Thanks to so many of you who joined our live conversation with Devi Sridhar! Professor Devi Sridhar is the Chair of Global Public Health at the University of Edinburgh. Over the past 2 decades she has become one of the world’s leading authorities and advisors for promoting global health. Her new book —How No to Die Too Soon—provides a unique outlook for extending healthspan with a global perspective admixed with many personal stories. We talked about lifestyle factors with lessons from Japan (on diet) and the Netherlands (on physical activity), ultra-processed foods, air pollution and water quality, the prevention model in Finland, guns, inequities, the US situation for biomedical research and public health agency defunding, and much more. Get full access to Ground Truths at erictopol.substack.com/subscribe
Chapter 1: What insights does Devi Sridhar share about her book 'How Not to Die (Too Soon)'?
And I am thrilled today to have a chance to reconnect with Professor Debbie Svitter, who is a chair of global health at University of Edinburgh in Scotland. I've had the chance to interview her once before, years back when she had her book, Preventable. She has a new book out, which is just getting in the U.S.
right now, How Not to Die Too Soon, the lies we've been told and the policies that can save us. It's an extraordinary book, and the convergence with the book I recently had published, Super Ages, is also notable. We look at it very differently. I'm looking at it more from an individual level and Debbie from the world level.
I mean, she has a planetary perspective, which we'll get into, which is quite remarkable. So welcome, Debbie.
Yeah, thanks for having me.
Yeah, well, it's such a treat to be able to talk to you about the insights you have. because you really are the wizard for me in global health and one of the leading public health faculty, professors, resources in the world.
So first thing I wanted to get to is when you were putting this together, what was the main premise about, you know, it wasn't, I don't think, longevity per se, but maybe you could get us straightened out on it.
Yeah, I guess it was looking at the gap between our knowledge of health and how to live longer and the amazing scientific research that's happened. I should say research, but it's Americans.
And life expectancy going backwards, especially since the pandemic and also seeing the rise of chronic disease in younger people like diabetes and cancers and trying to think, why is there this gap between our knowledge and actually what's happening?
And then in the course of it, I started looking at people like Brian Johnson, who I know you look at in your book, thinking, oh, wow, there are a lot of people thinking about this issue. But the way I'm thinking about it was much more, I think, global. I'm American, but I've lived in Britain. I've lived in a bunch of different countries. My team does research across the world.
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Chapter 2: How do lifestyle factors in Japan influence health outcomes?
And I was like, actually, not really. I think most people, when they're faced with their mortality, don't accept it. They actually want to fight it. Luckily, I was treated. I was able to get an appointment after a few months. But it did lead me to think about how one of the factors is your access to medical care.
And if I was living in India or Malawi, somewhere else in the world, I wouldn't even have access to a screening program, most likely. If I was in the States, it would depend on my insurance. Could I pay for it? The nearest clinic? And here in the UK, it was dependent on the waitlists and actually trying to get in in time, which is the biggest problem with the NHS, I think.
There are barriers to care. And that's what I talk about in the book between the United States and Britain. In the States, it seems to be cost and having insurance, where in Britain, it's actually there is no cost. There is no bill when you go to the doctor. But the biggest issue is a waitlist. Will you actually see someone in the end? So, yeah.
So I started with that to kind of reflect a bit on that. You know, I'm someone who tries to, I guess, similar to you or others in health. We try to like do everything we can. We take the supplements. We do our exercise. We eat well. You know, we think we're doing everything right. But actually, in the end, if you need medical care, it doesn't matter how much wellness or well-being you do.
In the end, you need access to someone who's experienced. You need access to labs. And that depends on the place you live and what you have access to there.
Yeah, and I think the place that you're living and some of the things we learn from other countries, that's what I really got out of the book is how you have such wisdom about the culture of places around the world. So I thought maybe we'd start with the diet story. Of course, we share in the UK and US the worst consumption of ultra-processed foods in the world.
And there's still people doubting the ultra-processed foods, which I find quite remarkable. Can you give us your perspective about that? Because I'm not aware of countries that are really bearing down on this. It's almost like we're tolerating it, not taking on big food, whereas this seems like a real recipe for adding to the burden of chronic diseases and chronic inflammation. What do you think?
Yeah, completely. And that was something that I think, especially in the past 10 years, has come to light. If I think back to when I was a kid in Miami, eating my Lucky Charms and my Froot Loops and just getting the ADHD and everything else we now know from the additives, I don't think we had the knowledge. I don't think the research was done yet on these. But now there's such growing research.
