult questions of calibration that mature societies need to create the space to discuss and debate.

Meet Sandro Galea And The Theme

Manya Chylinski 0:24

Hello and welcome to Notes on Resilience. I'm your host, Manya Chylinski. My guest today is Sandro Galea. He's a physician, epidemiologist, author, and he currently serves as the Margaret C. Ryan Dean of the Bersky School of Public Health at Washington University in St. Louis. We talked about treating health as something to fix when it's broken versus treating it as an infrastructure that requires continuous investment. And we wrapped in the concept of resilience in there as well. You are really going to enjoy this conversation. Sandro, I'm so excited to be chatting with you today. Thank you for being here.

Sandro Galea 1:04

Thank you for

Thin Skinned And Self-Reflection

Sandro Galea 1:05

having me.

Manya Chylinski 1:05

First question: everyone gets this in 2026. What would the title of a book be about you if your worst enemy wrote it?

Sandro Galea 1:16

It's a great question. Uh Thin Skinned.

Manya Chylinski 1:19

Oh. Okay. Care to elaborate?

Sandro Galea 1:20

e Yeah, I think I um take things too much to heart sometimes. I think uh it's um it is uh it is a uh documented in my mind weakness, and I try to work on it, but uh I um listen to things too much and uh let them get to me too much. And I realize that uh a uh healthy engagement in a complex world, particularly when you're taking on complex uh uh professional positions, requires one to be uh more robust to things like that. So I think that's a I think that's a weakness which uh can well be uh used to uh illustrate the things I don't do as well as I should.

Manya Chylinski 2:00

Okay. Okay. I find it hard to believe that there's anything you don't do as well as you should. I feel like you have such a complicated job and such an important job in the world of public health.

Sandro Galea 2:14

Well, it's very that's very, very kind of you. You know, I think um in any anyone who has uh any complicated job, I think um, you know, our responsibility is to try to do it as well as we can and uh to hopefully be a little bit self-reflective as we do to try to figure out what we can do better, and what we can do better is always starts with what we can do better about ourselves. So there you go. That's my self-reflection for the day.

Manya Chylinski 2:36

I like it. Thank you so much for sharing. I do appreciate it. So everyone has had a moment in their lives that changes how they think about being a leader or how they think about taking care of other people. What was one of those moments for

The Elevator Moment In Leadership

Manya Chylinski 2:53

you?

Sandro Galea 2:53

When I was in uh in uh early on in my um in my tenure in a prominent leadership job, I'll just sort of mask some of the details just to uh, you know, I'm I'm I'm uh an introvert, uh really quite uh sort of dispositionally quite introverted. And uh so it's hard for me to um spontaneously sort of engage people um randomly, which you know I think for people who are extroverts, it's much more natural. And anyway, I was doing this uh this is one of my earlier uh jobs, and uh the um somebody that we did a sort of an assessment of how I was doing, and somebody wrote this anecdote, and they said uh they walked in an elevator and uh they were in the elevator and I was in the elevator, walked in with them, and I didn't say a word. And the person said, it was actually very, I thought kind. The person wrote, I realize that's because you're shy and introverted, but uh in uh in your role, it did not make me feel good that actually you didn't say anything. And um I really reflected on that and I actually thought, wow, that's actually a really um, that's a really important comment that this person made. And I was grateful to them. I don't know who it was who made this comment. And um, I realized that um part of my responsibility goes back to what we started talking about, was to be aware of these things. And in my role, it wasn't fair to just indulge my comfort zone by being introverted, and uh that I um needed to make sure that I embraced the perhaps pastoral part of the role, and that required my making an effort at all times to engage with people. And that was a very um it was an instructive moment for me, and it stayed with me now for decades.

Manya Chylinski 4:29

Right. And it also sounds like it was written in a way to be constructive, not simply complaining about something you did or didn't do that they had wanted you to do.

Sandro Galea 4:39

Yeah, yes, yes. And I I uh I was uh very uh grateful to the person, whoever the person is, uh um uh for that, because uh we're all human. And I think the fact that it was it was framed uh constructively, it allowed me to be open to it. And uh, you know, I would like to think I would have been open to it no matter how it was framed, but I think, again, recognizing my our own frailty, um, when something is framed with such openness and uh really explicitly aiming to be helpful, which I think this person who wrote it went to be helpful, uh, it was uh very influential for

Health As Infrastructure Not Repairs

Sandro Galea 5:13

me.

