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More than 5 million people have died from COVID-19 since the virus emerged two years ago, according to data released Monday from Johns Hopkins University.

Even as total cases and deaths continue to rise, public health experts are already thinking about how to prepare for and respond to future pandemics.

In a new book called “The Contagion Next Time,” Dr. Sandro Galea, an epidemiologist and dean of the Boston University School of Public Health, argues that pandemic preparation should include addressing underlying flaws in the economy. 

He spoke with Marketplace’s Amy Scott about how systemic issues like racism and economic inequality made the United States more vulnerable to COVID-19. The following is an edited transcript of their conversation. 

Learning from the pandemic

Amy Scott: A lot of people might hear your title, “The Contagion Next Time,” and think, “Wait a minute, we’re still dealing with the one in front of us.” Why do you think it’s time to talk about the next time?

Dr. Sandro Galea: Well, the pandemic has really been a tragedy, and there’s nothing that redeems a tragedy. But certainly it would be even more of a tragedy if we do not learn from it. Yes, we’re not through the pandemic right now, but I don’t think it’s too early to start thinking about the next one, because there are a lot of things that are fresh in our minds and becoming clearer about what happened.

Scott: And you make the argument in the book that a big part of this is not just the investment in vaccines and medicines and biotech, but in what you call “the foundational drivers of health.” What do you mean by that?

Galea: What I mean by that is that, obviously, this was a pandemic that was caused by a virus and the vaccines help us mitigate the virus — but the consequences of the virus played out the way they did because of our economic structures and the way our society was structured. So just to take one example, the people who are at greatest risk of exposure to this unknown virus were those who were in jobs where they could not work from home, they could not protect themselves. When we think about the next contagion, we should be thinking about how to fix these underlying structures — not when a pandemic hits us, but before — and that should start now.

Scott: It’s interesting that you are an epidemiologist, but in many ways, you’re making an argument that the economy is really the big driver. 

Galea: Well, by disciplinary stripe, I’m a social epidemiologist. And social epidemiology is a field that emerged in the past 25 years that really is concerned with how social-economic structures — things like wages, things like racism, things like how we build our cities — how all of that becomes health. Now, this is a relatively new area in epidemiology, but if one thinks about it, it actually goes back to the very roots of epidemiology. The very roots of public health come from mid-19th century, industrialized countries that were cleaning up cities to reduce disease, and all of that was foundational to epidemiology and public health. So in many respects, I’m urging us to think about our foundations and to say, “We should create a world where our foundations do not leave us exposed to the ravages of a virus like this one.”

The difference between health and health care

Scott: It strikes me that it’s a little bit like the debate about expanding the definition of infrastructure to include social supports like child care. Do you think we need to rethink what we think of as health care in our society?

Galea: I do. And I think our words matter quite a bit. You’re right about the rethinking of the term “infrastructure.” When we think of “health,” we tend to think of medicine. And by medicine, we tend to think of pills or surgery. Well, if I were to tell you that your education matters more for your health than does any pill a doctor is going to give you, well, maybe we should be thinking about education in the same breath as we think of medicine, if we care about our health.

And I was intrigued that you asked me this question, and you use the term “health care” in your framing because actually, I don’t think you meant health care, I think you meant health. And the reason I’m actually pointing that out is simply to say that we often mistake the two. The problem with mistaking the two is that we think that all of health is about health care and medicine, but actually, it’s not. Most of “health” is about where we live, where we work, where we play, and once we turn our brain to that, we move away from spending all our resources only on medicine and spending more resources on what’s going to keep us healthy to begin with.

The role of housing in health

Scott: I wonder if you could talk a little bit about the role that housing plays in these foundational forces. Housing has been a huge issue during the pandemic, and it was the concern about the spread of the virus that led the [Centers for Disease Control and Prevention] to impose a moratorium on evictions. How do you think this will change how we think about the role of housing in health?

Galea: Yeah, the housing example in the context of [the] pandemic is, I think, a perfect illustration of how underlying structures determine how we live through pandemics like this. People who were in crowded houses were at much greater risk of passing the virus amongst themselves within the family. That’s No.1. No. 2, housing provides shelter, particularly at a time of economic downturn, and if now we have people who are unemployed because of the shutdown and because their jobs no longer exist, who are now also homeless, that is going to introduce a full other range of health problems. So, housing is a good example of how our health is all interconnected and inextricable from the conditions in which we live.