I know you cover it in your book about the not only tendency to become obese or put on weight. So even for the same amount of calories, ultra processed food is worse for you, but also messing up your gut microbiome. you know, changing actually your immune response.
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Chapter 3: What role do ultra-processed foods play in public health?
And there is a sense of fatalism, which is like, it's cheap, it's there in stores, it has long shelf life. And so I don't think any place has figured out how to manage it beyond, I give the positive examples of like Denmark, Netherlands, South Korea, Japan, places that are kind of reversing childhood obesity, which is the, like the outliers compared to the rest of the world.
And there they seem to be focusing on children and saying, actually, if you can prevent the first 10 years obesity and get diet in place for then, it seems to maintain itself. But if children become obese by the age of 5 or 10, it's very, very difficult to reverse that. And that's tied into kind of the diet as well and the diet environment.
Yeah, I mean, I think the link to young people's cancers, as you mentioned, is something that's so notable. And we don't have to hunt too far to find an incriminating factor. But one of the things I really liked was the 80% rule. Was that Hachibu? And tell us a little bit about that because, you know, I wasn't familiar with that rule before I read your book.
Yeah. So, you know, talking about like, you know, people who study, people who make it to 100 and they were saying, oh, they have nothing in common. And I'm like, but they seem to be a lot of them in Japan. It's like there's nothing going on there. And so they're looking at places like Okinawa and I should say it's changing now. Actually, they are going backwards. Yeah.
You do see that they follow this dietary rule of eating to 80% full, meaning you don't have to eat. Think of like Thanksgiving in the States or Christmas here where you just eat to like you feel sick. Like there it's learning the opposite. It's learning actually I could eat a bit more, but I'm going to stop because I've had enough. I'm not hungry, but I'm not like stuffed.
I've tried instituting it since reading about it. Let's see if you could try it. And it's hard. It's really hard to stop. Because we're so conditioned to finishing your plate, eating till you're like absolutely full to be like, I'm okay. But also even things like they use sweet potato as a main source of carb.
Which is such a healthy, a healthy aspect, but also the idea of like your body is a temple and that what you eat actually is nutritious and should be like feeding that. And it's not kind of a garbage dispenser. And sometimes I guess when you're at an all you can eat buffet, you're actually just trying to finish stuff. Right. And like kind of you're just piling it in.
Right.
I did find it fascinating that Japan is one of the countries, I think the country of the G7 with the lowest obesity rates, lowest chronic disease, best survival. And it has to be tied to their diet and how they've tried to maintain that. Even though I didn't put it into the book, the idea that they have nine a day. It's not the five fruits and vegetables a day. It's nine a day.
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Chapter 4: How does air pollution impact health and what are the solutions?
People don't see it as complimentary, but really complimentary, both to medicine, right? So medicine sees people once they're unwell and tries to help them, but also really complimentary to research because you actually can start to talk to people at an individual level to understand why
I guess similar to medicine, like the larger studies, the larger epidemiological studies and say actually at your level. And the reason I brought up Netherlands is, again, it has to do with you or I or anyone else in the States move to the Netherlands, to Amsterdam, you're likely to be more active. That's why I'm moving there.
Because of how the city is set up, how life is set up, what everyone else around you is doing. All of a sudden, it's actually, you don't need to have special willpower to go to a gym. You don't need to figure out how in your busy day you're going to get your 30 minutes of steps or your 10,000 steps. It's built into natural life. And it just made me think, actually, it's invisible.
It's accessible. It's free. And more importantly, there are some people who don't like sport. Like they just don't like exercise. But if you make it that it's not exercise or sport, it's literally go get your shopping, get to work, go to school. You're not doing exercise. You're just going about your day and inadvertently getting it.
So I thought that was such an interesting way to think about exercise and sport beyond, you know, the kind of campaigns. And I talk about Dubai and Delhi and Ghana, where it's just like YouTube campaigns, which kind of reaches the people who already fit. It's like saying, You already are kind of probably exercise isn't a reason you're going to die too soon, but you're trying to optimize.
And that's what you see a lot in like the fitness influencer communities, people who are already like 98% fit. And they're like, how do I get, you know, 1.5% more, do 60 press-ups instead of 30 or, you know, how do I do? And I'm like, okay, that's fine. But you're saying, what do you do with all the people who are sedentary? Right?
Like that's the real population challenge and where we are seeing how you get that going. Yeah.
Well, I mean, I didn't know about this Dutch capability of 96%, you know, into the – I think it's just – imagine if the whole world was like that. Wow. Now, you basically get into every aspect of how we can have better healthspan on a global level, this unique picture of knowing, you know, pockets around the world that are best and worst practices, I guess. Air quality.