Manya Chylinski 5:13

Yeah, it sounds like it if you've remembered it after all of these years. Um we connected in part because um I'm an avid reader of your newsletter and pretty much anything that you write. But in a recent edition of your newsletter, you were talking about how we treat health as something that we need to fix versus thinking about it as infrastructure that requires continuous investment. I'm just so curious. I I completely agree with that, and I'm curious kind of how did you come to that position?

Sandro Galea 5:51

Yes, I think it reflects reality and how we think about health in the US. And I've often used in my uh speaking, maybe less in my writing, the analogy of uh of a car that, you know, you um I I sometimes I ask people in a room, you know, raise your hand if you like going to the mechanic or the auto shop. And nobody does, right? And uh that's the difference between treating our car as something we want to keep running well, meaning by having roads that are not too potholed, by making sure that uh roads are safe, people are not running into us, versus accepting the fact they keep breaking down and then we keep going into the uh repair shop. And uh I think similarly, health, you know, us as humans with our our bodies, uh, we uh are all happier if we invest in keeping in creating the conditions so that we can be healthier and not have to spend time at the doctors. I mean, I'm I mean you know, I think uh, you know, hopefully many people who are listening to this have perfectly lovely uh doctors who they don't mind. But at the same time, I'm pretty sure that essentially everybody would rather not spend much time with a doctor at all. So I think the uh extending the metaphor, it is about we should be investing in the infrastructure, which is a term that I used, to keep us healthy. And that means having safe environments to live in, having clean air to breathe, safe water to drink, food that is nutritious and healthy, opportunities to exercise, being able to live in stable, safe housing. I mean, these are the elements that create health. And uh I think uh we are all better off for that.

Workplaces Shape Health Every Day

Manya Chylinski 7:31

Yes, absolutely. I also think about it from the perspective of the workplace or other organizations that we're part of, that though that infrastructure that we all interact with every day in some way also needs to be supportive and structured in a way to be healthy. Um, you know, I think about toxic workplaces or bullying at work and these these situations that are kind of allowed to continue that are also negatively impacting our health.

Sandro Galea 8:07

Yeah, I I think that's really important. And it is important that um we um that anyone who has any any um position of responsibility authority over workplaces does everything they can to create a healthy, productive, positive workplace. And we all have responsibility to our own workplaces. So I think uh the um what creates a healthier, better world is uh the conditions within which we live. And those conditions extend very well to workplaces where we spend the majority of our working week.

Manya Chylinski 8:42

Yes, we spend, I've seen the statistics, you know, we spend so much time at work that our our manager has an equivalent influence on our mental health as a spouse does, or and even more than your doctor does. So I it just seems so important to me that we're also paying attention to these very same things out in the work environment.

Sandro Galea 9:02

I I couldn't agree more.

Resilience And The Goldfish Water

Manya Chylinski 9:04

Yeah. What question about resilience or health do you think we're still not asking?

Sandro Galea 9:48

Well, I think we misunderstand resilience sometimes. Resilience is not about not having downturns, it is actually about bouncing back. And uh when when uh one encounters adversity in everybody, everybody encounters some adversity in life, but it doesn't matter how gilded one's life may be, um, we have downturns. There can be downturns to our physical health, downturns to our mental health. And what really matters is bouncing back. That's what resilience is. So it is about what gives us the capacity to bounce back. And we, I think, make the mistake of individualizing that answer, of thinking that that answer is about some one very specific thing that I can do or some one very specific drug that I can take. But that's not really the answer. The answer is being in a context that allows you to bounce back. And you mentioned that you uh read my blog for which I'm grateful. Yeah, the blog is called The Healthiest Goldfish. And uh the uh metaphor, the central metaphor at the heart of the blog is that um we you want goldfish in their bowl to be healthy, and to be healthy, they need healthy water. So the blog is about the water, it is about the world in which we live. That, of course, is pretty expensive remit. Um, but fundamentally, what I'm trying to do is to write about the pieces of our experiences that matter to us as we navigate this complex thing we call living.

Manya Chylinski 11:22

Absolutely. And I love that metaphor. And to carry it a little bit further, the goldfish doesn't think about the water. So you're trying to get us to think about the water that we're in.

