IOP Fellow Dr. Abdul El-Sayed served as the Executive Director of the Detroit Health Department from 2015 to 2017. He is also the host of “America Dissected,” a podcast by Crooked Media which investigates a variety of public health issues. He is a physician and an epidemiologist, and in 2018 he ran for governor of Michigan. His forthcoming book, Healing Politics, diagnoses the epidemic of insecurity in the United States. The Gate sat down with El-Sayed to discuss the biggest public health issues facing major cities in America, the broken healthcare system, and how we can address the root of the mental health crisis in the U.S.
The Gate: Based on your experience as the executive director of the Detroit Health Department from 2015 to 2017, what did you see as the biggest public health challenge facing Detroit?
El-Sayed: Detroit is the poorest city in America and 85 percent black. The history of that city is written by a series of large corporations that invested in very particular ways in Detroit that left a lot of those people marginalized. That marginalization has left them in unwalkable communities without access to cars, in places where food access and clinical medical access are limited, where jobs are scarce, and without a functioning city infrastructure.
All of that has led to one of the highest infant mortality rates in the country; some of the highest asthma hospitalization rates in the country; a prevalence of lead poisoning that is higher in Detroit than it was in Flint at the height of the Flint water crisis; higher rates of obesity; and high cholesterol and hypertension and diabetes, which lead to higher rates of death from cardiovascular disease, stroke, and cancer. Higher homicide rates, high depression and PTSD rates, and economic and social security leaves people profoundly without the basic means of a dignified life.
The Gate: What do you think is the best way to address the root of these issues?
El-Sayed: I think there needs to be a level of investment in the basic means of a dignified life.
I think we need to reinvest in local communities where people live, invest in their schools and their access to basic things like parks, social squares, grocery stores. There needs to be a deep level of regulation on the corporations that have both limited economic opportunity, but also dumped their externalities, like air and water pollution, into those local communities. There needs to be an investment in basic primary care support, including comprehensive family planning services, dental services, and mental health infrastructure. And there needs to be a level of agency for the folks living in the community.
The Gate: Do you think these problems are representatives of the problems that other major cities in America face?
El-Sayed: Absolutely. And it's not just major cities in America—any urban community that is disproportionately poor and disproportionately black is going to suffer very similar types of outcomes. It’s a syndrome. But even beyond that, if you go to rural communities, there are very similar circumstances. The mechanism is different, but the antecedents and the consequences are the same.
The Gate: The primary elections are happening, with healthcare being a forefront issue. What do you think, ideally, the future of the health care system in the United States needs to look like?
El-Sayed: I do think that we need to move to a Medicare for All system for a lot of reasons. But one of the main ones that doesn't get talked about as often is that, insofar as healthcare makes a lot of people money, there's an incentive to provide health care. And in order to provide healthcare, people have to get sick.
So, in the system that we have now, there is no real incentive to prevent disease. If we're serious about public health, then we have to decouple making money on sick people from our health system.
The Gate: You host a podcast called “America Dissected.” One of the episodes is about the broken incentives of the pharmaceutical industry. How does that relate to what you’re talking about?
El-Sayed: It’s very similar. To give you an example, the pharmaceutical industry has basically stopped investing in research and development of antibiotics. Why? Because if you think about how we use an antibiotic, you use it once for two weeks and then never use it again. That's how most people use it. There's very little money in that.
Think about Viagra. Why is Viagra such a great drug for the pharmaceutical companies? Because you use it regularly for the rest of your life. If you know somebody's going to be using something X number of times a week to a month, you want to make that drug because it's money in the bank.
A lot of people die of infectious disease. Our antibiotics are quickly becoming obsolete because we're misusing them and bacteria is becoming resistant. But there's no money in them so [the pharmaceutical companies] don't make them. So you can see how the incentives for the public good are becoming decoupled from the incentives of the corporations who make them.
The Gate: How do you fix these broken incentives? Do you think Medicare for All would?
El-Sayed: There are a lot of things we could do even before Medicare for All. One example is that Medicare is the single biggest insurer in the country and it legally cannot negotiate prescription drug costs. The pharmaceutical industry is the single biggest lobbyist in the entire country—over the last twenty years, they have spent $4.4 billion lobbying the government.
[If Medicare were able to negotiate drug costs], we would be able to vastly reduce the cost of a lot of pharmaceuticals.
The Gate: What about the future of mental health care? What do you think that needs to look like, especially in cities?
El-Sayed: There’s both mental illness and mental health. I think not everybody who is not mentally healthy is mentally ill. There's a lack of mental wellness that I think more and more of us are experiencing, in part because of technology, in part because we have not replaced the fundamental unit of organization, despite leaving the one that we had, which is family.