This is a big one because we know air pollution is a potent pro-inflammatory risk of cancer, cardiovascular, neurodegenerative disease, this pollution fatalism that you have. refer to. And the fact like, for example, in Delhi, it's like just breathing the air there is like having 10 or 15 cigarettes a day, which is incredible. Nothing seems to be getting done to get this on track.
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Chapter 5: What are the challenges surrounding access to clean water?
I mean, I also raise it because here, let's say in Edinburgh, we have a new low emission zone. There's huge efforts to make the air clean, but people take them for granted. And that's why I bring these examples of places where they don't Nothing is done. And I say, that's what it could be. That's the future. If we don't actually actively manage our air quality and what it does to our lungs.
And coming back to Delhi, the idea that 50% of kids living in the city have damaged lungs already. I'm like, you can go about your day, do what you can. And then the rise of the bottled air industry, which I hadn't known about, which is like mottled off bottled water, which is trying to bottle air and bring it to places that don't have clean air.
So you can individually breathe your clean air alongside your air purifier. But yeah, it's a huge challenge for the world and probably the thing that invisibly affects us when we don't think about.
Or even the idea I talk about that if you're in a place with air pollution, if you're outside running or cycling, you could be doing more harm to your health doing that than actually the good of the exercise because of the pollution going through your system. Yeah. I brought it up in the book because I think it's something that people do feel it's beyond their control.
They might follow like the air quality indicator, but we need to have like collective action to actually say this is a problem. It matters to health. And this is why. And these are solutions. And these are places trying to do things differently. And if we don't take these measures, we could into a place where too many kids are having, you know,
very severe asthma episodes because actually they're being triggered by that and you can have as many hospitals as you want, but if you're not fixing the air, how do you actually manage it? So, yeah.
Well, I hope we'll get over this kind of fatalistic approach here and really get on it. It's such a critical matter. It's just not getting enough attention and you really brought it to the fore. Like air, there's also the desire to have clean water, right?
And here, I think, along with air, you highlighted Switzerland as a place that seems to be more into this, trying to aspire to the cleanest water. What are we going to do about the water? Because this is another serious mess that we're in.
Yeah, so I think I talk about water because I guess people reading it might be in a place where they have great tap water and they can drink it. I'm lucky in Scotland. So Scottish water is publicly owned. It provides basically kind of free tap water throughout the country. There's water stations you can go to in parks. It's not like Brussels and Paris, which have sparkling water stations.
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Chapter 6: How do inequities affect health outcomes globally?
And if we don't kind of maintain those gains and invest in these systems, you know, people die. And I give the example also of places where it's not yet fixed, like Haiti. Waterborne diseases are the number one cause of dying too soon. Right.
And so also to provide the example that just because of where we live, we could be like in a very kind of bubble where it works, but there are many places that it doesn't work. And we have to not only fix those, but think about making sure we maintain where we are.
Yeah, no, it's so important. I mean, you're getting into the big topics that so far have not nearly the attention or the action, not just the talk, but the walk. And that gets us also to the topic of inequities that you, as a chair of global health at a great university, this quote I thought really grabbed me. This grotesque inequality is breaking the bonds that hold us together in humanity.
This is inequality that literally kills. So, so much of what we've been talking about, of course, is exacerbated greatly because of inequities. And there doesn't seem to be nearly enough work on that if we're going to have this idea of a better, healthier, approaching much greater than where we are today, which is in the 80 or so category for lifespan, but not necessarily at all for healthspan.
Are you optimistic that we can address this? For example, I know there was some work in the UK, which was specifically intended for for example, a mental health app that was for people in greater need rather than just putting out there for everyone. What do you think about?
Yeah, I mean, I think this is almost like the elephant in the room for a lot of issues. I'll give you an example. So we know GLP-1s are seen as these wonder drugs. So I was asked, should we just distribute them in Scotland or even obesity problems to the NHS to supply them and give them to children? And I said, but my question back is,
Why is it that you can correlate house prices to childhood obesity? That actually I can tell you where obesity is based on house prices. That tells me it's not a metabolic issue. It's not that these children are different in terms of their biological makeup. It tells me it's where they're living and probably what things cost. And that's where inequality comes into it.
And it's a really tricky conversation because it gets into how do you actually create some kind of balance within a society and looking at the bottom 20 or 30 percent and saying, how do we lift people up who are really struggling? That has to come through some kind of redistribution. And nobody likes talking about that because it's the idea of taxation, social investment.