Sandro Galea 11:34

That is correct. That's correct. That is exactly right. And metaphor, you know, that's that's what animates the healthiest goldfish. You know, others have used similar metaphors, David Foster Wallace to something similar. Um, um, it is about these forces that are around us that are invisible because we don't think about them, because they're with us at all times. And what I'm trying to do, I suppose, with the uh the healthiest goldfish is to surface these forces. And uh, and that that's been roughly what I've tried to do in all my writing. I have a new book coming out called Why Health. And it is really about elevating the making visible the underlying practical foundations of how we should think about health. And uh, I'm trying to put these things in front of us, put in front of us what we should be thinking about when we think about health.

Manya Chylinski 12:21

Right. And I love that about your work because it you are trying to get us to see the water, to see the infrastructure and how it impacts us. You know, it's so earlier we were talking a little bit about prevention, and you mentioned, you know, people are just looking for the what's

Prevention And Freedom From Harm

Manya Chylinski 12:38

the drug I can take to make me better. And we want that. We want the drug, we want the button we can push, and everything's better. And but we really need to be investing in the prevention. Why is it so hard to be focused on that side of the equation?

Sandro Galea 12:58

I think it's hard because we're human. And uh, and I think for us as humans, it is hard to focus on what doesn't happen. You know, we focus on what happens. It is hard for us to pay as much attention as we should on what we are mitigating. And I think that's okay. I mean, it's just human nature, which is of course why those of us who are in the field of health have a responsibility to keep surfacing the things that matter. And I argue that what matters most is fundamentally what doesn't happen. That that is the the that's the paradox that uh, you know, we we talk in in the US in particular a lot about freedoms. And we talk a lot about freedoms. And when we think about freedom, we think about freedom to do things, but we do not think enough about freedoms from things, you know, freedom from disease, freedom from dying in an unnecessary car accident, freedom from dying because of uh random acts of violence, freedom from dying from uh uh because of contaminated food and water. These are also freedoms. We don't think about those, we don't, we do not see those because it's hard for us to focus on freedoms from. And uh in part, in part, this is the balance, of course, that we have to strike in health, making sure that we preserve everybody's right to have freedom to do whatever they wish while also protecting us and creating the freedom from unnecessary burden of disease.

Manya Chylinski 14:28

Right. You know, as you were talking, I was thinking back to Y2K, the whole experience of technology and the fear that our computer systems were gonna go crazy on January 1st, 2000, because of the way they had been programmed. And then that didn't happen. And so many people said, see, you were worried about nothing, versus recognizing that all the work that went into it perhaps saved us from something going wrong.

Sandro Galea 15:05

It is uh hard for us to value what has saved us from things going wrong and what happens time and again. And I think for those of us who are in the business of health, as a result, we need to tell the story of health effectively. And part of our story of health is telling the story of what could go wrong if we do not create a healthy world and making our job, that of creating a healthy world, really important.

Manya Chylinski 15:37

All right, thank you for that. So looking at my questions here, what do you think is one

Stop Saying Snap Out Of It

Manya Chylinski 15:44

thing we should stop doing in the name of resilience or in the name of health that doesn't really help people? We think it does, but it doesn't.

Sandro Galea 15:56

That's an excellent question. Um, where my mind went to is um is telling people to snap out of it. That is individualizing approaches that ultimately are systemic and structural approaches. And that's I and I don't think that helps. I think uh I think it's okay to say to ourselves and to others that um we all need to make an effort to move on, find purpose, find mission, engage with the world. But um often when um we have challenges, adversity, and health, it is not about us snapping out of it. It's actually about having the conditions that can help us move towards getting better. Uh so I think if you're asking me what's the one thing we should probably stop doing, I think that's one thing we should probably stop doing.

Manya Chylinski 16:43

Yes, definitely. Um What kinds of things are then um helpful? You know, if especially if someone has just gone through something difficult or is dealing with a health issue, what actually helps people

Social Connection As A Health Drug

Manya Chylinski 16:59

recover and move forward?

Sandro Galea 17:01

Well, I mean, there's a whole host of things help people recover and move forward, but um in working concentric circles, we know that one of the most um important elements of bouncing back resilience is having the networks of care around you. And by that I don't just mean clinical care. I mean, I mean the social networks, social connections that can move people into health. And being embedded in those social networks, having those bonds that can move you into health is critical. You know, beyond that, obviously having clinical care if relevant in a particular disorder is important, uh, but having then meaning and purpose, having a reason to engage with the world, having the social connections, having meaning and purpose to engage with the world, and having the means to engage with the world at some level that is reasonable by how one wishes to live. Those, I think, are the pathways to re-engaging with the world so that one can live one's life fully.