We're not as independent as we think we are. We like to be with people, it's what makes life worth living. We've become atomized and we've replaced our real interactions where you actually talk to somebody with the interactions that you get on on a phone or the interactions those facilitate.
Think about the concept of ghosting someone before the era of a phone. You really couldn't ghost someone. We've created these systems where the investment upfront in a relationship is so low, that the cost of leaving it is so low. I think part of the investment that we need to make in that is to create social space where people actually come together. And we need to train people on how to have relationships again, that sometimes people will say things you don't like, and sometimes they hurt you, and sometimes they're not the funnest. Yet they are more than worth having, because without them we end up being very sad and lonely. And right now we're so worried about the risk of a relationship being lost that we don't build them in the first place.
There's this therapy called dialectical behavior therapy, and it’s about engaging in conflict with yourself and others. Like, how do you talk to yourself and how do you talk to others? And how do you deal with your emotions? [My wife’s a psychiatrist and] she's like, we should be teaching that to kindergarteners. There’s emotions that are never dealt with. Having the language and the skills to deal with that, to mitigate the consequences, to know when there might be a problem and who you can go talk to if and when you're suffering or somebody around you is suffering, just seems like something we should be telling everyone.
When it comes to mental illness, we just don't have mental health infrastructure. One of the things that happened in the ‘70s, which I think was a good thing, was the decommissioning of psychiatric hospitals. They had sort of become a catch-all for people with any level of mental illness. There was a push to be able to treat people out in the outpatient setting, so they could be in the world. We shut down hospitals, but we never rebuilt the outpatient clinics. What has risen up to catch the folks who were left without care has been the jail system. Twenty percent of people incarcerated have a diagnosable mental illness.
I think we also have to stop differentiating between the head and the rest of the body. Right now we sort of think about mental health as being something separate from health. That's codified in a lot of our policies. For example, you can't get reimbursements from federal insurance programs if you're getting treatment for a mental illness in a large hospital. It has to be a specific mental hospital. It's a broken policy. It makes no sense. But that has to be fixed.
And then we've got to do something about how we engage substance abuse. In the opiate epidemic, the pharmaceutical industry has sort of gotten off scot-free, and yet we're still criminalizing opioid use. It should be the opposite. We need to invest in harm reduction strategies like needle exchange or observed therapy. And I think we need to generally destigmatize both drug use and mental illness.
The Gate: You said before that to address mental health, we need to invest in public spaces and training. When you say public spaces, does that look like infrastructure?
El-Sayed: Literally like parks, benches, playgrounds, and dog walking areas. There's pretty good evidence that those things really do facilitate social interaction, and without them, you know, that interaction is far more limited. The problem with private space is that it's excludable. And the problem with exclusion is that it means you don't interact with other people. So having public spaces that are incentivized and great actually create social interactions that are really meaningful. That is a real infrastructure investment that needs to be made.
The Gate: Can you talk about your upcoming book, Healing Politics? What inspired you to write it?
El-Sayed: I ran for governor in Michigan in 2018. I trained as an epidemiologist, which is literally somebody whose skills are understanding and diagnosing patterns of disease in people and what causes those diseases. And I thought, when I ran for office, that my days as an epidemiologist were over. It turns out that that skill never really leaves you.
As I was running around the state, talking to people, I realized that instead of analyzing lines of data, I was analyzing real people. I came to appreciate that our politics right now is being shaped by a disease that we are all facing, which is a disease of insecurity. And so in that book, I diagnose what that is, leveraging my own story, as a son of immigrants and in growing up in suburbs of Detroit, and introducing the concepts of epidemiology. This sort of gives the reader some tools and some space to then walk through systematically how our society is creating the space for this, this epidemic of insecurity, and what our politics ought to do to solve it.
The Gate: What advice would you give to a student who wants to go into public health work as a career?
El-Sayed: Get started early. Make a habit of talking to people, listening to them, and hearing their stories, and asking what are the consistent patterns that you see across the people that you meet.
I think health is fundamentally political, and we assume that it's not. Everyone is like, “well, science is beyond politics.” But whether or not we fund science, what we do with the scientific information we have, that's all political. I always tell folks, there's two ways to deal with politics. Either stick your head in the sand or run right into it. And I think being able to appreciate that if health is a scarce resource, and politics is how we deal with scarce resources and how we allocate them, then figuring out how to maneuver politics to empower people to have sustainable equitable experiences of long healthy lives. That's the work.