And there, I guess I do probe at the end, which is, you know, when is enough enough? And do we accept the growth, the number of billionaires, which COVID brought, you know, record number of billionaires created with the rise in extreme poverty? At what point do we say, actually, you have enough if you have 100 million or if you have 500 million? After that, you need to put back things.
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Chapter 7: What lessons can be learned from Finland's health policies?
Well, interesting approach there. Now, you mentioned Finland, and that was one of the things I also wanted to highlight with you, with the book, that this is a place where prevention is really a big thing. And all the things that we've been talking about are trying to prevent major diseases, promote health. What do you think about Finland? Is that the right model?
Yeah. So when I looked across different metrics in terms of like happiness, health, health systems, longevity, Finland just emerged as a country. It can't be due to the weather, saying it's Scotland. It's so far north. They do have very dark winters. So it must be obviously something else going on there. And I think just looking back that it was a set of policy choices.
One of the most interesting ones was in the 20s and 30s about gender equality. and actually raising the position of women through employment laws, I mean, representation. Um, and that's, I think one of the really interesting stories is actually how can something, and I know like Bill Gates came to this and Melinda Gates as well, that actually how can gender do with health?
And you start reeling out, actually there is something that connects those agendas. And so, um, Yeah, I guess it's called the happiest place on earth, not only because I guess Santa Claus lives there in Lapland, but because they have really progressive ways of approaching provision and prevention.
And Finland was one of the few countries that saw life expectancy increases despite the COVID pandemic because of how active they were. They have the advantage of being a small population, you know, five, six million. So actually, it's not like the states, which is massive.
But as on a micro scale, it's quite an interesting place to look for their efforts in terms of employment, gender, education, really good, strong position of state education, quality education through the public sector. And as well, I'd mentioned that they have like basically eradicated rough sleeping or homelessness.
And that's been through, again, a deliberate policy of saying someone who is homeless and sleeping on the streets can't figure out their life. Like it's too complicated. So you start by providing them a short term solution of a home and social support to help them find a job, get on their feet and transition them back.
And the idea being that actually you should see someone who is homeless as, you know, I don't want to use the word victim, but someone needs a hand up. You help them get a hand up and you transition them back instead of thinking, oh, why do we have all these people on the streets? What's their problem? And again, it was an interesting policy.
I think they put together like, you know, someone, a pastor, you know, a social scientist, a doctor and a politician. And they said, find a solution to this. And they came up with a really creative solution that mixes empathy, you know, pragmatic care. But the idea being that actually,
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Chapter 8: What is the significance of addressing gun violence in public health?
And the story you told in the book, and also that we've seen in Australia and many other parts of the world, that if you do the restriction, you get rid of these lethal military-type weapons, assault rifles and whatnot, you see a tremendous change in the pattern of not just mass shootings, but all sorts of other gun disasters.
So we have this now somehow normalized, immune almost on a daily basis, something here in the US. Now, that gets me to my last question to you. You, as an American, raised in Miami, you decided to immigrate to the UK and to set up shop there, the University of Edinburgh.
I don't know how prescient you must have been knowing how this place has become such a mess with respect to lack of support for health, as you know, gutting National Institutes of Health and gutting public health agencies. Did you know about that when you decided years ago that you were gonna move to the UK?
Not at all. And it's quite... Incredible to see, I think, even for probably Americans in the States, like the rollbacks around vaccinations, around this idea of data analysis, evidence, what counts as truth. Absolutely astonishing to see.
And so, yeah, I think sometimes it is good to be American, but to live in different places, to travel to different places, to see actually there are lots of different ways to do things. There are a lot of different ways that, you know, societies run and operate often very effectively.
And I think what really does scare me as well in the States is kind of the rise of like the lack of freedom of speech now to be able to say things. But even as you have that as that, can you dissent? And I can just say, that's one thing I'm very happy about in Scotland, that you can dissent and you can criticize government and you can say, and that's considered healthy and part of the dynamic of,
But let's hope it's a few years and, you know, the arc continues towards progress. But, yeah, absolutely astonishing to see it from abroad and actually really devastating, I think, in terms of the cutback in scientific grants and the dismantling of CDC and the FDA and so many essential American institutions abroad.
Because America is, regardless of where you are in the world, the most influential country in terms of health. I think we accept that in different places. Often the American news dominates here. When I'm back in the States, it is the American news. Rarely another country dominates in the same way.
So I wish those living there strength in these difficult times to get through because it is a difficult patch. I'm working on a column now actually about the Make America Healthy Again movement. The idea being that there are nuggets of truth. I think you and I would accept America's health needs more work, needs more investment.
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