Manya Chylinski 18:09

Recently, in the last few years, there's been a lot of talk about loneliness. And some people have said we have an epidemic of loneliness, and certainly the pandemic uh, I think altered some of our social connections. Is are those things that if we're talking that there really is a loneliness epidemic, that is preventing people potentially from healing?

Sandro Galea 18:32

It is. Insofar, I mean, loneliness is one very particular aspect of not having social connections. Uh, but insofar as um as one, as not having those kind of social bonds inhibits us from healing, from from bouncing back, from getting to a place where we can live full, rich, healthy lives, then yes, loneliness is a feature that is keeping us from healing. And it sounds odd to say because when you talk about healing, I think one's mind goes to, okay, let me take a drug that will make me better. Right. But um the um social connections have as much of an influence on health as do any of the most powerful drugs. And uh these are ways in which we create a world that allows for healing, as we were discussing a few minutes ago, and being integrated into that world is essential to that healing.

Manya Chylinski 19:34

Yes. Interesting. Okay. And since it just popped into my head when I asked you that question, um, I'm so curious your thoughts

Pandemic Recovery And Hard Tradeoffs

Manya Chylinski 19:43

about how we as a society, maybe just in the US, are healing from the pandemic.

Sandro Galea 19:51

Are we getting back to Yeah, I think we're I think I think I think we're doing it in fits and starts. I think uh I think in in in some aspects, I think we have um well gotten over it. And in fact, we'd rather not talk about the pandemic, which perhaps has some there's some healthy element there. Uh, I think in other aspects we haven't had some of the conversations that we should have, because perhaps it's been too soon. I think we haven't fully grappled with in our mind with the um question of how we balance protecting each other from uh in an event like that, with the needs and the imperatives of society to uh um to create openness and engage fully in living. I think there are a number of questions that we haven't dealt with, some of which inspired my book that I mentioned about or I mentioned earlier. So I think it's in fits and starts. You know, I was always I feel I find it always helpful to think back to other large-scale traumatic events. I mean, the and a number of elements of uh of how the world operated did not return to baseline for about six years after the September 11th terrorist attacks. And uh yeah, the pandemic was uh a bigger event, arguably. So it takes time. I think it takes time to restore to an equilibrium. I wouldn't say normal, I would just say to an equilibrium, to a place where we don't have rapid cycling changes. And I don't think we're there yet.

Manya Chylinski 21:17

From my perspective, it was such a case study of individual behavior and collective good. And how do we, as individuals, balance taking care of myself, doing what works for me versus my behavior and how it impacts you and others?

Sandro Galea 21:37

Yes, and that's part of the equation, part of the question around one of the set of questions that we should be thinking about when we think about health. And then there is no easy answer to that. It is actually quite complicated to address what is my responsibility to the collective, and how much should I be giving up, and how much should the collective be giving up? These are difficult questions of calibration that mature societies need to create the space to discuss and debate. And in part, some of our failings around the pandemic were that we did not have the space for honest discussion and debate around these issues.

Manya Chylinski 22:20

Yeah, absolutely. Well, thank you for that. Well, we're getting close to the end of our time. And I'm curious, when you think about the future, what is giving you hope right now?

Sandro Galea 22:31

A

Hope Through Conversation And Closing

Sandro Galea 22:32

lot of things give me hope. I think the world is um always getting better, actually. And um, it's I think one generation is better than the other and on and so on and so forth. You know, I um I work in a university, so I'm surrounded by students who give hope. But I think I'll center on uh conversations, give me hope. I think the fact that we're having this conversation gives me hope. I think uh society advances through conversations so we can get to places where we can advance our thinking collectively forward. As long as we're doing that, that gives me hope.

Manya Chylinski 23:05

Nice. I like that. And before we say goodbye, Sandro, can you please share with our listeners a little bit more about yourself and what you do?

Sandro Galea 23:14

I serve as the dean of the Bursky School of Public Health at Washington University in St. Louis. I have been doing this almost for the past two years now. I came here from Boston to build a School of Public Health here at Washington University in St. Louis. And I've had the privilege of doing that with um some excellent colleagues uh in uh here in St. Louis and around the country, around the world.

Manya Chylinski 23:38

Fabulous. Well, the work that you do is so important. And um, thank you for sharing a little bit of your wisdom with us today.

Sandro Galea 23:45

Thank you, Manya, for hosting me.

Manya Chylinski 23:47

And thank you to our listeners for checking out this episode, and we will see you next time.